Sunset Villa Post Acute

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure ongoing assessment and evaluation for the continued use of a sensor pad alarm (a device designed to detect moisture or movement, alerting someone immediately) for one of one sample resident (Resident 142).This failure has the potential to result in restricting the residents' movement, loss of dignity, sleep disturbance due to the sound of alarm, confusion, fear, agitation, and anxiety or irritation.Findings:During a review of Resident 142's admission Record, the admission Record indicated the facility admitted Resident 142 on 11/7/2024, and readmitted on [DATE] with diagnoses including anoxic brain damage (occurs when the brain is totally cut off from oxygen, causing brain cells to die within minutes), cognitive communication deficit (difficulties with communication that arise from underlying problems with thinking skills, rather than primary language or speech disorders), and abnormalities of gait and mobility (an abnormal working…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 14) was free of unnecessary psychotropic medications (any drug that affects brain activity related to mental processes and behavior) by failing to:1.Ensure Resident 14's Lexapro (a prescription medication that helps keep more serotonin available in the brain which helps improve mood, anxiety (constantly feeling worried and nervous), and emotional stability) order had the correct indication for anxiety as indicated by the physician.This failure had the potential to place Resident 14 at risk for unnecessary exposure to psychotropic medications and adverse drug reactions (a harmful or unwanted effect caused by a medication when taken normally and correctly), which could result in impairment or decline in the residents' physical and functional condition, and mental and psychosocial status.Findings:During a review of Resident 14's admission Record, the admission Record indicated the facility admitted Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide accurate information in the Minimum Data Set ([MDS], a resident assessment tool) for two of four sampled residents (Resident 17 and Resident 40) when:a. Resident 17 was taking an anti-anxiety medication (medication to treat symptoms such as feelings of fear, dread, uneasiness, and muscle tightness) for anxiety (constantly feeling worried and nervous).b. Resident 40 was taking an anti-coagulant medication (medications that prevent harmful blood clots from forming) for diagnosis of atrial fibrillation (irregular heart rate that can cause poor blood flow).This deficient practice had the potential to result in inaccurate assessment and services for the residents due to the inaccurate MDS assessment and care screening tool practices.Findings:a. During a review of Resident 17's admission Record, the admission Record indicated Resident 17 was originally admitted to the facility on [DATE] and readmitted on [DATE] 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 interview and record review, the facility failed to ensure two of five sampled residents (Residents 14 and Resident 19) Preadmission Screening and Resident Review (PASARR- a federal assessment requirement to help ensure that individuals who have a mental disorder -MD- are placed in facilities that can provide the appropriate care) were reassessed appropriately by:1.Failing to ensure a PASARR level 1 resident review screening was resubmitted for Resident 14's and Resident 19's new mental health diagnosis and medications.This deficient practice placed Resident 14 and Resident 19 at risk of not receiving necessary care and services needed for mental illness or developmental disability. Findings:During a review of Resident 14's admission Record, the admission Record indicated the facility admitted Resident 14 on 3/30/2018 and was readmitted on [DATE] with diagnoses including bipolar disorder (mood swings that range from the lows of depression to elevated periods of emotional high) and anxiety disorder…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a person-centered care plan was implemented for two of four sampled residents (Resident 17 and Resident 1) when:a. Resident 17 who was receiving a psychotropic medication (a medication that alters chemical levels in the brain, affecting mood, perception, thoughts, and behavior). b. addressing Resident 1's arteriovenous (AV) (connection or interaction between arteries and veins) shunt (a direct connection between an artery and a vein, bypassing the capillary network, which can be natural or surgically created for medical access).These deficient practices had the potential to negatively affect the quality of life and wellbeing for Resident 17 and Resident 1 to prevent them from achieving their highest practical well-being. Findings: a. During a review of Resident 17's admission Record, the admission Record indicated Resident 17 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including diabetes mellitus…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility failed to ensure adequate supervision to prevent one of one sampled resident (Resident 27) from accessing and consuming food from another resident (Resident 25).This failure had the potential to result in choking, allergic reaction, consumption of food inconsistent with the resident's prescribed diet and exposure to contaminated food.Findings:During a review of Resident 27's admission Record, the admission Record indicated the facility admitted Resident 27 on 12/9/2024 and readmitted on [DATE] with diagnoses including metabolic encephalopathy (any damage or disease that affects the brain), dysphagia (difficulty swallowing) and respiratory failure (any condition that affects breathing function and results in lungs not functioning properly).During a review of Resident 27's History and Physical (H&P), dated 3/13/2026, the H&P indicated, Resident 27 did not have ability for medical decision making. During a review of Resident 27's Minimum Data Set (MDS- a resident assessment tool), dated 3/17/2026, 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 proper catheter management for three of three sampled residents (Resident 10, 50, and 184) with an indwelling catheter (flexible tube inserted into the bladder to drain urine) by failing to: a. Clean the catheter, assess urine for signs and symptoms of infection, and monitor the urine output for Resident 10 and 184. b. Ensure Resident 50 had an order for a suprapubic catheter (a tube inserted through the lower abdomen directly into the bladder to drain urine) and monitoring for a urinary tract infection ([UTI]- an infection in the bladder/urinary tract) were in place.These deficient practices had the potential for the residents to develop an UTI and result in fever, pain or blood in the urine.Findings: a. During a review of Resident 10's admission record, the admission record indicated Resident 10 was admitted to the facility on [DATE] with a diagnoses including hydronephrosis (swelling of one or both kidneys) with ureteropelvic junction…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 three of three hemodialysis ([HD]a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) residents (Resident 1, 6, and 103) with dialysis care and services consistent with standards of practice when the facility failed to:a. Ensure a blood pressure (measures the force in arteries when heart beats and rests) reading was not obtained on Resident 6 and 103's left upper extremity where the arteriovenous (AV) shunt (a direct connection between an artery and a vein, bypassing the capillary network, which can be natural or surgically created for medical access) was located. b. Notify the physician on 2/17/2026 and 2/19/2026, educate Resident 6 regarding risk for missing HD, call the Dialysis center to reschedule the dialysis, and monitor