Alvarado Care Center

Based on observation, interview and record review the facility failed to ensure the lunch menu was followed on 1/20/2026, when:1. One Dietary aide (DA2) did not communicate the allergies listed on two of three (the gluten free meal ticket [lists resident's food preferences, allergies, and the food items on the menu to be served and portions] and the lactose intolerant meal ticket) meal tickets.2. [NAME] 2 did not prepare the non-breaded plain hamburger patty replacement for the gluten free diets. As a result, the cooks served pureed country fried steak (breaded beef patty) containing gluten on a tray for a resident who was allergic to gluten, and potato gratin (sliced potatoes in creamy sauce) prepared with milk served on a tray for a resident who was lactose intolerant (milk intolerant). This deficient practice had the potential to result in decreased meal satisfaction, decreased caloric intake and residents experiencing symptoms associated with intolerance in two residents who had gluten intolerance and two residents who had lactose intolerance.Findings: A review of 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 observation, interview and record review, the facility failed to ensure: The minced and moist diet (diet for residents who experience biting, chewing or swallowing limitations. Food is soft and moist; the size of the lumps should be approximately 4 mm in size fits through gaps of fork prongs.) Au gratin potatoes (sliced potatoes in creamy sauce) were served in a form that was in accordance with the international Dysphagia Diet initiative (IDDSI - a framework made up of levels and describes food textures and drink thickness) Level Five (Minced and Moist foods) when breaded beef patties were chopped and not minced and the texture of the minced and moist was not small (minced) did not fit through the gaps of fork prongs and breaded beef patty was dry. This failure had the potential to result in meal dissatisfaction and increased choking risk for ten residents on the minced and moist diet.During an observation in the facility's kitchen on 1/20/2026 at 10:00AM, Cook1 removed a portion of baked breaded beef patties from the oven and placed them on a chopping board. Cook1 started…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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.Clean and sanitized resident trays and cups were stored on the counter next to the handwashing sink and in the splash zone (the area within roughly 3 feet of a handwashing sink or drain, where water spray and particles from handwashing can contaminate surrounding surfaces). 2. The floor in the dry storage area located in the kitchen was not kept clean, food debris, a hair net, a lighter, condiments packages and plastic wrappers were on the floor. 3. Expired food was stored in the dry storage area. One unsealed bag of chocolate chips with no date, one bag of powder/ground graham crackers stored with the bag opened and received date of 8/30/2024 (expired), one container of Worcestershire sauce with a use by date (the final recommended date for safe consumption, indicates when food is at peak quality and should be treated as a safety deadline) of 3/21/2025, and one container of sesame oil with a use by date of 11/20/2025…

