Villa Serena Healthcare Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the legally recognized decisionmaker and physician signed the Physician Orders for Life-Sustaining Treatment ([POLST] form that contains written medical orders for healthcare professionals regarding specific medical treatments that can or cannot be done at the end-of life) form for one of three sampled residents (Resident 1). This deficient practice had the potential to cause Resident 1 to receive treatment or services against their wishes.Findings:During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE], and originally admitted to the facility on [DATE], with a diagnosis including chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing) and atherosclerotic heart disease (the buildup for plaque on the artery walls causing reduced blood flow to the tissues and increases risk for a blood clot).During a review of Resident 1's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to initiate a change of condition (COC) when one of five sampled residents (Resident 1) was found with unknown skin discoloration on his right arm and not doing a pain assessment when Resident 1 was found with a skin tear. This deficient practices placed Resident 1 not being monitored for the COC and had the potential for delay in 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 was readmitted on [DATE] with diagnoses including dementia (a progressive state of decline in mental abilities), muscle wasting and atrophy, and Type 2 (II) Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool) dated 1/3/2025 the MDS indicated Resident 1's cognitive skills (the mental action or process of acquiring knowledge…

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

Based on interview and record review the facility failed to ensure the facility's Water Management Plan (plan that identifies hazardous conditions and steps to take to minimize the growth and spread of bacteria[germs]) was implemented when the water management assessment was not completed. This deficient practice had the potential to expose residents and staff to Legionella (bacteria that can cause serious lung infections) and waterborne infections. Findings: During an interview and record review on 1/16/2025 at 9:19 a.m., there was no documented facility water management plan, and the Infection Prevention Nurse (IPN) confirmed the water management assessment was not completed. The IPN stated we need to complete the assessment to ensure microbial growth (germs) was not spreading. During an interview with the Administrator on 1/16/2025 at 1:00 p.m. the administrator stated the facility will complete the water management assessment because it was required. During a review of the facility policy and procedure (P&P) titled Legionella, implemented 2/9/2024, the P&P indicated the facility…

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

Based on interview and record review, the facility failed to provide documented evidence of all employees screening, education, offering, and current Corona virus disease, COVID-19 (contagious infectious disease), vaccination (medications used to prevent diseases usually given by injection or by mouth) status. This failure had the potential to place staff and residents at risk for serious outcomes such as being hospitalized due to COVID-19. Findings: During an interview and record review on 1/16/2025 at 12:07 p.m., with the Infection Prevention Nurse (IPN), the facility's employee records of COVID-19 status 2024 to 2025 was reviewed, and the physicians and consultants COVID-19 immunization status were unknown. The IPN stated she did not know she had to get the physicians and consultants Covid-19 immunization status. During a review of the facility's policy and procedure (P&P) titled, Covid-Vaccination, implemented 2/9/2024, the P&P indicated the policy was to prevent and minimize transmission of Covid-19. The P&P indicated the facility will educate and offer Covid-19 vaccinations 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.