Resident 6 for complications after Resident 6 missed HD.c. Ensure Resident 1's AV shunt on the right upper extremity was assessed,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that one (1) expired medication, fluticasone furoate Ellipta (a once-daily inhaled corticosteroid used for long-term maintenance treatment of asthma, which lowers swelling and helps the body fight inflammation) oral inhaler was not stored in one out of four (4) sampled medication carts (Medcart) 2A on Station 2 and administered to a resident (Resident 79) two times after expiration on [DATE] and [DATE]. These deficient practices had the potential for loss of potency of the medication and for Resident 79 to receive ineffective medication necessary to help maintain and/or improve the resident's breathing.Findings:During a review of Resident 79's admission Record, the admission Record indicated the facility admitted Resident 79 on [DATE] and readmitted on [DATE] with diagnoses including Asthma (a chronic condition where the airways become inflamed and narrow, making it hard to breathe), Chronic Obstructive Pulmonary Disease (COPD, a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow up on a recommendation for an ultrasound ([US] equipment used to produce high-frequency sound waves that travel deep into tissue and create therapeutic heat) of the right thyroid nodule ( unusual lump (growth) of cells on your thyroid gland [produces hormones and regulate metabolism, energy levels, growth]) for diagnostic testing for one of seven sampled residents (Resident 101).This deficient practice had the potential to delay necessary care and services.Findings:During a review of Resident 101's admission Record, the admission Record indicated Resident 101 was originally admitted to the facility on [DATE] and was admitted on [DATE] with diagnoses including spondylosis with myelopathy in the cervical region (progressive spinal cord dysfunction caused by chronic, age-related degeneration that compresses the spinal cord in the neck), disorder of bone density and structure, and osteoarthritis (a progressive disorder of the joints, caused by a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of seven sampled residents (Resident 101) received Restorative Nursing Assistant ([RNA] promotes a resident's ability to adapt and adjust to living independently and safely) services as ordered by the physician.This deficient practice had the potential to delay treatment and services for Resident 101 and placed Resident 101 at higher risk for further decline and weakness.Findings:During a review of Resident 101's admission Record, the admission Record indicated Resident 101 was originally admitted to the facility on [DATE] and was admitted on [DATE] with diagnoses including spondylosis with myelopathy in the cervical region (progressive spinal cord dysfunction caused by chronic, age-related degeneration that compresses the spinal cord in the neck), disorder of bone density and structure, and osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage) in the left and right hand.During a review of Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to obtain consent for an arbitration agreement (legally binding contract where parties agree to resolve disputes through a private arbitrator rather than a public court trial) from the resident representative for one of three sampled residents (Resident 19), who did not have the capacity to make decisions.This failure had the potential to result in the resident signing a legal binding agreement while not comprehending his/her right to access court remedies. During a review of Resident 19's admission Record, the admission Record indicated the facility admitted Resident 19 on 11/14/2001 and was re-admitted on [DATE] with diagnoses including metabolic encephalopathy (brain dysfunction caused by chemical imbalances).During a review of Resident 19's Minimum Data Set (MDS - a resident assessment tool), dated 10/30/2024, the MDS indicated Resident 19's cognition (ability to think) was severely impaired. The MDS indicated Resident 19 ability to understand others…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 and Performance Improvement (QAPI) Committee failed to identify and implement corrective action of systemic problems identified thereby affecting 173 of 173 residents by failing to:a. Ensure person-centered care plan was initiated and implemented for every resident in the facility.b. Ensure the Preadmission Screening and Resident Review ([PASARR], a federal assessment requirement to help ensure that individuals who have a mental disorder or intellectual disabilities are placed in facilities that can provide the appropriate care) was done in a timely manner. c. Ensure the Minimum Data Set ([MDS], resident assessment tool) was accurate according to the residents' needs and services.The deficient practices placed the residents at risk of not receiving the quality treatment necessary to adequately meet their highest practicable well-being.Findings: During an interview on 4/9/2026 at 4:50 p.m., with the Administrator (ADM), the ADM stated the following systemic issues identified were not identified by the QAPI…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement infection control policies and procedure (P&P) when:a. The facility failed to provide documented evidence of 32 out of 32 licensed practitioners, Annual Influenza ([Flu] highly contagious respiratory infection) vaccine (medications used to prevent diseases usually given by injection or by mouth) status and the provision of education on benefits and potential side effects and offering of the 2025 to 2026 flu vaccine. b. The facility failed to ensure Licensed Vocational Nurse (LVN) 1 wore personal protective equipment ([PPE] clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments) when touching Resident 114's gastrostomy tube ([G-tube] a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems), not disconnecting Resident 114's tube feeding from the g-tube when it was turned off, and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the licensed nurses documented vital signs and nursing interventions when a resident (Resident 1) was coughing up blood, for one of four sampled residents (Resident 1). This deficient practice resulted in missing documentation indicating care that was given to Resident 1 and had the potential for Resident 1's progress during a change of condition to be undetermined and/or unidentified and the provision and/or escalation of his care to be delayed.Findings:During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including cerebrovascular disease (a condition that interfere with blood flow to the brain, which can lead to problems like stroke or brain damage) and seizures (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness).During a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) who had poor safety awareness (a resident's inability to recognize physical dangers and follow safety instructions, which puts them at risk for injury - especially during mobility and self-care activities), a history of a falls, and was a moderate risk for falls, was supervised by the nursing staff while seated in her wheelchair. The facility failed to:1. Ensure the nursing staff promptly provided redirection and cueing (the use of verbal, visual, or tactile prompts to guide a resident's behavior or actions in a safe and appropriate manner) to prevent Resident 1 from getting up from her wheelchair unattended.2. Ensure the nursing staff followed the facility's Policy and Procedure (P&P) titled, Safety and Supervision of Resident, indicating the importance of ensuring interventions are implemented correctly and consistently.This deficient practice resulted in Resident 1 getting up from her wheelchair 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.

