The Beach Post-Acute

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, facility staff failed to provide implement post fall interventions for one of three sample residents (Resident 1). Facility failed to: 1. Ensure Resident 1's bed was maintained in the lowest position to help prevent additional falls. This deficient practice placed Resident 1, identified as a fall risk, at increased risk for further falls and potential injury. 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 hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body), hemiparesis ( a condition that causes partial paralysis or weakness on one side of the body) following intracranial hemorrhage (a bleeding inside the skull from a ruptured blood vessel ) affecting left dominant side. During a review of Resident 1's Minimum Data Set ([MDS] resident assessment tool), dated 11/24/2025, the MDS indicated Resident 1's had severe…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to ensure that one of three sampled residents (Resident 1) was treated with dignity and respect during personal care. Certified Nursing Assistant (CNA 1) used derogatory and offensive language toward Resident 1, including statements such as It smells bad and stinkyThis failure resulted in Resident 1 feeling humiliated, insulted, and emotionally distressed. The resident reported staying awake all night due to the incident on 11/29/2025.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 broken left leg, broken left wrist and generalized muscle weakness. During a review of Resident 1's History and Physical (H&P), dated 11/21/2025, the H&P indicated Resident 1 had the capacity to make decisions for herself. During a review of Resident 1's Minimum Data Set (MDS-a resident assessment tool), dated 11/26/2025, the MDS indicated Resident 1 had…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the following for two of five sampled residents (Resident 1 and Resident 5): 1. Failed to ensure Resident 1 did not develop a Moisture Associated Skin Damage (MASD: skin inflammation caused by prolonged exposure to various sources of moisture such as urine and stool) to her peri-area (region between the buttocks and female reproductive area). 2. Failed to ensure Resident 1's family was able to contact Resident 1 via telephone while residing in the facility. 3. Failed to address ongoing concerns expressed in written grievances for answering call lights for Resident 1 and Resident 5. A. During a review of Resident 1's admission Record (Face Sheet), the admission Record indicated Resident 1 was admitted to the facility 5/9/2025 with diagnoses including dislocation of right shoulder joint (two or more bones connect), injury of axillary (armpit) artery (major blood vessel in the upper limb that supplies blood to shoulder and arm put) on right side,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure one out of four sampled residents (Resident 2) received care and services to promote wound healing and to prevent worsening pressure injuries (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence) from occurring by failing to implement interventions such as a special low air-loss mattress (designed to prevent pressure injuries, treat pressure injuries) and vitamin supplements such as zinc (mineral that plays a crucial role in numerous bodily functions, including immune system support and wound healing), vitamin C (form protein called collagen to make skin and blood vessels), and a multivitamin (dietary supplement that provides foundational support for daily nutritional needs that is not taken through diet) to promote wound healing for Resident 2. This deficient practice resulted in Resident 2's sacrococcyx (fused bone structure that consist of the sacrum [triangular bone at the base of the spine]…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the physician and Responsible Party (RP) for one of four sampled residents (Resident 1), who had a history of gastrointestinal bleeding ([GI] bleeding anywhere in the digestive tract from the mouth to the rectum), anemia (when the blood doesn ' t have enough healthy red blood cells and hemoglobin [a protein in the red blood cells that carries oxygen) to carry oxygen all through the body], and a low hemoglobin, were notified when Resident 1 refused to have his blood drawn in order to obtain a Complete Blood Count ([CBC] a common blood test that measures red blood cells {specialized cells in the blood that play a crucial role in transporting oxygen throughout the body}, white blood cells {a type of blood cell that play a crucial role in the body ' s immune system}, platelets {a tiny disc shaped pieces of cells in the blood that help stop bleeding by forming clots [a mass of blood that forms when clot platelets, proteins, and cells stick together]…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 promptly identify and intervene to ensure Resident 1 received treatment and care in accordance with professional standards and their comprehensive person-centered care plan when two physician's orders for Stat (immediately) laboratory (lab) tests were not completed within the required time frame for one of four sampled residents (Resident 1), reviewed for gastrointestinal bleeding ([GI] bleeding anywhere in the digestive tract from the mouth to the rectum). The physician placed a STAT order for Complete Blood Count ([CBC] a common blood test that measures red blood cells {specialized cells in the blood that play a crucial role in transporting oxygen throughout the body}, white blood cells {a type of blood cell that play a crucial role in the body's immune system}, platelets {a tiny disc shaped pieces of cells in the blood that help stop bleeding by forming clots [a mass of blood that forms when clot platelets, proteins, and cells stick together] when 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 three out of three sampled residents, Residents 26,31 and 61 who were receiving hemodialysis (clinical purification of blood as a substitute for the normal function of the kidney) treatments had an emergency dialysis kits (supplies needed to use in an emergency) at bedside, to respond to a potential medical complication, such as bleeding. This failure had the potential to cause a delay in treatment in case of an emergency. Findings: During a review of Resident 61s admission Record, dated 1/10/2025, the admission record indicated, Resident 61 was readmitted to the facility on [DATE] with diagnoses including end stage renal disease (ESRD-irreversible kidney failure), dependence on renal dialysis and type 2 diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 61's Minimum Data Set (MDS - a resident assessment tool) dated 1/2/2025 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.