Based on observation, intervention, and record review the facility failed to provide a minimum of 80 square feet (sq. ft. ) for resident per resident in multiple rooms resident bedrooms ( 2, 3, 4, 5, 6, 7, 8, 9, 10, 11,12, 13, 14, 15, 16, 17, 18, and 19 for (17 of 19 residents room). This deficient practice had the potential to impact the ability to provide nursing care to the residents. Findings : During and observation on 1/14/2025 at 00:00 a.m., with the Maintenance (MN), observed multiple resident's rooms with two, three and six beds in a room. Observed residents go in and out of beds with adequate spacing, side tables, chairs, wheelchairs readily available without impending any movement. During an interview on 1/14/2025 at 00:00 a.m., with the MN , the MN stated we have a room waiver now and will apply for one in 2025. During a review of the room size waiver dated 1/2024 submitted by the Administrator (ADM), for 17 residents' room was reviewed, the letter indicated there was ample room to accommodate residents and enough space for residents care and health and safety of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure one of two sampled residents (Resident 4), who was assessed at a moderate risk for developing a skin injury and had intact skin, did not develop the following: a. Stage II (Partial-thickness loss of skin, presenting as a shallow open sore or wound) pressure injury (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence) on the sacrum area (tailbone) measuring 0.5 centimeters [(cm) unit of measurement] in length, 0.5 cm in width and 0 cm in depth on 1/5/2025. b. An open area 0.5 cm round superficial red open area on the right buttocks area on 5/25/2024, resolved (healed) on 6/7/2024. c. Stage II pressure injury on coccyx (tailbone area) measured 1.5 cm length by 1.3 cm in width, and 0.2 cm in depth on 6/21/2024, resolved on 7/16/2024. The facility failed to: 1. Implement Resident 4's (untitled) care plan intervention to turn and reposition the resident as needed when in bed or 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 one of one hemodialysis ([HD]a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) resident (Resident 22) received dialysis care and services based on professional standards. The facility failed to: a. Notify the physician, assess Resident 22, educate Resident 22 regarding and risk for missing HD, and monitor Resident 22 for complications after Resident 22 missed HD on 1/2/2025 and 1/3/2025. b. Assess Resident 22 and complete Resident 22's Dialysis Transfer Information (form used by facility and dialysis center to communicate regarding resident status) prior to sending Resident 22 to dialysis on 12/14/2024. These deficient practices had the potential to result in complications from dialysis. Findings: During a review of Resident 22's admission Record, the admission Record indicated Resident 6 was originally admitted to the facility on [DATE] with diagnoses including end stage…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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) One of three sampled resident's (Resident 22) informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered) for psychotropics (drug or other substance that affects how the brain works and causes changes in mood, awareness, thoughts, feelings, or behavior) was obtained. b) Three of six sampled resident's (Resident 22, 41, and 18) were evaluated for a gradual dose reduction (involves the stepwise tapering of a dose to determine if symptoms, conditions, or risks can be managed by a lower dose or if the medication) of psychotropic medications. c) One of one sampled resident's (Resident 44) was appropriately being monitored for the signs and symptoms of lithium toxicity (occurs when you have too much of the prescription medication lithium in your body). d) One of one sample resident's (Resident 42) had one of his benign prostatic hyperplasia (BPH:…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 administer medications appropriately for one (Residents 39) of three residents observed during the medication pass. During medication pass, there were two medication errors out of twenty-six opportunities. These medication administration errors resulted to a medication error rate of 7.69 percent. Findings: During a review of Resident 39's admission Record, the record indicated Resident 39 was admitted to the facility on [DATE] with a diagnosis including malignant neoplasm (cancer - abnormal mass of cells that grows uncontrollably and can spread to other parts of the body) of breasts. During a review of Resident 39's Minimum Data Set (MDS), a resident assessment tool, dated 12/29/2024, the MDS indicated Resident 39's cognition (ability to think) was intact. The MDS indicated Resident 39 needed substantial assistance (helper does more than half the effort) when eating, performing oral hygiene, toileting hygiene, personal hygiene, 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: a. Failed to ensure medications for one of three residents (Resident 41) were stored in a secure location. b. Failed to ensure the medication refrigerator temperature was within normal range (30 to 4g degrees Fahrenheit). These deficient practices had the potential to result in unauthorized use of medications and the loss of viability (ability to work) of medication for improper storage temperature. Findings: During a review of Resident 41's admission Record, the admission Record indicated Resident 41 was originally admitted to the facility on [DATE] with diagnoses including allergic rhinitis (inflammation [redness and swelling] of the inside of the nose) and asthma (a chronic lung disease caused by inflammation and muscle tightening around the airways which makes it harder to breathe). During a review of Resident 41's Minimum Data Set (MDS - a resident assessment tool), dated 8/13/2024, the MDS indicated Resident 41's cognition was intact. The MDS…

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

Based on observation, interview and record review, the facility failed to ensure staff followed food production recipes and fortified diet (diet to increase caloric intake) guidelines during lunch preparation and tray line observation on 1/13/2025 when: 1.cook used small scoop size to serve pureed fish for residents on pureed diet. 10 residents on pureed diet received 3/8 cup (3 ounces (oz.)) of pureed fish instead of ½ cup (4ounces (oz).) per menu. Three residents on the renal diet (a diet aimed at keeping levels of fluids, electrolytes, and minerals balanced in the body in individuals with kidney disease or who are on dialysis) received peas for lunch instead of green beans per menu. 2.Fortified diets (diet enhanced to increase caloric content) were not prepared and were not served to residents who were on fortified diet. These deficient practices had the potential to result in meal dissatisfaction, decreased caloric intake and weight loss for 10 residents on pureed diet who received less protein and seven residents who required a fortified diet. Findings: According 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.