Based on interview and record review, the facility failed to follow up on a podiatry consultation referral for one of three sampled residents (Resident 1). This failure had the potential to result in a delay in delivery of care and services, and risk for skin breakdown and infection for Resident 1. Findings:During a review of Resident 1's admission record, the admission record indicated the facility admitted Resident 1 on 2/18/2025 with diagnoses including Type 2 diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing) and dependence on renal dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidneys have failed).During a review of Resident 1's History and Physical (H&P), dated 4/08/2025, the H&P indicated Resident 1 had no capacity to understand and make decisions.During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 8/15/2025, the MDS indicated Resident 1 had moderately impaired cognitive skills (ability to learn, reason, remember,…

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

Based on observation, interview and record review, the facility failed to provide one of three sampled residents (Resident 2) with meals that accommodated the resident's food preferences. This failure had the potential to result in decreased meal intake and malnutrition. Findings:During a review of Resident 2's admission Record, the admission Record indicated the facility admitted the resident on 2/26/2025 with diagnoses including hyperlipidemia (a condition characterized by high levels of lipids in the blood including cholesterol and triglycerides) and type 2 diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 2's History and Physical (H&P), dated 2/27/2025, the H&P indicated, Resident 2 has the capacity to understand and make decisions. During a review of Resident 2's Minimum Data Set (MDS, a resident assessment tool) dated 6/5/2025, the MDS indicated Resident 2 had moderate cognitive (ability to think, understand and make decisions) impairment and was independent with eating and required 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 notify one of eight sampled residents (Resident 7's) physician when Resident 7 was observed with multiple open sores on her hands on 7/8/25.This failure had the potential for delayed treatment on Resident 7 multiple open sores and placed Resident 7 at risk for wound infection.Findings:During a review of Resident 7's admission Record dated 7/10/25, the admission Record indicated Resident 7 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including rheumatoid arthritis (a chronic progressive disease-causing inflammation in the joints and resulting in painful deformity and immobility), communication deficit and encephalopathy (disturbance of brain function causing confusion and memory loss).During a review of Resident 7's History and Physical (H&P) dated 2/17/25, the H&P indicated Resident 7 could make needs known but cannot make medical decisions.During a review of Resident 7's Minimum Data Set (MDS - a resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure the Minimum Data Set (MDS - a resident assessment tool) accurately reflects used of antipsychotic (medications- affecting the chemical messengers in the brain) medications for one of three sampled residents' (Resident 4) This deficient practice had the potential to negatively affect Resident 4's plan of care and delivery of services.Findings:During a review of Resident 4's admission Record dated 7/10/25, the admission Record indicated Resident 4 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including encephalopathy (disturbance of brain function causing confusion and memory loss), diabetes mellitus type 2 (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), and depression (mood disorder characterized by persistent sadness, with loss of interest in activities).During a review of Resident 4's Minimum Data Set (MDS - a resident assessment tool) dated 6/5/2025, The MDS indicated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure resident who was assessed at risk for falls, had the resident care plan revised to include the use of non-skid socks for one of three sampled residents ( Resident 2). This deficient practice had the potential to increase the risk of a fall for Resident 2.Findings:During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including right femur (thigh bone) fracture (broken bone), dementia (a progressive state of decline in mental abilities) and history of falling.During a review of Resident 2's History and Physical (H&P) dated 6/10/25, the H&P indicated Resident 2 had fluctuating capacity to understand and make decisions.During a review of Resident 2's Minimum Data Set (MDS - a resident assessment tool) dated 7/15/25, the MDS indicated Resident 2 had severe cognitive (ability to think, understand, learn, and remember) 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure one of three sampled residents (Resident 1's) who was on Enhanced Barrier precautions (EBP- infection control measures to reduce the spread of multidrug-resistant organisms (MDRO's) for the use of a midline (a long peripheral catheter inserted into a vein) was implemented when toileting Resident 1.This deficient practice placed Resident 1 at risk for possible worsening of her infection. Findings:During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including, hypertension (high blood pressure), communication deficit and metabolic encephalopathy (disturbance of brain function causing confusion and memory loss).During a review of Resident 1's History and Physical (H&P) dated 6/28/25, the H&P indicated Resident 1 had the capacity to understand and make decisions.During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to ensure residents medical records were up to date as per the facility's policy and procedure (P&P) titled,Advance Directive, revised 2/2025, regarding Advance Directives ([AD], a legal document indicating resident preference on end-of-life treatment decisions) for two of six sampled residents (Resident 530). This deficient practice violated the residents' rights to be fully inform of the option to formulate an AD and had the potential to cause conflict with the residents' wishes regarding health care in the event residents became incapacitated (unable to participate in a meaningful way in medical decisions) or unable to make medical decisions that would not be identified and/or carried out by the facility staff. Findings: During a review of Resident 530's admission Record, the admission Record indicated Resident 530 was admitted to the facility on [DATE] with diagnoses including metabolic encephalopathy (a condition where the brain's function is…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement recommendations from the Level II Preadmission Screening and Resident Review (PASARR - a federal assessment requirement to help ensure that individuals who have a mental disorder or intellectual disabilities are placed in facilities that can provide the appropriate care) for one of six sampled residents (Resident 140). This deficient practice had the potential to negatively affect Resident 140's plan of care and delivery of necessary care and services. Findings: During a review of Resident 140's admission record, the admission record indicated Resident 140 was initially admitted to the facility on [DATE] and readmitted on [DATE] with the diagnosis of unspecified psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality). During a review of Resident 140's MDS, dated [DATE], the MDS indicated had cognition (ability to learn, reason, remember, understand, and make decisions) 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 follow through with the Preadmission Screening and Resident Review (PASRR- a federally mandated program ensuring individuals with mental illness, intellectual/developmental disabilities, or related conditions receive appropriate placement and services) recommendation to obtain a PASARR level II evaluation for one of three sampled residents (Resident 25). This deficient practice had the potential to result in an inappropriate placement and delay of the resident's needed services. Findings: During a review of Resident 25's admission Record, the admission Records indicated Resident 25 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including paranoid schizophrenia (a mental illness that is characterized by disturbances in thought), bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), schizoaffective disorder (a mental…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to: 1. Implment the interventions in Resident 55's care plan to monitor, and document the effectiveness and side effects of seizure medications he was receiving. 2. Develop a comprehesive care plan for Resident 530 a comprehensive care plan for a bed sensor alarm (alarm that triggers if the resident tries to get out of bed) that was placed in her bed. 3. Develop a baseline care plan for a psychotropic (medication that affects the brain)medication for Resident 427. 4. provide bilateral bed bolsters (a long narrow pillow or cushion used to improve bed safety without the use of side rails, preventing patients from rolling too far to the left or right) as indicated in Resident 43's untitled care plan for Falls. 5. ensure Resident 43's head of bed (HOB) was elevated at least 30 degrees as indicated in Resident 43's untitled care plan for enteral nutrition (TF): at risk for complications related to aspiration. 6. ensure implementing fall prevention…