Based on observation interview and record review the facility failed to ensure a label of open date and use by dates were placed on an open bag of frozen pancakes and cinnamon rolls. This failure had the potential to expose residents to a food-borne illnesses (any illness resulting from eating contaminated/spoiled foods). Findings: During an observation 1/07/2025 at 8:10 a.m. in the kitchen freezer an open bag of pancakes and cinnamon rolls did not have a label of open date or use by date on the bag. During an interview on 1/7/2025 at 8:10 a.m., with the Dietary Supervisor (DS), the DS stated that there was not a label of open date or use by date on the open bag of pancakes or cinnamon rolls. DS stated there always needs to be label of open date and use by date on food after it has been opened to ensure the quality of the food was good and palatable for the residents. During an interview on 1/10/2025 at 2:34 p.m. with the Director of Nursing (DON), the DON stated all open food needs to have a label of open date and best by date to ensure the food was fresh. The DON stated there was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY During an interview and record review the facility failed to ensure one out of 18 sampled residents Resident 40 had an updated Pre-admission 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) to reflect Resident 40's medical condition. This failure had the potential to result in inappropriate placement and unidentified specialized services for Resident 40. Findings: During a review of Resident 40' s admission Record, dated 1/10/2025 the admission Record indicated, Resident 40 was admitted to the facility on [DATE] with diagnosis including psychoses (a severe mental condition in which thought, and emotions ae so affected that contact is lost with reality) and anxiety (emotion characterized by feelings of tension, worried thoughts). During a review of Resident 40's Minimum Data Set ({MDS}- a resident assessment tool) dated 12/26/25 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 provide daily wound care treatment and services for one of five sampled residents (Resident 41) per physician order. This failure had the potential for Resident 41 wound to worsen and delay wound healing. Findings: During a review of Resident 41's admission Record, the admission Record indicated Resident 41 was admitted to the facility on [DATE] with diagnoses including, gastrostomy tube (GT-surgical opening that allows for nutritional support or stomach drainage), chronic obstructive pulmonary disease ( COPD-is a chronic lung disease that causes breathing difficulties.), muscle weakness ( loss of muscle strength), pressure ulcer (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence) of the right heel. During a review of Resident 41's Minimum Data Set (a resident assessment tool) dated 11/8/2024 indicated Resident 41 was able to make self-understood, and able to understand others. 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 21 sampled residents (Resident 37), received the Restorative Nursing Assistant (RNA, certified nursing aide program that helps residents to maintain their function and joint mobility) program as recommended by the physical therapist (PT, licensed professional aimed in the restoration, maintenance, and promotion of optimal physical function) on 12/12/2024. This failure had the potential to result in range of motion [ROM, full movement potential of a joint (where two bones meet)] decline and contracture (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints). Findings: During a review of Resident 37's admission Record, the admission Record indicated Resident 37 was admitted to the facility on [DATE] with diagnoses including amputations a surgical procedure that removes a limb or part of a limb) of the left and right leg below the knee, muscle weakness,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 21 sampled residents (Resident 31) received a new upper and lower denture as recommended by Resident 31's dentist on 8/22/2024. This failure had the potential to result in the inability to effectively chew foods, weight loss, and low self-esteem. Findings: During a review of Resident 31's admission Record, the admission Record indicated, Resident 31 was admitted to the facility on [DATE] with diagnoses including diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), end stage renal disease (ESRD-irreversible kidney failure), dysphagia (difficulty swallowing), and severe protein calorie malnutrition (a condition where a person is severely deficient in both protein and calories). During a review of Resident 31's Order Summary Report, dated 7/1/2024, the Order Summary Report indicated, Resident 31 may have a dental consultation with follow up treatment as needed. 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 infection control measures by not ensuring Licensed Vocational Nurse (LVN) 2 and Certified Nursing Assistant (CNA) 2 perform hand hygiene for one out of five sample residents (Resident 41). This failure had the potential to result in cross contamination (the physical movement or transfer of harmful bacteria from one person, object, or place to another) and place the residents at risk for the spread of infection. Findings: During a review of Resident 41's admission Record, the admission Record indicated Resident 41 was admitted to the facility on [DATE] with diagnoses including, gastrostomy status (surgical opening that allows for nutritional support or stomach drainage), chronic obstructive pulmonary disease ( COPD-is a chronic lung disease that causes breathing difficulties.), muscle weakness ( loss of muscle strength), pressure ulcer (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement Antibiotic Stewardship Program (measures used by the facility to ensure antibiotics [drug to treat infection] are used only