Based on observation, interview and record review the facility failed to ensure safe and sanitary food storage and preparation practices in the kitchen when: 1.One open bag of frozen pepperoni with and one large plastic bag of diced chicken were stored in the freezer with no open date or label. One bag of frozen chicken thighs stored uncovered in the reach in freezer. 2.One Dietary Aide (DA1) working in the dish machine area did not wash hands and change gloves when removing the clean and sanitized dishes from the dish machine. 3.Dishware were not sanitized with adequate amount of sanitizer per manufactures guidelines. Sanitizers and disinfectants are used on food contact surfaces to prevent food borne illness. These deficiencies had the potential to result in harmful bacteria growth and cross contamination (transfer of harmful bacteria from one place to another) that could lead to foodborne illness in 45 out of 48 residents who received food from the kitchen. Findings: 1.During an observation in the kitchen on 1/13/2025 at 9:12AM there was one open bag of pepperoni with no open…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 10 hours of continued education in the field of Infection Prevention and Control (IPC) for the one of one facility staff (Infection Prevention Nurse -IPN). This failure had the potential to result in negative health outcomes for the staff and residents of the facility. Findings: During an interview on 1/16/2025 at 9:07 a.m., with the IPN, the IPN stated she did not have annual 10 hours of continuing education in the field of Infection Prevention and Control after the initial IP training was completed in 2023. During a record review of the California Department of Public Health All Facilities Letter (AFL) 20-84, titled, Infection Prevention Recommendations and Incorporation into the Quality and Accountability Supplemental Payment (QASP) Program, 11/4/2020, the AFL indicated it was important that each facilities Infection Preventionist have training in fundamental Infection Prevention and Control principles to effectively perform the IP duties. Ongoing education was necessary to remain aware 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 implement its protocol for antibiotic stewardship program (coordinated program that promotes the appropriate use of antibiotics by clinicians) by not monitoring the side effects and addressing antibiotic (a substance used to kill bacteria and to treat infection) use for one of two sampled residents (Resident 16). This failure had the potential for the Resident 16 to receive inappropriate antibiotics and develop adverse reactions for long term antibiotic use. Findings: During a review of Resident 16's admission record, the admission record indicated Resident 16 was admitted to the facility on [DATE] with diagnosis including hepatic encephalopathy (a brain disorder that occurs when the liver fails and toxins build up in the blood). During a review of Resident 16's Minimum Data Set (MDS - a resident assessment tool), dated 12/11/2024, the MDS indicated Resident 16's cognition was intact. The MDS indicated Resident 16 needed supervision (helper provides…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation , interview and record review, the facility failed to ensure two of 19 residents' bedroom , rooms( 2 and 19) accommodate no more than 4 residents in each room. This deficient practice had the potential to result in inadequate space to provide nursing care. Findings: During an observation on 1/14/2025 at 3:14 p.m., observed room two occupied with six residents and room three was occupied with six residents . The residents were able to move in and out of their rooms and there was space for wheelchairs, beds, and bedside tables. During a record review of the waiver signed by the administrator dated submitted by the administrator indicated resident 2 and 3 did not meet the four resident per room requirement by federal regulation . The letter indicated room [ROOM NUMBER] and 3 had enough space to provide each resident care without affecting their health and safety or impending any of the residents in the room to attain his or her wellbeing.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility's interdisciplinary team (IDT-a coordinated group of experts from several different fields who work together) failed to ensure one of one resident (Resident 41) was assessed to determine if the resident was capable of self-administering medications. This deficient practice had the potential for Resident 41 to self-administer medications incorrectly resulting in subtherapeutic (below the level necessary to treat effectively) medication effects which can lead to health issues. Findings: During a review of Resident 41's admission Record, the admission Record indicated Resident 41 was originally admitted to the facility on [DATE] with diagnoses including allergic rhinitis (inflammation [redness and swelling] of the inside of the nose) and asthma (a chronic lung disease caused by inflammation and muscle tightening around the airways which makes it harder to breathe). During a review of Resident 41'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 the residents' medical records were updated to show documentation that a resident has an advance directive (written statement of a person's wishes regarding medical treatment made to ensure those wishes are carried out should the person be unable to communicate them to a doctor) for one of three sampled residents (Resident 42). This deficient had the potential to cause conflict with the residents' wishes regarding health care. 