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

Based on observations, interviews, and record review, the facility: 1. Failed to ensure there was documentation on the usage of an Emergency kit (E-Kit, a kit containing a small amount of medication that can be dispensed when the pharmacy services are not available) on a designated log. 2. Failed to receive and review daily activity and discrepancy reports of the Cubex (a computerized system that stores, dispenses, and tracks medications in a healthcare setting) since 10/13/24, or for at least 4 months. These deficient practices had the potential for medication errors, loss and/or diversion (transfer of medication from a lawful to an unlawful channel of distribution or use) of medications. Findings: 1. During an observation on 3/4/25 at 12:16 PM in the medication room at nursing station 4, the surveyor asked to review the E-kit and the licensed vocational nurse (LVN 3) presented a binder. Inside this binder was a loose yellow slip dated 1/9/25 and pharmacy log forms filed according to the months of a year. During a concurrent interview and a review of the e-kit pharmacy log under…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 dental services were provided and followed up for two of five sampled residents (Resident 9 and Resident 113) as evidenced by: A. Failing to follow up and update Resident 9 and Responsible Party(RP) for the status of Resident 9's denture. B. Failing to follow up on recommended dental services (Resident 113). These failures had the potential to result in Resident 9 and Resident 113 having discomfort while eating or chewing foods that could lead to unintended weight loss and lower self-esteem. Findings: A. During a review of Resident 9's admission Record, the admission Record indicated, Resident 9 was initially admitted to the facility on [DATE] and last re-admission was on 10/28/2024 with diagnoses including dysphagia (difficulty swallowing) and dementia (a progressive state of decline in mental abilities). During a review of Resident 9's History and Physical (H&P), dated 10/28/2024, the H&P indicated, Resident 9 had fluctuating…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 530) had a call light that was within reach of the resident who was a high fall risk when the call light was observed on the floor out of reach for the resident. This failure had the potential for Resident 530 to feel frustrated when she could not summon help due to the call light not being within reach, her needs not being met and also delay of care and services. Findings: During a review of Resident 530's admission Record, the admission Record indicated Resident 530 was admitted to the facility on [DATE] with diagnoses including metabolic encephalopathy (a condition where the brain's function is impaired due to an underlying metabolic disturbance), respiratory failure (a serious medical condition where the lungs are unable to adequately exchange oxygen in the blood), end stage renal disease ([ESRD], irreversible kidney failure), and anxiety disorder (a group of mental health conditions…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 use of a bed alarm (an alarm with sensors that will alarm when a resident leave or attempt to leave their beds unassisted to help prevent falls by alerting staff) was assessed, monitored and documented for one of three sampled residents (Resident 165). This failure had the potential to result in Resident 165 inhibiting to have quality sleep and restrict the mobility. Findings: During a review of Resident 165's admission Record, the admission Record indicated, Resident 165 was admitted to the facility on [DATE] with diagnoses including dementia (a progressive state of decline in mental abilities), open angle glaucoma (an eye disease that causes slow, symptomless vision loss), and history of falling. During a review of Resident 165's History and Physical (H&P) dated 1/10/2025, the H&P indicated, Resident 165 had no capacity (ability) to understand and make decision. During a review of Resident 165's Minimum Data Set (MDS - a resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the Minimum Data Set (MDS-a resident assessment tool) was accurately documented for one of five sampled residents (Resident 140.) This deficient practice had the potential to negatively affect Resident 140's plan of care and delivery of necessary care and services. Findings: During a review of Resident 140's admission record, the admission record indicated Resident 140 was initially admitted to the facility on [DATE] and readmitted on [DATE] with the diagnoses including unspecified psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality). During a review of Resident 140's MDS, dated [DATE], the MDS indicated had cognition (ability to learn, reason, remember, understand, and make decisions) was moderately impaired and requires supervision for eating and moderate assistance (helper does less than half the effort) for toileting, bathing, and dressing. During a review of Resident 140'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 ensure one of six sampled residents (Resident 34) received quarterly Interdisciplinary Team (IDT - a group of medical professionals from different disciplines who work together to help a resident achieve their goals) meetings for one of six sampled residents (Resident 34). This deficient practice had the potential to result in Resident 34 not being informed of their care and have concerns addressed. Findings: During a review of Resident 34's admission record, the admission record indicated Resident 34 was admitted to the facility on [DATE] with the diagnosis of major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). During an interview on 03/03/25 11:23 a.m. with Resident 34 in their room, Resident 34 stated she did not know her plan of care and stated the staff did not tell her when she can leave. During a review of Resident 34's Minimum Data Set (MDS - a resident assessment tool), dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to follow professional standards of care and ensure one out of 16 sampled residents (Resident 43) who was receiving tube feeding (TF, delivers liquid nutrition through a flexible tube that goes directly into your stomach or small intestine) had the head of bed (HOB) elevated at least 30 degrees while TF was turned on. This deficient practice had the potential for Resident 43 to aspirate (accidental breathing in of food or fluid into the lungs). Findings: During a review of Resident 43's admission Record, the admission Record indicated Resident 43 was originally admitted to the facility 8/29/2023 and was readmitted on [DATE] with diagnoses of seizures (a sudden burst of abnormal electrical activity in the brain that can cause changes in movement, behavior, and consciousness), encounter for attention to gastrostomy (GT, an opening into the stomach from the abdominal wall, made surgically for the introduction of food), dysphagia (difficulty…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to ensure one of one sampled resident (Resident 77) was provided care and services to maintain good grooming and personal hygiene. This deficient practice had the potential to result in a negative impact on Resident 77's quality of life and self-esteem. During a review of Resident 77's admission record, the admission Record indicated Resident 77 was admitted to the facility on [DATE] with diagnoses including dementia (a progressive state of decline in mental abilities), cerebral infarction (blood flow to the brain is interrupted causing brain cells to die), and Type II Diabetes Mellitus (DM: a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 7's Minimum Data Set ([MDS] a resident assessment tool) dated 12/10/2024, the MDS indicated Resident 77's cognitive skills (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) were moderately…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure one out of three sampled residents (Resident 43) with history of falls, had bilateral bed bolsters (a long narrow pillow or cushion used to improve bed safety without the use of side rails, preventing patients from rolling too far to the left or right) in place as care planned and recommended by the interdisciplinary team (IDT, a group of health care professionals with various areas of expertise who work together toward the goals of their clients). This deficient practice has a potential for Resident 43 at risk for recurring falls and injury. Findings: During a review of Resident 43's admission Record, the admission Record indicated Resident 43 was originally admitted to the facility 8/29/2023 and was readmitted on [DATE] with diagnoses of other lack of coordination, hemiplegia (cannot move one side of the body) following cerebral infarction (stroke, a lack of blood flow to an area of the brain leading the brain cells to begin to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to monitor specific target behaviors for a psychotropic medication (any drug that affects brain activities associated with mental processes and behavior) for one of two sampled residents (Resident 427). This deficient practice had the potential to result in over use of an antipsychotic medication, without monitoring for the effectiveness and/or ineffective of the medication and can lead to adverse drug reactions. During a review of Resident 427's admission Record, the admission Record indicated Resident 427 was admitted to the facility on [DATE] with diagnoses including paranoid (pattern of behavior where a person feels distrustful and suspicious of other people) schizophrenia (a mental illness that is characterized by disturbances in thought), depressive episodes (persistent low mood, loss of interest or pleasure), and history of other mental and behavioral disorders (disruptive patterns of behavior that cause problems in daily life). 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 store food in a sanitary manner to prevent growth of microorganisms (an organism that can be seen only through a microscope) that could cause food borne illness (food poisoning: any illness resulting from the food spoilage of contaminated food, pathogenic bacteria, viruses, or parasites that contaminate food, as well as toxins) for 172 out of 186 total residents in the facility by not: A. Ensuring food Items were dated, labeled, and discarded before the used by date (expiration dates). B. Ensuring the temperature of a small freezer in dry storage was monitored and documented. C. Ensuring the proper level of the concentration of the quaternary ammonium in sanitization bucket was monitored and maintained. D. Ensuring Dietary Aid (DA) 1 took off her wristwatch that was not covered with gloves. These failures had the potential to affect residents and result in pathogen (germ) exposure and placed residents at risk for developing foodborne illness (food poisoning) with symptoms including upset stomach, stomach…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 implement infection control measures by failing to ensure Quality Assurance Nurse (QAN-a nurse who is evaluating nursing practices within an agency and recommending changes for improvement) 1 performed hand hygiene while she was checking lunch trays in dining room. This failure had the potential to result in compromised infection control measures to prevent the potential spread of infection among residents, staff, and visitors. Findings: During a concurrent observation and interview on 3/5/2025, at 12:12 p.m., with QAN 1 in dining room, QAN 1 was checking the residents' tray against the printed sheets of diet orders. QAN 1 pulled the tray out of the lunch tray cart, and she lifted the plate cover up to check the food items on the plate. QAN 1 noticed the metal closure part from the lunch cart was coming down and left side door was moving toward the center while she was checking the tray. QAN1 pushed the metal closure part up and turn to right side and pushed the door to the right side to open. After touching…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement the antibiotic stewardship program policy when the antibiotic (a substance used to kill bacteria and to treat infections) did not meet Loeb's or McGeer's Criteria (criteria used to determine appropriate use of antibiotics) for one of three sampled residents (Resident 164)for prescribed doxycycline (antibiotic used to treat bacterial infections. This deficient practice had the potential to increase antibiotic resistance and provide antibiotics unnecessarily. Findings: During a review of Resident 164's admission Record, the record indicated Resident 164 was admitted to the facility on [DATE] with diagnoses including hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (weakness or paralysis on one side of the body) following unspecified cerebral infarction (CVA-stroke, loss of blood flow to a part of the brain) affecting left non-dominant side and sepsis (a life-threatening blood infection).…