when necessary and appropriate) for one of 21 sampled residents (Resident 42). This failure had the potential to put Resident 42 at risk for antibiotic resistance (when bacteria change to resist antibiotics used to effectively treat them) and inappropriate use of antibiotic. Findings: During a review of Resident 42's admission Record, the admission Record indicated, Resident 42 was admitted to the facility on [DATE] with diagnoses including left temporomandibular joint disorder (a condition that affects the joint that connects the jaw to the [NAME] and causes pain and discomfort in the jaw, face, neck and shoulders.), muscle weakness and chronic viral hepatitis C (a lifelong liver infection caused by the hepatitis C virus). During a review of Resident 42's Physician Progress Notes History and Physical, dated 12/23/2024,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure two out of five sampled residents, Residents 42 and 71 were provided with education regarding the risk and benefits of refusing an influenza (Flu-a contagious respiratory illness), pneumonia (PNA-an infection of the lungs), Corona virus-19 (COVID 19 virus that causes fever and cough) vaccine (medication to prevent a particular disease). This failure violated the resident or responsible party's rights to make an informed decision and placed two residents at a higher risk of acquiring and transmitting the influenza, pneumonia and COVID19 to other vulnerable and immunocompromised (a weak immune system) residents in the facility. Findings: During a review of Resident 42's admission Record, dated 1/10/2025, the admission Record indicated, Resident 42 was admitted to the facility on [DATE] with diagnoses including hepatitis c (a viral infection of the liver that leads to illness and can be spread by contact with the contaminated blood), asthma (airways…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 care plan for one of four sampled residents (Resident 1) was revised when Resident 1 had two unwitnessed falls on 10/4/2024 and 10/12/24 and the fall risk assessments on 9/17/2024 and 10/14/2024 identified Resident 1 as high risk for falls. These deficient practices resulted in Resident 1 ' s third unwitnessed fall and subsequent injury on 10/17/2024, when Resident 1 was found on the floor with bleeding on the top of the right side of his head, and later at a General Acute Care Hospital (GACH) was assessed with a subdural hematoma (bleeding in the area between the brain and the skull 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 diagnosis including Parkinsonism (an umbrella term that refers to brain conditions that cause slowed movements, rigidity [stiffness] and tremors), osteoporosis (a condition in which bones become weak 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 residents have the right to be free from physical abuse for one of two sampled residents (Resident 1). This deficient practice resulted in Resident 2 hitting Resident 1 on the right knee twice. Findings: a. During a review of the Resident 1 ' s admission record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including pancytopenia (condition in which there is a significant reduction in the number of blood forming cells), hypertension (high blood pressure), heart failure (progressive heart disease affecting function of the heart), end stage renal disease (ESRD: chronic condition in which the kidneys lose the ability to remove waste and fluids), abnormalities of gait and mobility, and Type II Diabetes (diseases that affects the way the body processes blood sugar). During a review of Resident 1 ' s Minimum Data Set [(MDS) a standardized assessment and care screening tool], dated 7/5/2024, 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 initiate a person-centered base line care plan for one of two sampled residents (Resident 2) for a behavior of throwing water at her previous roommate. This deficient practice potentially led to Resident 2's agression not being addressed and escalating, compromising other residents' safety. Findings; During a review of the Resident 2 ' s Face Sheet, the Face Sheet indicated Resident 2 was admitted to the facility on [DATE] with diagnoses including hemiplegia (immobility of one side of the body) and hemiparesis (weakness on one side of the body), major depressive disorder (serious mental illness that affects how a person feels and acts), anxiety (unpleasant feeling of fear or uneasiness) disorder, and Type II Diabetes. During a review of Resident 2 ' s miminum data set (MDS-a standardized assesment and care screening tool) dated 7/11/2024, the MDS indicated Resident 2 ' s cognitive skills were intact. The MDS indicated Resident 2 was dependent 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 call light was answered in a timely manner for two of two sampled residents (Resident 2 and Resident 4). This deficient practice resulted in Resident 2 and Resident 4 sitting in their urine and feces for a long period of time and has the potential for Resident 2 and Resident 4 to feel embarrassed and humiliated. Findings: During a review of Resident 2 ' s admission Record, the admission Record indicated Resident 2 was admitted on [DATE] with diagnoses including diabetes mellitus type 2 (a condition in which the body fails to process glucose (sugar) correctly) depression (serious mental health condition that involves a persistent low mood or loss of interest in activities), and transient ischemic attack (blockage of blood flow to the brain) During a review of Resident 2 ' s Minimum Data Set (MDS comprehensive assessment and care screening tool), dated 6/12/ 2024, the MDS indicated Resident 2 was able to understand and make decisions. The MDS…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure two of two sampled Residents (Residents 2 and 5) and/or their Responsible Parties (RPs) were informed and/or