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 major depressive disorder (MDD: a mood disorder that causes a persistent feeling of sadness and loss of interest), dementia (a progressive state of decline in mental abilities), and hypertension (high blood pressure). During a review of Resident 42's History and Physical (H&P) dated 9/18/2024, the H&P indicated Resident 42 had fluctuating capacity to understand and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure two of four sampled residents' (Residents 39 and Resident 44) Preadmission Screening and Resident Review (PASRR) assessment screening was reassessed to determine the facility's ability to provide the special needs of the residents. This deficient practice placed the residents at risk of not receiving necessary care and services they need. a. During a review of Resident 39's admission Record, the admission Record indicated Resident 39 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including major depressive disorder (MDD a mood disorder that causes a persistent feeling of sadness and loss of interest), anxiety disorder (group of mental health conditions characterized by fear, nervousness, and excessive worry), and post-traumatic stress disorder (PTSD: mental health condition that develops after experiencing or witnessing traumatic events). During a review of Resident 39's History and Physical (H&P) dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure one of three residents' (Resident 7) Restoril (medication for insomnia - trouble falling or staying asleep) was available. This deficient practice had the potential to result in Resident 7's lack of sleep which can result in negative health outcomes. Findings During a review of Resident 7's admission Record, the admission Record indicated Resident 7 was admitted to the facility on [DATE] with diagnosis including insomnia. During a review of Resident 7's Minimum Data Set (MDS), a resident assessment tool, dated 11/14/2024, the MDS indicated Resident 7's cognition was intact. The MDS indicated Resident 7 needed set up assistance when eating, performing oral hygiene, and supervision with upper dressing, toileting hygiene, personal hygiene, and showering. During a review of Resident 7's Order Listing Report for Temazepam (Restoril), from 12/1/2024 to 1/31/2025, the summary indicated on 1/11/2025, Restoril 30 milligrams (mg - unit 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 inform the physician about an abnormal laboratory (bodily specimen test process and resulting) result in a timely manner for one of one sampled resident (Resident 44). This deficient practice placed Resident 44 at risk for delayed treatment of abnormal laboratory results. During a review of Resident 44's admission Record, the admission Record indicated Resident 44 was admitted to the facility on [DATE] with diagnoses including bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs) with current episode manic without psychotic features, alcohol abuse (drinking alcohol in a harmful way or when dependent on alcohol), and adult failure to thrive (decline in health and ability for older individuals). During a review of Resident 44's History and Physical (H&P) dated 11/10/2024, the H&P indicated Resident 44 had the capacity to understand and make decisions.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure Resident 34 had a peanut butter sandwich that was requested for a snack. This deficient practice had the potential to affect the resident's rights , wellbeing and can lead to insufficient food intake. Findings: During a review of Resident 34's admission Record (AR), the AR indicated Resident 34 was originally admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses including malignant neoplasm of unspecified part of unspecified bronchus ( cancer of the large airway that leads from the windpipe to the lungs ), Anemia ( lack of blood) and acute on chronic systolic congestive heart failure ( a weekend heart condition that causes fluid buildup in the feet , arms, lungs and other organs). During a review of Resident 34's History and Physical (H&P) dated 10/3/2024, the H&P indicated Resident 34 has fluctuating capacity to understand and make decisions. During a review of Resident 34's Minimum Data Set [(MDS), 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.