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

Based on interview and record review, the facility failed to provide documented evidence of facility employees' screening, education, offering, and current Corona virus disease, ([COVID-19] a contagious infectious disease), vaccination (medications used to prevent diseases usually given by injection or by mouth) status. This deficient practice had the potential to place the facility staff and residents at risk for outcomes such as severe pneumonia (inflammation of lungs that cause difficulty breathing) which could lead to hospitalization due to COVID-19. Findings: During an interview on 3/6/2025 at 11:14 a.m. with the Infection Prevention Nurse (IPN), the IPN stated she did not finish auditing the employee Covid-19 vaccination status and indicated she does not easily have access to Certified Nursing Assistant 1 (CNA 1)'s Covid-19 vaccination status and would have to look in her employee file. The IPN stated the facility would need to know everyone's vaccination status including activities staff, admissions staff, the Administrator (ADM), social services staff, CNA's, Licensed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 verbally confirm with five of five sampled resident ' s (Residents 1, 2, 3, 4 and 5) primary care physician (PCP) 1 that he was no longer returning to the facility and failed to follow their policy and procedure titled, Choice of Attending Physician, indicating the facility must inform the resident in writing of the name and contact information for his or her attending physician. This failure resulted in the residents being told that the physician was being changed to a new physician and interrupting the consistent continuity of care of the resident ' s previous physician. Findings: 1. During a review of Resident 1 ' s admission Record (Face Sheet), the face sheet indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis including vascular dementia (a progressive state of decline in mental disabilities), cerebral infarction (a type of stroke that occurs when an area of brain tissue dies due to lack…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 to ensure Licensed Vocational Nurse 1 (LVN 1) notified the physician and the Responsible Party (RP) for one out of three sampled residents (Resident 1) when Resident sustained an unwitnessed fall and complained of severe pain. This deficient practice resulted in Resident 1 being found on the floor after sustaining an unwitnessed fall, experiencing unrelieved pain for approximately two hours, and Resident 1 ' s RP and physician being unaware that Resident 1 fell, thus causing a delay in care and/or the inability for Resident 1 ' s physician to prescribe treatment and transfer for a higher level of care in a timely manner. Findings: During a review of Resident 1 ' s admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] with the diagnosis including history of a fall and subdural hemorrhage (a buildup of blood on the surface of the brain). During a review of Resident 1 ' s Nursing admission assessment dated [DATE],…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 to care of one of three sampled resident (Resident 1) who sustained an unwitnessed fall, by ensuring LVN 1 was in-serviced on fall assessment, prevention of falls and procedures following a fall, when their Fall Prevention in Long Term Care Part 1: Risk Assessment video was available in 9/2024. This deficient practice resulted in Resident 1 sustaining an unwitnessed fall and no one being aware that Resident 1 fell and/or was in pain, when LVN 1 did not conduct an initial assessment of Resident 1 following her fall, did not report to Resident 1 ' s physician, that Resident 1 fell in order to obtain instructions for care and pain management, did not report to the Registered Nurse Supervisor (RNS 1) or Resident 1 ' s Responsible Party (RP) following Resident 1 ' s fall and did not report the physical therapist ' s (PT 1) findings that Resident 1 was guarding her left leg and screaming during PT 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 ensure one of three residents (Resident 1) and/or their responsible party (RP), was informed of the resident ' s transfer to another facility. This failure resulted in violating the residents ' right to make an informed decision regarding the transfer to another facility. Findings: During a record review of Resident 1 ' s admission Record, the admission Record indicated Resident 1 was admitted on [DATE] to the facility with diagnoses including dementia (loss of cognitive functioning such as thinking, remembering, and reasoning which can affect and interfere with daily life and activities), cerebral infarction (an interruption in the flow of blood to cells in the brain), and mental and behavioral disorders (affect the way you think and behave). During a record review of Resident 1 ' s Minimum Data Set (MDS- standardized screening tool) dated 8/7/2024, the MDS indicated Resident 1 ' s cognitive (the ability to think, reason, and understood) skills for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure an injury of unknown origin was reported to the California Department of Public Health (CDPH) for one of six sampled residents (Resident 1) when Resident 1 sustained a fracture (a break in a bone) of the distal right femur (the area of the leg and/or thigh just above the knee joint). This deficient practice resulted in the inability of CDPH to investigate Resident 1's femur fracture in a timely manner and had the potential for facts related to the injury to be forgotten by staff. Findings: During a review of Resident 1's admission Record (Face sheet), the Face Sheet indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses including cerebral infarction ([also known as stroke] a loss of oxygen to the area of the brain resulting in damage to the brain tissue) and encephalopathy (a condition of brain dysfunction as a result of infection, exposure to toxins and other body condition that causes…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 an injury of unknown origin was thoroughly investigated and the conclusion to their investigation reported to the California Department of Public Health (CDPH) for one of six sampled residents (Resident 1) when Resident 1 sustained a fracture (a break in a bone) of the distal right femur (the area of the leg and/or thigh just above the knee joint). This deficient practice resulted in the facility's inability to determine the cause of Resident 1's femur fracture and had the potential for other injuries to occur. Findings: During a review of Resident 1's admission Record (Face sheet), the Face Sheet indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses including cerebral infarction ([also known as stroke] a loss of oxygen to the area of the brain resulting in damage to the brain tissue) and encephalopathy (a condition of brain dysfunction as a result of infection, exposure to toxins and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of six Certified Nursing Assistants (CNA) 3 had an active State-approved CNA license while providing direct care to residents. This deficient practice had the potential for knowledge and training deficit leading to inadequate resident care. Findings: During a concurrent interview and record review on [DATE] at 1:10 p.m. with CNA 3, the Nursing Staffing Assignment and Sign-In Sheets, were reviewed. The Nursing Staffing Assignment and Sign-In Sheets dated [DATE], [DATE], [DATE], [DATE] and [DATE] had CNA 3's signatures which indicated CNA 3 was assigned to provide direct care to residents. CNA 3 stated she provided direct care to residents on [DATE], [DATE], [DATE], and [DATE] from 7:00 a.m. to 3:30 p.m. and on [DATE] from 7:00 a.m. to 9:00 a.m. CNA 3 stated she applied for the CNA license renewal before the expiration date, [DATE], however became aware the application for the CNA license renewal was not approved on [DATE] when CNA 3 read a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to notify the physician for three of six sampled residents (Residents 1, 2 and 3), when Resident 1, who was prescribed Clonazepam (a control medication in schedule IV [group of medicines has been associated with abuse, misuse and diversion] used to treat anxiety, panic attacks and seizures) for anxiety disorder (excessive worry and feelings of fear, dread, and uneasiness) manifested by severe panic and agitation that interfered with care, did not receive 23 doses of Clonazepam from 3/28/2024 through 4/14/2024, when Resident 2, who was prescribed Risperdal (a medication used to treat schizophrenia, and bipolar disorder) manifested by aggression that may interfere with needed care, did not receive four doses of Risperdal from 4/3/2024 through 4/8/202 and when Resident 3, who was prescribed Seroquel (a medication used to treat schizophrenia, bipolar disorder, and depression), for aggression which causes interference with needed care, missed five doses 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 storage and distribution of food was done under sanitary and safe conditions for all residents in the facility by failing to: 1.Ensure an employee's water bottle was not stored in the residents' refrigerator in the kitchen. 2.Ensure boxes delivered with resident food were not stored on the floor in the kitchen. These deficient practices had the potential to result in pathogen (germs) exposure to resident and placed residents at risk for developing foodborne illness (illness resulting from contaminated foods, pathogenic bacteria, viruses, or parasites that contaminate food). During an observation and interview on the initial tour on 3/19/2024 at 8:22 a.m. in the facility kitchen, there was an employee's water bottle stored in the designated resident's freezer and boxes of frozen foods delivered to the facility were placed on the floor in the dry storage area of the kitchen prior to being placed in the freezer. During a concurrent observation and interview on 3/19/2024 at 8:24 a.m., in the kitchen with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide care and reasonable accommodations in a manner that maintained or enhanced a resident's dignity and respect in full recognition of their individuality by: A. Failing to place the call light within reach for Resident 92. B. Failing to place the call light within reach for Resident 4. C. Failing to speak with respectable manner to Resident 69. D. Failing to provide Resident 117 with a working call light. E. Failing to change Resident 117 in a timely manner after being left wet in urine for hours. These failures resulted in Resident 92, 4, 69 and 117 feeling a lack of self-determination to make decisions, a loss of dignity and self-esteem, reasonable accommodations and the ability to call for staff when assistance is needed for activities of daily living ([ADLs] daily living are activities related to personal care, including bathing or showering, dressing, getting in and out of bed or a chair, walking, using the toilet, and eating).…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow through and accurately assess with the Preadmission Screening and Resident Review (PASARR- a comprehensive evaluation that ensures people who have been diagnosed with serious mental illness, intellectual, and/or developmental disabilities are able to live in the most independent settings while receiving the recommended care and interventions to improve their quality of life) level I and level II evaluation for three of four sampled residents (Resident 72, Resident 4, and Resident 92) to determine the facility's ability to provide the special need of the residents. This deficient practice placed Resident 40 and Resident 37 at risk of not receiving the necessary care and services they need. Findings: A. During a review of Resident 72's admission Record, the admission Record indicated, Resident 72 was initially admitted to the facility on [DATE] and last admission was 6/2/2022 with diagnoses including Schizophrenia (a serious mental illness that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to: a.Maintain proper storage of drugs and medical equipment used in the provision of care to residents. The facility failed to ensure medications were properly labeled with the opened-on date. This deficient practice had the potential for medications to be administered past the recommended dates rendering them ineffective or potential for negative side effects. b. Ensure medications were secure and inaccessible to unauthorized staff and residents. This deficient practice had the potential for residents, staff and visitors to have access and can ingest medications that could cause clinically significant adverse consequences necessitating hospitalization to stabilize. Findings: During an observation on 3/21/2024 at 9:11 A.M., in station 2B medication cart, with Licensed Vocational Nurse (LVN) 9, the medication cart contained the following medications and vials indicated that were not labeled with the initial open date; a.one package of…