provided a written notice when Resident 2 and 5's rooms were changed. These deficient practices resulted in Residents 2 and 5 and/or their RPs not being given the option to accept or decline the room change and being unaware of and not knowing why Resident 2 and 5's rooms were changed. Findings: a. During a review of Resident 2's admission Record (Face Sheet), the Face Sheet indicated Resident 2 was admitted to the facility on [DATE] with diagnosis including unspecified dementia (impaired ability to remember, think, or make decisions which interfere with doing everyday activities) and major depressive disorder ([MDD] a mood disorder which causes a persistent feeling of sadness and loss of interest). During a review of Resident 2's History and Physical (H/P) dated 7/22/2023, the H&P indicated Resident 2 could make his needs known but could…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 six of eight sampled residents (Residents 2, 3, 4, 7, 8 and 9) were not verbally abused by Resident 1 after the facility continued to allow residents to reside with Resident 1 despite having a history of threatening and harassing behavior's with his roommates. These deficient practices resulted in Residents 2, 3, 4, 7, 8, and Resident 9 being subjected to Resident 1's verbal abuse, bullying, harassment, and intimidating behavior. These deficient practices had the potential for other resident's admitted to Resident 1's room to suffer verbal abuse. Findings: a. During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] with diagnosis including paraplegia (a chronic [lasting for a long time or constantly recurring] condition which causes a loss of muscle function in the lower half of the body, including both legs), depression (a mental health condition which 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 report four allegations of resident to resident verbal abuse to the California Department of Public Health (CDPH), the State Long Term Care Ombudsman (a public advocate) and local law enforcement, within the regulated time frame of two hours for four of five sampled residents (Resident's 2, 4, 8, and 9). These deficient practices resulted in CDPH not being aware of the abuse allegations that occurred between 2/22/2024 and 8/1/2024 until 8/6/2024 and the inability to investigation the allegations. These deficient practices had the potential for pertinent information to be lost and/or forgotten, more allegations of abuse to go unreported. Findings: a. During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] with diagnosis including paraplegia (a chronic [lasting for a long time or constantly recurring] condition which causes a loss of muscle function in the lower half of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a care plan was developed for one sampled resident (Resident 1), who had a history of verbal abuse, threats, and harassment towards residents who were admitted in his room, to include not allowing admission of other residents to Resident 1's room. This deficient practice resulted in subjecting Residents 2, 3, 4, 8, and 9, who were admitted to Resident 1's room, to Resident 1's known and continued behavior of verbal abuse, threats, and harassment. Findings: a. During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] with diagnosis including paraplegia (a chronic [lasting for a long time or constantly recurring] condition which causes a loss of muscle function in the lower half of the body, including both legs), depression (a mental health condition which causes persistent feeling of sadness, and loss of interest in activities a person normally enjoys), and a…

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

Based on observation, interview and record review, the facility failed to ensure a medication cart (a movable piece of equipment used in healthcare facilities to store, transport, and dispense medicines, medical supplies, and emergency equipment), located on Station two was locked. This deficient practice resulted in unsecured medications and had the potential for resident's, visitors, and other unauthorized staff to access medications that were left unsecured and out of visual sight of the licensed nurse assigned to the medication cart, which could lead to theft, loss, and/or ingestion of medications not intended for resident's use. Findings: During an observation on 8/6/2024 at 12:11 p.m., on the Station two hallway, an unlocked and unattended medication cart was observed. During an interview on 8/6/2024 at 12:12 p.m., Licensed Vocational Nurse 1 (LVN 1) stated she forgot to lock the medication cart prior to stepping away from it. LVN 1 stated if the medication cart was left unlocked and unattended, everyone in the facility had access to the medications in the cart. During an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) was not verbally abused by a Certified Nursing Assistant (CNA 1), when CNA 1, during Resident 1's physical therapy ([PT] a branch of rehabilitative health that uses exercise and equipment to help patients improve their physical abilities) spoke to Resident 1 using a curse word in a loud, angry, and aggressive tone, in a foreign language that Resident 1 happened to understand. This deficient practice resulted in Resident 1's hurt feelings, because he (Resident 1) was making an effort to do the rehabilitation (a set of interventions designed to optimize functioning and reduce disability in individuals with health conditions) exercises and CNA 1 didn't have to curse at him. This deficient practice had the potential for other episodes of verbal abuse to occur. Findings: During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 3 was admitted to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a thorough investigation was conducted following two separate allegations of abuse by one sampled resident (Resident 1). This deficient practice resulted in the facility not identifying other potential residents who may have been affected by abuse and had the potential for the facility not to be able to determine if abuse actually occurred. 