Based on observation, interview and record review, the facility failed to ensure: 1.One resident (Resident 2) who was on mechanical soft texture diet (soft food) received quesadilla (a Mexican dish consisting of a tortilla that is filled with cheese and then cooked on a griddle or stove) texture in form that meet their needs when the quesadilla was dry with hard and golden brown crispy edges, was not chopped and resident was not able to eat and stated it was overcooked. This deficient practice had the potential to result in decrease intake related to inconsistent texture, meal dissatisfaction, and increase choking and aspiration risk. Findings: During a review of Resident 2's admission Record, the admission record indicated the facility initially admitted Resident 2 on 5/2/2024 with diagnosis including, but not limited to chronic obstructive pulmonary disease (COPD, a common lung disease causing restricted airflow and breathing problems), Dysphagia, Oropharyngeal phase (swallowing problems occurring in the mouth and/or the throat.) During a review of Resident 2's physician diet…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of three sampled resident's (Resident 2) care plan was revised to include interventions to reduce Resident 2's fall risk, such as staff to always provide direct line of sight (unobstructive view) supervision while Resident 2 was awake. The facility also failed to include Resident 2's Responsible Party (RP) in the care planning process during the interdisciplinary Team (IDT-team of healthcare professionals and the resident and/or Resident's RP working together to meet resident's goals) meeting held after Resident 2's sustained fall on 5/15/2024. These deficient practices had the potential to result in future falls for Resident 2 resulting in injury and it violated Resident 2's and Resident 2 RP's rights to be involved in the care planning process. 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 diagnoses including overactive bladder…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 2) who had a history of multiple falls, was supervised, and monitored while sitting in her wheelchair in the dining room. This deficient practice resulted in Resident 2 sustaining an unwitnessed fall on 5/14/2024 when Certified Nurse Assistant (CNA) 1 left Resident 2 unsupervised in the dining room. 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 diagnoses including overactive bladder (sudden urge to urinate that is hard to control) and major depressive disorder (persistent feeling of sadness which can affect daily activities) with severe psychotic (seeing or hearing things that are not there) symptoms. During a review of Resident 2's Minimum Data Set ([MDS] a standardized assessment and care-screening tool), dated 4/3/2024, the MDS indicated Resident 2's cognitive skills for daily decision-making were…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 there were enough bath and shower towels for 50 out of 50 sampled residents . This deficient practice places the residents at risk for infection, decrease in hygiene and comfort. Findings: During an interview on 5/6/2024 at 09:23 a.m., Resident 2 stated the facility run out of things like towels, Resident 2 stated she has to wait until the next day before we get towels to bathe. Resident 2 stated there is a towel shortage. During a concurrent observation and interview on 5/6/2024 at 10:30 a.m., with Central Supply (CS), CS stated that there were no towels and stated sometimes it takes more than one day before there are towels available to the facility. During a concurrent observation at the linen room and interview on 5/6/2024 at 10:34 a.m., with laundry assistant ( LA), LA stated clean towels are delivered by a company called Medical every Tuesday and Friday , she stated the last delivery was on 5/3/2024 and the next one will be delivered on 5/7/2024 LA walked to cart 1, cart 2, Cart 3, cart 4 also…