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

Based on interview and record review, the facility's Quality Assessment and Assurance ([QAA] a group which develops and implements appropriate plans of action to correct identified quality deficiencies) committee and Quality Assurance Performance Improvement ([QAPI] a group who takes a systemic, interdisciplinary, comprehensive, and data driven approach to maintaining and improving safety and quality in nursing homes while involving residents and families, and all nursing home caregivers in practical and creative problem solving) committee failed to discuss findings for trends, analysis and recommendations regarding residents' pain management according to the facility's recent re-recertification survey's (3/26/2024) plan of correction. This deficient practice placed the facility at risk to have repeated deficiencies in pain management and potential negative outcomes for residents. Findings: During a review of the facility's QAPI meeting minutes dated 4/16/2024, the meeting minutes indicated no information regarding trends and findings concerning residents' pain management. During a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to observe and practice infection control measures by failing to: A. Ensure Resident 325 's nasal cannula's prongs ( small flexible tube that contains two open prongs intended to sit on the nostril to deliver oxygen) did not touch the floor before applying it to the resident. B. Observe contact isolation precaution (precautions used for disease, germs and infection that are spread by touching the patient and items in the room) during mealtime for Resident 323. C. Prevent, identify, and assess Resident 5, Resident 110, and Resident 269 for scabies( contagious, itchy skin rash caused by a tiny burrowing mite and can spread quickly through close person-to-person contact) D. Ensure Resident 269 who was re-admitted from the General Acute Care Hospital (GACH) with scabies was isolated from other residents. E. Ensure to follow Scabies Outbreak guidelines as indicated in the facility policy and procedure (P&P). These failures had the potential to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 162) had a completed acknowledgement of advance directives and Physician Orders for Life-Sustaining Treatment (POLST- a medical order that helps give people with serious illness more control over their care during a medical emergency) in their medical records. These failures had the potential for delay of care and treatment or inadvertently missed health care wishes or decisions of the residents during emergency, end of life, and changes in condition. Findings: During a review of Resident 162's admission Record, the admission Record indicated, Resident 162 was initially admitted to the facility on [DATE] and last re-admission was on 3/12/2024 with diagnosis including cerebral infarction (a loss of blood flow to part of the brain), schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves), epilepsy (a sudden, uncontrolled burst of electrical activity in the brain), 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.

Based on interview and record review, the facility failed to investigate and include a summary of pertinent findings of the investigation for one of one sampled resident (Resident 1) when Resident 1 filed a grievance on 5/13/2024 regarding a Certified Nursing Assistant (CNA) 1 on the night shift. This deficient practice violated Resident 1's right to have his grievance investigated. Findings: During a review of Resident 1's admission Record, the record indicated an admission date of 1/11/2024 with the diagnosis including osteomyelitis (infection in the bone). During a review of Resident 1's Minimum Data Set ([MDS]- a standardized assessment and care screening tool) dated 4/18/2024, 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. The MDS indicated Resident 1 was dependent (helper does all the effort and resident does none of the effort to complete the activity) on facility staff for activities of daily living (ADLs- such as toileting and showering). 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.