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 diagnosis including right hemiplegia (paralysis on one side of the body) and hemiparesis (weakness or inability to move on one side of the body) following a cerebral infarction ([stroke] damage to tissues in the brain due to a loss of oxygen). During a review of Resident 1's History and Physical (H&P) dated 3/22/2024, the H&P indicated Resident 1's cognition (thought process) was intact. During a review of Resident 1's Minimum Data Set ([MDS] a standardized…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to report an allegation of resident to resident physical abuse to the California Department of Public Health (CDPH) and the State Long Term Care Ombudsman ([LTC] public advocate) within the regulated time frame of two hours and they failed to report the results of their investigation to CDPH within five working days of the incident for one of two sampled residents (Resident 4). This deficient practice resulted CDPH not being aware of the abuse allegation that occurred 1/2024 until 4/2024 and the inability to investigation the allegation. This deficient practice had the potential for pertinent information to be lost and/or forgotten, more allegations of abuse to go unreported and continued abuse to occur. Findings: a. During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including paranoid (a pattern of behavior where a person feels distrustful 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's Quality Assessment and Assurance ([QAA] a committee that develop and implement appropriate plans of action to correct identified quality deficiencies) and Quality Assurance Performance Improvement ([QAPI] a committee that takes a systematic, interdisciplinary, comprehensive, and data-driven approach to maintaining and improving safety and quality in nursing homes while involving residents and families, and all nursing home caregivers in practical and creative problem solving) committee failed to identify Resident 1's elopement (a situation in which a resident leaves the premises or a safe area without the facility's knowledge and supervision) on 1/19/2024. They failed to develop and implement appropriate plans of action to ensure the QAA/QAPI committee systematically implemented and evaluated measures to monitor, review, and analyze data for performance improvement regarding elopements to help prevent the reoccurrence of incidents of elopement and include…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 care plan was developed for one of eight sampled residents (Resident 1), who had a prior history of three strokes. This deficient practice resulted in the care needs of Resident 1, related to prior history of strokes, not being addressed and had the potential for care interventions to not be implemented that would provide Resident 1 with appropriate care to recognize changes in Resident 1 ' s health status, assess, monitor, and/or prevent a recurrence of Resident 1 ' s stroke. Findings: During a review of Resident 1 ' s admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including cerebral infarction (a stroke that occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it) with left sided hemiplegia (paralysis of the arm, leg, and trunk on the same side of the body), respiratory failure with hypoxia (develops when the lungs…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 eight sampled residents (Resident 1), who had a change of condition (COC) and was found lethargic (decreased level of consciousness similar to sleepiness, fatigue, or drowsiness) on 2/19/2024 at 1:06 p.m., was continually assessed, monitored and documentation of Resident 1 ' s status was completed. This deficient practice resulted in Resident 1 ' s medical status being unknown by nursing staff from 1:06 p.m. through 5:39 p.m., on 2/19/2024 (four hours and 30 minutes after Resident 1 was assessed as lethargic), no assessment conducted to determine the cause of Resident 1 ' s lethargy and/or as a baseline assessment, such as a blood sugar (b/s) check and neurological assessment (an assessments to identify if there is a change to the resident ' s level of consciousness). Findings: During a review of Resident 1 ' s admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] with diagnoses…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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'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 implement corrective action from their recent re-recertification survey (12/22/2023) focused on monitoring, treating, and evaluating residents' pain. These deficient practices resulted in Resident 1 experiencing increased, unrelieved severe pain for approximately 6 hours which had the potential to affect Resident 1's sleep, appetite, mental health and delay her recovery. Findings: During a review of the CMS 2567 Statement of Deficiencies and Plan of Correction (POC)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 sufficiently train one of four licensed nurses, Licensed Vocational Nurse 1 (LVN 1), regarding pain management when LVN 1: 1. Failed to monitor, assess, and document interventions provided to Resident 1 to alleviate the pain, when Resident 1 complained of 10/10 pain. 2. Failed to access the medications in the emergency medication kit (E-Kit, medication kit which contains a small supply of medication that can be dispensed when the medication is not available from the pharmacy) because of lack of knowledge regarding when to use the E-Kit, how to access the medications and the protocol/procedure necessary to obtain the medications from the E-kit. 3. Failed to contact Resident 1's physician