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

Based on interview and record review, the facility failed to obtain an informed consent (a process during which residents or caregivers are educated regarding the potential risks and benefits of medication therapy) from the resident or their responsible party (a person delegated to make medical decisions for the resident in the event they are unable to do so) prior to the treatment with Cymbalta (a medication used to treat mental illness) in one of five sampled residents (Resident 69) for unnecessary medications.The deficient practice of failing to obtain an informed consent prior to initiating treatment with a psychotropic (medications that affect brain activities associated with mental processed and behavior) medications could have prevented Resident 69 from exercising her right to decline treatment with Cymbalta. This increased the risk that Resident 69 could have experienced adverse effects (unwanted, uncomfortable, or dangerous effects that a drug may have) related to Cymbalta leading to impairment or decline in her mental or physical condition or functional or psychosocial…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 feeding assistance during meals for one of three sampled residents (Resident 69). This deficient practice had the potential not to meet Resident 69's specific needs and had the potential for Resident 69's activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) to decline.Findings:During a review of Resident 69's admission Record, the admission Record indicated the facility admitted Resident 69 on 4/9/2025 with diagnoses that included unqualified visual loss (a significant loss of vision in one or both eyes where the specific cause[blindness category, underlying disease] has not been clearly identified) both eyes, unspecified dementia (a progressive state of decline in mental abilities), unspecified severity, without behavioral disturbance (acting out, agitated, aggressive or mood/personality changes), psychotic disturbance(hallucinations or strong delusions), mood disturbance (disruptive sadness, irritability), and anxiety…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that a Pre-admission Screening and Resident Review (PASRR - a federal requirement ensuring people with mental illness, intellectual disabilities, or related conditions are not inappropriately placed in nursing homes) was done for one of five sampled residents (Resident 42) diagnosed with a mental illness prior to admission in the facility. This failure had the potential for Resident 42 not to receive the necessary and appropriate psychiatric evaluation (is a comprehensive mental health assessment by a professional to diagnose emotional, behavioral, or cognitive conditions, guide treatment, and understand a person's overall mental state) and level of treatment at the facility.Findings: During a review of Resident 42's admission Record, the admission Record indicated the facility admitted Resident 42 on 8/18/2025 with diagnoses that included end stage renal disease (ESRD - irreversible kidney failure), essential (primary) hypertension (HTN - high…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 79) reviewed for skin care received the care required to prevent pressure ulcer/injury (localized damage to the skin and/or underlying tissue usually over a bony prominence) by failing to: -Ensure to set Resident 79's low air loss mattress (LALM - a medical bed surface designed for immobile patients to prevent or treat bedsores) according to Resident 79's weight. This failure had the potential for Resident 79 to develop pressure injuries and/or worsen skin wounds (injury that break the skin or other body tissues).Findings: During a review of Resident 79's admission Record, the admission Record indicated the facility originally admitted Resident 79 on 1/22/2019 and readmitted Resident 79 on 1/15/2026 with diagnoses that included cerebral palsy (a lifelong condition that leads to problems with movement, balance, and posture, like a broken communication line between the brain and muscles), type 2…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure a resident received appropriate treatment and services to prevent urinary tract infections (UTI-an infection in any part of your urinary system, your kidneys, ureters, bladder and urethra) for one of two sampled resident (Resident 9) by failing to:1. Provide an on-going assessment of the use and removal of Resident 9's indwelling foley catheter (foley catheter - a hollow tube left implanted in a body canal or organ, especially the bladder, to promote drainage).2. Review and revise the individualized care plan when Resident 9 had UTI on 3/24/2025 and 09/15/2025.3. Initiate an interdisciplinary team (IDT) review when Resident 9 had UTI on 3/24/2025 and 09/15/2025 and a change of condition on 11/30/2025.These deficient practices has caused Resident 9 to develop catheter associated urinary tract infection (CAUTI - an infection of the urinary tract caused by a tube [urinary catheter] that has been placed to drain urine from the 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 observation, interview, and record review, the facility failed to ensure that the necessary medication (Biktarvy) used to treat Human Immunodeficiency Virus (HIV- is a virus that attacks the body's immune system. HIV damages the immune system so that the body is less able to fight infection and disease. Without treatment, it can lead to acquired immunodeficiency syndrome- a chronic condition of the disease) was available and administered as ordered by the physician on six consecutive days for one of three sampled residents (Resident 2).This failure resulted in an interruption and delay of treatment for Resident 2, causing emotional and psychological distress for Resident 2, and placed Resident 2 at risk of avoidable decline in health status.During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was admitted to the facility on [DATE] with a diagnosis of HIV.During a review of Resident 2's Minimum Data Set (MDS- a standardized resident assessment and care screening…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 necessary medication (Biktarvy) to treat Human Immunodeficiency Virus (HIV- a virus that attacks the body's immune system. HIV damages the immune system so that the body is less able to fight infection and disease. Without treatment, it can lead to acquired immunodeficiency syndrome- a chronic condition of the disease) was available and administered as ordered by physician for six consecutive days for one of three sampled residents (Resident 2).This failure resulted in an interruption and delay of treatment for Resident 2, causing emotional and psychological distress for Resident 2, and placed Resident 2 at risk of avoidable decline in health status.During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was admitted to the facility on [DATE] with a diagnosis of HIV.During a review of Resident 2's Order Summary (part of the resident's medical record that synthesizes all physician orders,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop a comprehensive care plan for one of two sampled residents (Resident 1). For Resident 1 who was assessed on 5/29/25 as at risk for fall, the facility failed to develop a plan of care to address the risk of fall for Resident 1. This deficient practice had the potential to cause a delay or lack of necessary care for Resident 1. During a review of the admission Record indicated the facility admitted Resident 1 on 5/29/25 with diagnoses including diabetes (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), dysphagia (difficulty swallowing), lack of coordination and absence of right leg above knee.During a review of the Minimum Data Set (MDS, a resident assessment tool) dated 6/5/25 indicated Resident 1 had moderately impaired cognition. Resident 1 was dependent on shower, lower body dressing, putting on/taking off footwear, personal hygiene, substantial assistance (helper does more than half the effort) with…