Based on interview and record review, the facility to report an allegation of abuse to the California Department of Health ([CDPH] the state department responsible for public health in California) within 24 hours, implement the facility's abuse prevention policy and failed to report the results of the abuse investigation within 5 days for one of eight sampled residents (Resident 270). These failures placed Resident 270 at risk for further abuse and had the potential to cause feelings of intimidation, neglect and not feeling safe in the facility which is considered their home. Findings: During initial tour on 3/19/2024, during the facility recertification survey, Resident 270 reported that Certified Nurse Assistant (CNA) 8 hit her on the shoulder last night on 3/18/2024 around 9:45 p.m., and she reported to the licensed nurse, but nothing was done. During a review of Resident 270's admission Record, the admission Record indicated Resident 270 was admitted to the facility with diagnoses of major depressive disorder (mood disorder that causes a persistent feeling of sadness and loss of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure the resident, who was a wanderer (a person who walks around aimlessly) and was assessed as a moderate risk for falls, did not sustained right hip fracture (process of breaking or the state of being broken) of the unknow source for one of eight sampled residents (Resident 153). The facility failed to investigate the source of Resident 153's right hip pain to rule out possible abuse. This deficient practice resulted in the cause of Resident 153's right hip fracture and having requiring surgery on 3/12/2024 for a right hip arthroplasty (removal of a broken bone and/or cartilage and replaced with prosthetic components) not being investigated for an injury possibly caused by abuse. Findings: During a concurrent observation and interview on 3/19/2024 at 11:32 a.m., Resident 153 was observed lying in bed on her left side and yelling for help. Resident 153 was observed having uncovered right hip incision with 23 staples without a surgical…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 foot care on one of six sample residents(Resident 61) by : 1. Failing to check and monitor if a podiatry service is needed for Resident 61's toenails who had thick and overgrown toenails. This failure had the potential to cause discomfort and for Resident 61's toenails to cut into the skin due their length. Findings: During a record review of Resident 61's admission Record, the admission Record indicated the resident was admitted on [DATE] to facility with diagnoses that included diabetes (too much sugar in the blood), unspecified osteoarthritis (degenerative joint disease in which the tissues in the joint break down overtime), and difficulty in walking. During a record review of Resident 61's History and Physical (H and P) dated 12/23/2023, the H and P indicated the resident had the capacity to make decision. During a record review of Minimum Data Set ([MDS] standardized screening tool) dated 1/7/2024, the MDS indicated the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure one of one five sampled residents (Resident 138) who received hemodialysis (a medical procedure to remove fluid and waste products from the body) had an emergency kit at resident's bedside. This failure had the potential for delayed intervention during accidental bleeding on Resident 138. Findings: During a record review of Resident 138's admission Record, the admission Record indicated the resident was admitted on [DATE] to the facility with diagnoses that included end stage renal disease( ESRD, kidneys no longer support body's needs), dependence on renal dialysis ( a person is dependent on dialysis to remove fluids and waste products from the body) and bipolar disease (disorder associated with episodes of mood swings ranging from depressive low or manic highs). During a record review of Resident 138's Minimum Data Set ([MDS] standardized screening tool) dated 12/28/2023, the MDS indicated the resident had an intact cognition (…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of four nursing staff had the specific competency and skill necessary to care for 169 residents who had full code status ( if a person's heart stopped beating or stopped breathing all resuscitation procedures will be provided to keep them alive) by failing to: 1. Ensure Certified Nursing Assistant (CNA4) and Registered Nurse 1 (RN1) had Basic Life Support (BLS, training to equip healthcare professionals the necessary skills to respond to life-threatening or emergency situations) Certification. 2. Ensure that employees completed a skills competency checklist at the time of hire and annually. These failures had the potential for RN1, CNA 4, and CNA 3 unable to help residents in the facility who are in full code status during a life-threatening situation or when these skills are needed to be applied. Findings: During a record review of CNA 4 employment file, there was no documentation to indicate CNA 4 had taken the BLS course. During a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interview, and record review, the facility failed to ensure correct administration of medication as instructed by the manufacturer's label for medication to ensure it was free of significant medication error for one of four sampled residents (Resident 116). Resident 116, had a physicians order for Aspirin (medication used to prevent formation of blood clots) 81 milligrams (mg - a unit of measure of weight) chewable, the Licensed nurse (LVN) # did not follow the route of administration and rather administered the medication with five other different medication to Resident 116 to swallow together at the same time. This deficient practice had the potential to inhibit the correct absorption and effective functioning of the Asprin 81 mg used for prophylaxis (prevention) cerebrovascular accident (CVA - brain tissue damage due to a blood clot) for Resident 116. Findings: During a review of Resident 116's Face Sheet (admission record), the admission record indicated the resident was initially…