and/or the facility's pharmacy to request access to the emergency kit (E-Kit) to obtain Dilaudid, per the facility ' s policy and procedure, to administer to Resident 1 for pain. This deficient practice resulted in Resident 1 to experience unrelieved 10/10 burning pain…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure Licensed Vocational Nurse 2 (LVN 2) administered medication ([Lenalidomide] a medication used to treat cancer) on time, to one of two sampled residents (Resident 2) when LVN 2 administered Lenalidomide to Resident 2 at 11:28 a.m., instead of 9 a.m., as prescribed and no later than 10 a.m. This deficient practice resulted in Resident 2 receiving Lenalidomide two hours and 30 minutes after the ordered administration time and one hours and 30 minutes after the accepted administration time, which had the potential for mismanagement of Resident 1's medication regimen. Findings During a review of Resident 2's admission Record (Face Sheet), the Face Sheet indicated Resident 2 was admitted to the facility on [DATE] with a diagnosis of malignant neoplasm of the brain (brain cancer). During a review of Resident 2's Minimum Data Set ([MDS] a standardized assessment and care screening tool) dated 1/2/2024, the MDS indicated Resident 2 was able…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 the observation, interview and record review, the facility failed to follow the food preference for one sampled resident (Resident 2) when they served him rice and chicken for lunch when his tray card indicated Resident 2 disliked rice and chicken breast. This deficient practice resulted in Resident 1 purchasing his own food and had the potential for Resident 1 to go without food and potentially lose weight. Findings: During a review of Resident 2's admission Record (Face Sheet), the Face Sheet indicated Resident 2 was admitted to the facility on [DATE] with a diagnosis of malignant neoplasm of the brain (brain cancer). During a review of Resident 2's Minimum Data Set ([MDS] a standardized assessment and care screening tool) dated 1/2/2024, the MDS indicated Resident 2's was able to make independent decisions that were reasonable and consistent. During a record review of Resident 2's tray card (a list that provides specific resident diet order, food preferences, dislikes, and allergies) dated 2/13/2024,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to follow infection control measures for 0ne sampled residents (Resident 2) when Licensed Vocational Nurse 2 (LVN 2) administered Tramadol 1 tablet (a pain medication) to Resident 2 after the tablet fell onto the top of a dirty medication cart. This deficient practice resulted in Resident 2 ingesting medication that was potentially contaminated and had the potential to lead to health related issues. Findings: During a review of Resident 2's admission Record (Face Sheet), the Face Sheet indicated Resident 2 was admitted to the facility on [DATE] with a diagnosis of malignant neoplasm of the brain (brain cancer). During a review of Resident 2's Minimum Data Set ([MDS] a standardized assessment and care screening tool) dated 1/2/2024, the MDS indicated Resident 2's was able to make independent decisions that were reasonable and consistent. During a review of Resident 2's Physician's Order dated 11/03/2023, the Physician's Order indicated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to maintain a safe environment for two of eight sampled residents (Resident 383 and Resident 183) who were identified high risk for fall, when Resident 383's and 183's bed was not in the lowest position and one of eight sampled residents (Resident 51) was at the smoking area without supervision and with unsafe keeping of smoking materials (cigarette and lighter). This deficient practice had the potential for Resident 383 and 183 to sustain an injury due to a fall and Resident 51 to accidently burn while smoking. Findings: a) During a review of Resident 383's admission Record indicated, Resident 383 was admitted to the facility on [DATE] with diagnoses of unspecified hallucinations (sensations of hearing, seeing, smelling, tasting, feeling, or thinking that are not real), and dizziness. During a review of Resident 383's Fall Risk Assessment, dated 11/29/2023, indicated a score of 75. A score above 45 on the Fall Risk Assessment indicated…

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

Based on observation, interview, and record review, the facility staff failed to ensure all food items stored in the kitchen refrigerators were labeled and dated and failed to remove expired foods from the refrigerator. These deficient practices could expose residents to harmful bacteria growth, leading to foodborne illness for 83 residents who received food from the kitchen. Findings: During an initial tour and observation of the kitchen on 12/19/2023 at 8:30 a.m., the following were in the kitchen refrigerator: nine cups of unlabeled applesauce in a tray, two unlabeled cabbages, three unlabeled green papers, and parsley in a wet plastic bag labeled 11/12/2023. During a concurrent observation and interview on 12/19/2023 at 9:00 a.m., the dietary supervisor (DS) 1 stated the parsley looked old and needed to be discarded from the refrigerator. DS 1 could not identify the preparation date of the nine applesauce cups, the delivery date, or the best-buy date of the cabbages and green peppers. During an interview on 12/21/2023 at 2:23 p.m., DS 1 stated that everyone, including her,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility staff failed to perform hand hygiene while administrating medication for one of eight sampled resident (Resident 27) and ensure for one of eight sampled residents (Resident 218) 's indwelling catheter (also known as Foley catheter, a tube that allows urine to drain from the bladder into a bag that is usually attached to the