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

During observation, interview and record review the facility failed to ensure food was stored under food safety requirement by: 1.Unplugging the freezer for over 30 minutes while storing resident food. 2. Resident food stored in the freezer with a temperature of 15 degrees Fahrenheit (°F- scale of temperature). These deficient practices placed residents at risk for food-borne illness also called food poisoning caused by eating contaminated food or eating food not kept at appropriate temperatures) and can lead to other serious medical complications and hospitalization for 48 residents residing in the facility. Findings: During an observation 1/19/2024 at 5:38 p.m. on the initial kitchen tour in the facility kitchen, observed the freezer was unplugged since 5 p.m. on 1/19/2024. Observed ice cream was melted. During an interview on 1/19/2024 at 5:55 p.m. with the Maintenance Director (MD), the MD stated the freezer was unplugged 30 minutes ago because ice was building up on the condenser. During a concurrent observation and interview on 1/19/2024 at 5:57 p.m. with the Dietary…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 proper infection control practices for the preparation and distribution of food was done under sanitary conditions in the kitchen for 48 out of 48 residents by: 1.Failing to ensure the Chlorine Sanitizer Agent (recommended to sanitize food contact surfaces including utensils, equipment, and tables) for the dishwasher was between 50-100 PPM (unit used to describe very small concentrations of a substance in a larger solution) for four dishwashing cycles. 2.Failing to ensure the Dish Machine Temperatures was within proper range of 120-160 degrees (a measure of temperature) for 5 dishwashing cycles. These deficient practices had the potential to result in pathogen (germ) exposure to residents and placed residents at risk for developing foodborne illness (food poisoning) with symptoms including upset stomach, stomach cramps, nausea, vomiting, diarrhea, and fever that can lead to other serious medical complications and hospitalization. Findings: During an observation on 1/19/2024 at 5:40 p.m. during 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 observation, interview and record review the facility failed to ensure three of 13 sampled residents rights were protected by: 1. Resident 49 received a cold temperature shower. This failure resulted in Resident 49 unknowingly being placed in a cold shower until the water temperature in the shower warmed up. 2.Resident 19 was not provided a dignity bag (restores the dignity of [catheterized-a procedure used to drain the bladder and collect urine, through a flexible tube patient by concealing urinary drainage bags from public view) for Resident 19 indwelling catheter ([foley catheter] plastic or rubber tube that is inserted into the bladder to drain the urine) drainage bag (collects urine). This deficient practice has the potential to affect resident's sense of self-worth and self-esteem. Findings: 1.During a review of Resident 49 admission Record (Face Sheet) the Face Sheet indicated Resident 49 was admitted to the facility on [DATE] with diagnoses including congestive heart failure (a serious condition 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 observation, interview and record review, the nursing staff member failed to ensure call light was within reach and in working condition for one of three sampled Residents (Resident 43). This deficient practice had the potential to result in Residents 43 not being unable to call facility staff for help when needed and delay in necessary care and services. Findings: During a review of Resident 43's admission Record (Face Sheet) the Face Sheet indicated Resident 43 was admitted on [DATE] and readmitted to the facility on [DATE] with diagnoses including type 2 diabetes mellitus with other specified complications ( a chronic condition that affects the way the body processes blood sugar, mixed hyperlipidemia ( an inherited condition in which levels of certain fats in the blood are higher than they should be ), schizophrenia ( a disorder that affects a person's ability to think, feel and behave clearly). During a review of Resident 43's History and Physical (H&P) dated 6/20/23, the H&P indicated Resident 43…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 13 sampled residents (Resident 48) had a Preadmission Screening and Resident Review (PASARR-a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care) assessment done when diagnosed with paranoid schizophrenia (a serious mental illness that affects how a person thinks, feels and behaves), bipolar disorder (a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration) prior to admission. This deficient practice had the potential for Resident 48 not receiving the necessary services and appropriate psychiatric level of treatment and evaluation in the facility. Findings: During a review of Resident 48's admission Record (Face Sheet), the Face Sheet indicated Resident 48 was admitted to the facility on [DATE] with diagnoses including paranoid schizophrenia, bipolar, anxiety, and insomnia (difficulty falling asleep). During a review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based an observation, interview and record review the facility staff failed to ensure a resident's low air loss mattress (mattress designed to distribute the patient's body weight over a broad surface area and help prevent skin breakdown. was inflated for one of two sampled residents (Resident 32). This deficient practice had the potential to negatively affect Resident 32 physical comfort and had Resident 32 pressure ulcer (injury to skin and underlying tissue resulting from prolonged pressure on the skin) to worsen. Findings: During a review of Resident 32's admission Record (Face Sheet), the Face Sheet indicated Resident 32 was admitted to the facility on [DATE] with diagnoses including ischemic with cardiomyopathy ( heart muscle that cannot pump well because of damage from lack of blood supply to the heart), pressure ulcer of unspecified part of back unstageable ( a type of pressure ulcer that occurs due to prolong pressure on a specific area of the skin, resulting in the lack of blood flow and oxygen to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to prevent the resident from having an unplanned severe (severe weight loss is the weight loss greater than 5 % in one month and greater than 7.5 % in three months) weight loss of 14 pounds ([lbs.] which constituted 7.4 percent % in one month and 10.3 % in two months) for one of 18 sampled residents (Resident 40). The facility failed to: 1. Ensure the licensed nurses followed the Registered Dietician (RD) dietary recommendations of Multivitamins (a pill containing a combination of vitamins), Prostat (a ready-to-drink concentrated liquid high in protein) 30 cubic centimeter ([cc]-unit of volume) daily, and iron (a mineral that the body needs to produce red blood cells) supplements on 11/16/2023, recommendations of including a complete blood count ([CBC] a blood test that measures the number and quality of red blood cells (RBCs or erythrocytes) and white blood cells), comprehensive metabolic panel (CMP]a blood test about resident's body's…

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

Based on interview and record review, the facility failed to obtain laboratory tests of complete blood count ([CBC] a blood test that measures the number and quality of red blood cells (RBCs or erythrocytes) and white blood cells), comprehensive metabolic panel (CMP]a blood test about resident's body's fluid balance and levels of electrolytes) and a thyroid stimulating hormone ([TSH] measures the amount of thyroid stimulating hormone in your blood) test on 12/15/2023 as ordered by the attending physician on 12/17/2023 for one of one sample resident (Resident 40). This deficient practice had the potential to delay necessary care and treatment for Resident 40. Findings: During a review of Resident 40's admission Record (Face Sheet) dated 11/10/2023, the Face Sheet indicated Resident 40 was admitted to the facility with diagnoses including cellulitis (a common skin infection caused by bacteria) of the left leg, hypertension (high blood pressure), and adult failure to thrive (a syndrome of weight loss, decreased appetite, and poor nutrition). During a review of Resident 40's Minimum…

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