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

Based on observation, interview, and record review, the facility failed to provide a functioning call light for one of six sampled residents (Resident 152). This deficient practice had the potential to result in delay in meeting the resident's need for assistance and accidents. Findings: During a review of Resident 137's admission Record (face sheet), dated 10/9/2023, the admission Record indicated Resident 137 was admitted to the facility with diagnoses including Wernicke's encephalopathy (brain disorder that can cause confusion, incoordination, and weak or paralyzed eye muscles). During a review of Resident 137's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 3/29/2024, the MDS indicated Resident 137's cognitive (the ability to understand or to be understood by others) skills for daily decision making was intact. The MDS indicated Resident 137 required supervision and assistance from staff with dressing and personal hygiene. During an observation on 5/28/2024 at 1:45 p.m., in Resident 137's room, Resident 137 pressed the call light button, and 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 the resident, who had the right below the knee amputation ([BKA] a surgical removal of the area of the leg below the knee) surgical wound, did not develop a pressure injuries ([PI] localized areas of injury that occur when skin and underlying tissue are compressed from pressure) for one of three sampled residents (Resident 1). The facility failed to: 1.Provide care consistent with the facility policies and procedures (P/P) titled Skin assessment, best practice, Pressure Wounds/Skin breakdown clinical protocol, Comprehensive person-centered care plans, and Charting and Documentation and Resident 1 ' s untitled care plans for skin integrity initiated on 11/12/2023, and 11/14/2023 to prevent an avoidable pressure injury. 2. Ensure the licensed nurses conducted a weekly assessment and monitoring of Resident 1 ' s, right BKA surgical wound and documented its condition from 11/11/2023 through 2/9/2024. This deficient practice resulted in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure resident's rights were maintained for one of three sampled residents (Resident 1) when the facility failed to notify Resident 1 ' s Responsible Party (RP) and primary physician after the Treatment Nurse (TN) assessed a new skin ulcer on Resident 1 ' s right below the knee (BKA-surgical removal of leg below the knee) area on 2/9/2024 and required treatment by the facility ' s wound care consultant (WCC) physician, This deficient practice resulted in a violation of residents ' rights and prevented Resident 1 and Resident 1 ' s family from being involved in Resident 1 ' s plan of care. Findings : During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including type two diabetes mellitus (disease when body cannot control the amount of blood sugar in the body) with diabetic polyneuropathy (caused by diabetes, affects…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to revise and implement two of three sampled residents' (Resident 1 and Resident 2) care plans after a change of condition was assessed by the nursing staff. The facility failed to; 1. Revise Resident 1 ' s care plan after the Treatment Nurse (TN) 1 assessed a new skin ulcer on Resident 1 ' s right below the knee (BKA-surgical removal of leg below the knee) area on 2/9/2024 and required treatment by the facility ' s wound care consultant (WCC) physician. 2.Ensure the Interdisciplinary Team (IDT-Resident's health care team from different specialties) conducted a meeting to discuss and revise Resident 2 ' s care plans after Resident 2 ' s reported an unwitnessed fall on 2/14/2024. 3. Revise Resident 2 ' s care plan to include the use of a Four wheel walker (4WW-device that provides stability and support for residents who are unsteady when walking or standing) These deficient practices; 1.Had the potential to delay the needed care and services for Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to monitor for the effects of anticoagulants ( medication used to prevent blood from clotting) for one of three sampled residents (Resident 2), by failing to: 1. Thoroughly assess Resident 2 ' s skin for bruising (skin discoloration due to underlying leaking blood vessels) consistent with Resident 2 ' s care plans and physician orders. 2. Implement pharmacist (PharmD) recommendations during the monthly medication regimen review (MRR-review of medications in order to promote positive outcomes and minimize adverse consequences associated with medication) conducted on 2/5/2024. These deficient practices resulted in the following : 1.Resident 2's purplish skin discoloration on Resident 2 ' s left hip not being assessed timely and leading to a delay in care and services. 2.An approximate 30 day delay in the Director of Nursing (DON) informing Resident 2 ' s physician of the PharmD ' s recommendations to order necessary laboratory (Lab medical tests conducted…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of six sampled resident's (Residents 1) Quetiapine Fumarate (medication used to treat depression [a constant feeling of sadness and loss of interest]) was administered as prescribed. This deficient practice resulted in Resident 1 missing three doses of Quetiapine and had the potential for Resident 1 to exhibit behaviors from missed medications like trouble sleeping, nausea or vomiting. Findings: A review of Resident 1's admission Record (Face Sheet) indicated Resident 1 was admitted to the facility on [DATE], with diagnosis including schizoaffective disorder (a mental illness which can affect a person's thoughts, mood, and behavior) and major depressive disorder (a mood disorder which causes a persistent feeling of sadness and loss of interest). A review of Resident 1's History and Physical (H/P), dated 1/26/2024 indicated Resident 1 had the capacity to understand and make decisions. A review of Resident 1's Minimum Data Set ([MDS] a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure one of six sampled resident's (Residents 2) Escitalopram (medication used to treat depression [a constant feeling of sadness and loss of interest) bubble pack (packaging in which the medication is sealed between cardboard backing and clear plastic cover), containing 21 tablets, was not left on the nursing station counter accessible to staff, visitors, and residents. The deficient practice had the potential for Resident 2's Escitalopram tablets to be lost, stolen, and/or consumed by another resident, visitor, or staff. Findings: A review of Resident 2's admission Record (Face Sheet), indicated Resident 2 was admitted to the facility on [DATE] with diagnosis including bipolar disorder (a mental illness which causes unusual shifts in a person's mood, energy, activity levels, and concentration), anxiety, and schizophrenia (a disorder which affects a person's ability to think, feel, and behave clearly). A review of Resident 2's H&P,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to notify the physician for one of five sampled residents (Resident 4) that Resident 4 did not receive Tamiflu (generic name for Oseltamivir Phosphate an antiviral medication to treat and prevent flu or influenza [acute respiratory infection]) during an Influenza Outbreak as ordered. This failure resulted in Resident 4 not receiving prophylaxis flu treatment for two weeks and had the potential to put the resident's health in jeopardy. Findings: During a record review of Resident 4's Face Sheet (admission record), the Face Sheet indicated Resident 4 was initially admitted on [DATE] and readmitted on [DATE] with diagnosis including asthma (chronic lung disease that causes inflammation and muscle tightening around the airway), ventricular tachycardia (abnormal heart rhythm of heart that beats too fast), Type II Diabetes (condition that affects the way the body processes blood sugar), disorder involving the immune mechanism (inability for the body to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure Tamiflu (generic name for Oseltamivir Phosphate an antiviral medication to treat and prevent flu or influenza [acute respiratory infection])) for one of five sampled residents (Resident 4), during an Influenza Outbreak (OB), was readily available and administered as the physician ordered. This failure resulted in Resident 4 not receiving prophylaxis flu treatments for two weeks and had the potential to put the resident's health in jeopardy. Findings: During a record review of Resident 4's Face Sheet (admission record), the Face Sheet indicated Resident 4 was initially admitted on [DATE] and readmitted on [DATE] with diagnosis including asthma (chronic lung disease that causes inflammation and muscle tightening around the airway), ventricular tachycardia (abnormal heart rhythm of heart that beats too fast), Type II Diabetes (condition that affects the way the body processes blood sugar), disorder involving the immune mechanism (inability for the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement their Covid-19 (highly contagious respiratory infection) policy by: a. failing to test three out of three residents (Resident 3, 4 and 5) on days 3, and 5 (response testing-48 hours after the first negative test and, if negative, again 48 hours after the second negative test) per Centers of Disease Control (CDC) guidelines and guidance provided by Long Beach Public Health when their roommates (Resident 1 and 2) tested positive for Covid-19 on 11/10/2023. b. Failing to conduct response testing for facility staff when Resident 2 tested positive for COVID-19 on 11/10/2023. c. Failing to report the COVID-19 outbreak (a resident who has been in the facility more than seven days and tests positive for Covid-19) to the California Department of Public Health (CDPH) when Resident 2 tested positive for COVID -19 on 11/10/2023. These deficient practices had the potential to result in undiagnosed or delayed diagnosis of Covid-19 within the facility which…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 thoroughly investigate an alleged resident-to-resident altercation between two of two residents (Resident 1 and 2) on September 1, 2023, by failing to submit an accurate summary report of the investigation of the alleged abuse. The report inaccurately indicated Resident 1 did not have redness on the forehead and the report inaccurately indicated there was substantial space between their (Resident 1 and 2) beds which made it impossible for Resident 2 to hit Resident 1 with the bed remote. This deficient practice had the potential to result in unidentified abuse in the facility and the failure to protect residents from abuse. Findings: During a review of the Resident 1's admission record, the admission record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included to pulmonary hypertension (high blood pressure in the arteries that go from heart to lungs), cholelithiasis (gallstones [hardened deposits] in the…

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

Based on observation, interview, and record review, the facility failed to ensure : A. dietary staff (DS- cooks, CK1 and CK2) had the appropriate competencies to report one out of four freezers (freezer number 2) in the kitchen, when freezer number 2 was not working appropriately for four days. B. DS did not served food that was stored in the freezer (garlic toast and French toast) was served to the residents when the food items were thawed and not frozen. This deficient practice had the potential to result in decreased food quality and to result in pathogen (germ) exposure to residents and placed 160 out of 176 residents at risk for developing foodborne illness (food poisoning) with symptoms including upset stomach, stomach cramps, nausea, vomiting, diarrhea, and fever and can lead to other serious medical complications and hospitalization. Findings: During an observation on 8/4/2023 at 10:40 a.m., freezer number 2 ' s digital thermometer was alternating the temperature reading of 43 degrees F (acceptable freezer temp should be below 0 degrees F) and the word HI. Freezer number 2…

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

Based on observation, interview, and record review, the facility failed to ensure food was stored in a sanitary manner to prevent growth of microorganisms (bacteria, virus, or fungus that can only be seen under a microscope) that could cause food borne illness (food poisoning: any illness resulting from the food spoilage of contaminated food, pathogenic bacteria, viruses, or parasites that contaminate food, as well as toxins) for 160 out of the 176 residents in the facility by not: a. Ensuring a clear bucket filled with mixed vegetables in the walk-in refrigerator was labeled and dated. b. Ensuring freezer number two (2) was working and the temperature was at or below zero degrees Fahrenheit (F, unit of measurement) c. Ensuring food including, Garlic Bread with real garlic and French toast that was being stored in freezer number 2 while it was not functioning properly was not served to the facility ' s residents These deficient practices had the potential to result decreased food quality and to result in pathogen (germ) exposure to residents and placed residents at risk for…

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

Based on observation, interview, and record review, the facility failed to ensure one out of four freezers (freezer 2) in the kitchen was in proper working order. This deficient practice had the potential to effect food quality and placed residents at risk for developing foodborne illness (food poisoning) with symptoms including upset stomach, stomach cramps, nausea, vomiting, diarrhea, and fever which can lead to serious medical complications and hospitalization. Findings: During a record review of the facility ' s freezer temperature log (FTL) for freezer number 2 for dates 8/1/2023 to 8/4/2023, the FTL indicated acceptable temperature for freezer: 0 degrees F or below. The FTL indicated the following temperature readings: 1. 8/1/2023 morning (AM): 36 degrees F 2. 8/2/2023 AM: 38 degrees F 3. 8/3/2023 AM: 39 degrees F 4. 8/4/2023 AM: no temperature recorded During an observation on 8/4/2023 at 10:40 a.m., freezer number 2 ' s digital thermometer was alternating the temperature reading of 43 degrees F (acceptable freezer temp should be below 0 degrees F) and the word HI. Freezer…

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