thigh) drainage bag was not touching the floor and Resident 218's oxygen nasal cannula tubing (a device used to deliver supplemental oxygen placed directly on a resident's nostrils) was not on the floor, improperly stored, and undated. These deficient practices placed Resident 27 and 218 at risk for contracting infections. Findings: a.During a review of Resident 27's admission record, the admission record indicated Resident 27 was admitted to the facility on [DATE] with diagnoses including hemiplegia (paralysis of partial or total body function on one side of the body) and hemiparesis (one-sided weakness without complete…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure dignity to one of eight sampled residents (Resident 218), when Resident 218 urine collection bag was not covered with a dignity or privacy bag and the bag visible to other residents and visitors. This failure resulted in Resident 218's rights to dignity and privacy being violated. Findings: During a review of Resident 218's admission Record (Face Sheet ), the Face Sheet indicated Resident 218 was admitted to the facility on [DATE] with diagnoses dysphagia, hypertension, diabetes, muscle weakness, and UTI. A review of Resident 218's Minimum Data Set ([MDS] a comprehensive standardized assessment and care-screening tool) dated 11/24/2023, the MDS indicated Resident 218 was alert, and oriented to person, place, totally dependent on staff for dressing, toilet use, personal hygiene, and bathing. During a concurrent observation and interview on 12/29/2023 at 11:26 a.m., in Resident 218's room with CNA 2, observed Resident 218's urine…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 reasonable accommodation to meet the residents needs when the residents' call light was out of reach for three of eight sampled residents (Resident 41, 218, and 46). This deficient practice had the potential to negatively impact the psychosocial well-being of the residents or result in delayed provision of care or services. Findings: a. During a review of Resident 41's admission Record (Face Sheet), the Face Sheet indicated Resident 41 as admitted to the facility on [DATE] with diagnoses of hypertension (high blood pressure), muscle weakness (a lack of strength in the muscles), and dysphagia (swallowing difficulties). During a review of Resident 41's Minimum Data Set ([MDS] a comprehensive standardized assessment and care-screening tool) dated 10/20/2023, the MDS indicated Resident 41 was totally dependent on staff for dressing, toilet use, personal hygiene, and bathing. During a review of Resident 41's Care Plan ([CP] a form where…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 Preadmission Screening and Resident Review (PASARR resident screening prior to admission, to determine if the person has, or is suspected of having, a mental illness) screening was completed for Resident 64. This deficient practice had the potential for Resident 64 had the potential for not receiving the necessary and appropriate behavioral treatment and services. Findings: During a review of Resident 64's admission record, the admission record indicated Resident 64 was admitted to the facility on [DATE] with diagnoses including paranoid schizophrenia (serious mental illness that affect how a person thinks, feels, and behaves), and Parkinson's disease (a movement disorder). During a review of Resident 64's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 9/19/2023, the MDS indicated Resident 64 's cognitive (mental process by which knowledge is acquired, including perception, intuition, and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to create and update a patient focused care plan to address fluid restrictions and significant weight gain for one of six sampled residents (Resident 68). This deficit practice resulted in Resident 68 inaccurately being monitored for a fluid restriction of 1.5 liters (L, a unit of measurement of volume) and placed Resident 68 at risk for increased weight gain and fluid overload (too much fluid in the body). Findings: During a review of Resident 68's admission record, the admission record indicated Resident 68 was admitted to the facility on [DATE] with diagnoses including hyponatremia (low sodium level in the blood), Type II Diabetes Mellitus (DM: condition that happens due to the way the body regulates sugar) diabetic neuropathy (nerve damage caused by diabetes), hyperlipidemia (high level of cholesterol and fat in the blood), acute kidney failure (sudden episode of kidney failure or kidney damage that causes the kidneys to keep the right…

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

Based on interview and record review, the facility failed to ensure one of 18 residents (Resident 62) was not left in a wet diaper which resulted in moisture associated skin damage ([MASD] skin damage from exposure to moisture for long periods of time). This failure resulted in Resident 62 developing MASD to his peri-anal (the skin around the anus), and groin area. Findings: During a review of Resident 62's admission Record, dated 8/1/2023, the admission record indicated Resident 62 was admitted to the facility 8/1/2023 with diagnoses not limited to diabetes mellitus (a disorder in which the body does not produce enough or respond normally to insulin (lowers the levels of blood sugar [glucose] in the blood) and cerebrovascular disease (a group of conditions that affect blood flow and blood vessels in the brain). During a review of Resident 62's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 8/14/2023, the MDS indicated Resident 62's cognitive skills for daily decision making was severely impaired. The MDS indicated there was no MASD anywhere on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to implement and follow the physician's order for fluid restrictions for one out of six sampled residents (Resident 68). This deficient practice had the potential for Resident 68 to experience worsening hyponatremia (low salt in the body) and develop fluid overload (too much fluid in the body). Findings: During a review of Resident 68's admission record, the admission record indicated Resident 68 was admitted to the facility on [DATE] with diagnoses including hyponatremia, acute kidney failure (sudden episode of kidney failure or kidney damage that causes the kidneys to keep the right balance of fluid in the body), and hypertension (high blood pressure). During a review of Resident 68's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 12/7/2023, the MDS indicated Resident 68's cognitive (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) skills…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 properly assess and manage pain for one of six sampled residents (Resident 75). The deficient practice resulted in Resident 75 experiencing uncontrolled pain. Findings: During a review of Resident 75's admission Record, the admission Record indicated Resident 75 was initially admitted to the facility 10/25/2023 and readmitted [DATE] with diagnoses of sepsis (infection in the bloodstream) and peripheral autonomic neuropathy (weakness, numbness, and pain from nerve damage) and colitis (swelling and inflammation of the large intestine [colon]). During a review of Resident 75's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 11/23/2023, the MDS indicated Resident 75's cognitive (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) skills were intact. The MDS indicated Resident 75 occasionally experienced pain that affected sleep and and limited…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 reviews, the facility failed to ensure that the medication room temperature was consistently monitored and recorded in a Room Temperature Log to ensure a safe temperature range for medication storage. This deficient practice had the potential to harm residents due to the potential loss of strength and effectiveness of the medications. Findings: During a concurrent interview and record review on 12/21/2023 at 1:37p.m. with Registered Nurse Supervisor 1 (RNS 1), the Temperature Record Report indicated the temperature was not documented on 11/31/2023 during the afternoon and night shift and on 12/20/2023 during the afternoon shift. The Temperature Record Report indicated to check the temperature daily. RNS 1 stated the licensed nurses are in charge of checking and logging the medication room temperature. RNS 1 stated that there are medications that need to be stored at certain temperatures, and if the temperatures are not checked, it can potentially degrade the effectiveness of the medication. During a review of the facility's policy 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 ensure one of three resident's (Resident 62) family representative understood the arbitration agreement (a document that settles any disputes between two parties through binding arbitration, a dispute resolution mechanism that is out of the court system. This failure resulted in a resident (Resident 62) entering into an agreement for binding arbitration (the process of resolving a dispute outside of the court system by using a neutral third party), without fully understanding what they were signing. Findings: During a review of Resident 62's admission Record, dated 8/1/2023, the admission record indicated Resident 62 was admitted to the facility 8/1/2023 with diagnoses not limited to diabetes mellitus (a disorder in which the body does not produce enough or respond normally to insulin (lowers the levels of blood sugar [glucose] in the blood) and cerebrovascular disease (a group of conditions that affect blood flow and blood vessels in the brain). During a review of Resident 62's Minimum Data Set (MDS), a standardized…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1), who tested positive for COVID-19 (Coronavirus disease -a contagious respiratory infectious illness) on 11/2/2023 and had a change of condition (COC) of shortness of breath and lethargy (condition of deep and lasting drowsiness from which the person can be aroused only with difficulty and temporarily) on 11/6/2023, was provided care. The facility failed to: 1. Ensure Resident 1 was assessed, monitored, and had vital signs (VS- measurements of the body's most basic functions temperature, pulse rate, respiration rate [rate of breathing] and blood pressure)including oxygen saturation ([O2 sat] blood oxygen level) checked every shift as ordered by the physician. 2. Ensure Resident 1 ' s physician was informed of the continuous shortness of breath after Resident 1 was seen by the medical doctor (MD) on 11/7/2023. 3. Ensure staff followed the facility ' s policy and procedure (P&P) titled, Change of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, for one of six sampled residents (Resident 1), the facility failed to: 1. Ensure Resident 1 was treated with respect when two Certified Nurse Assistants (CNA), CNA 3 and CNA 4, was speaking hostile (aggressive) and rudely (impolite, insulting) at Resident 1 and did not provide Resident 1 the opportunity to express herself in a language (spanish) she can fluently speak. 2. Ensure Resident 1, who speaks spanish, was offered, and provided translation services or a spanish-speaking staff to assist Resident 1 in making herself understood and her needs known. These failures resulted in Resident 1 feeling ignored and disrespected and had the potential to affect Resident 1's safety and health condition when health concerns were not heard and understood and can potentially cause poor-quality and delay of care and services necessary to maintain the highest practicable physical, mental, and psychosocial well-being of the resident (Resident 1). Findings: During observation 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.