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

Based on interview and record review the facility failed to update and revise the care plan for one of two sampled residents (Resident 1). For Resident 1, the facility failed to update and revise the care plan when Resident 1 had a fall on 8/18/25 and 8/30/25. This deficient practice resulted in the facility failing to develop and implement new interventions for Resident 1 to prevent future falls. Findings:During a review of the admission Record indicated the facility admitted Resident 1 on 5/29/25 with diagnoses including diabetes (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), dysphagia (difficulty swallowing), lack of coordination and absence of right leg above knee.During a review of the Minimum Data Set (MDS, a resident assessment tool) dated 6/5/25 indicated Resident 1 had moderately impaired cognition. Resident 1 was dependent on shower, lower body dressing, putting on/taking off footwear, personal hygiene, substantial assistance (helper does more than half the effort) with oral hygiene, toileting hygiene, upper body dressing 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 residents received adequate nutrition for one of two sampled residents (Resident 1). For Resident 1, the facility failed to provide interventions when Resident 1 refused to eat on 8/18/25 at 5:30 p.m. and refused to eat all meals on 8/19/25 and 8/23/25. This deficient practice resulted in Resident 1 not meeting his adequate nutritional status. During a review of the admission Record indicated the facility admitted Resident 1 on 5/29/25 with diagnoses including diabetes (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), dysphagia (difficulty swallowing), lack of coordination and absence of right leg above knee.During a review of the Minimum Data Set (MDS, a resident assessment tool) dated 6/5/25 indicated Resident 1 had moderately impaired cognition. Resident 1 was dependent on shower, lower body dressing, putting on/taking off footwear, personal hygiene, substantial assistance (helper does more than half the effort) with oral hygiene, toileting hygiene, upper body dressing 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 maintain accurate and complete record for one of two sampled residents (Resident 1). For Resident 1 the facility failed to ensure:1.The Fall Risk Assessments dated 8/18/25 and 8/30/25 reflected Resident 1's risk of fall, whether Resident 1 was low risk or high risk for fall. 2.The Fall Risk assessment dated [DATE] accurately reflected that Resident 1 had a history of falls. These deficient practices resulted in an inaccurate and incomplete record for Resident 1. During a review of the admission Record indicated the facility admitted Resident 1 on 5/29/25 with diagnoses including diabetes (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), dysphagia (difficulty swallowing), lack of coordination and absence of right leg above knee.During a review of the Minimum Data Set (MDS, a resident assessment tool) dated 6/5/25 indicated Resident 1 had moderately impaired cognition. Resident 1 was dependent on shower, lower body…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 their policy for Unusual Occurrence Reporting included major accidents and follow it to report a major accidental fall with injury according to the State and Federal regulations for one of three sampled residents (Resident 1). This deficient practice resulted an outdated policy and procedures being implemented when the facility made the decision not to report a major accidental fall with injury to the State Agency (SA). During a review of Resident 1's admission Record dated 7/10/25, indicated the resident was admitted to the facility on [DATE] with diagnosis including unsteadiness on feet, lack of coordination, Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), repeated falls, major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of…

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

Based on interview and record review the facility failed to notify the resident's Power of Attorney (POA, allows someone else to manage the personal and financial matters of another person) for one of two sampled residents (Resident 1). For Resident 1, the facility failed to notify Resident 1's POA when Resident 1 had an appointment for Magnetic Resonance Imaging (MRI, medical imaging procedure for making images of the internal structures of the body) on 6/25/25. This deficient practice resulted in Resident 1 and Resident 1's POA not given their right to participate in decision making before services were provided.Findings. During a review of the admission Record indicated the facility admitted Resident 1 on 11/21/24 with diagnoses including dementia (a progressive state of decline in mental abilities), hypertension (high blood pressure) and depression. During a review of the History and Physical dated 2/15/25 indicated Resident 1 does not have the capacity to understand and make decisions. During a review of the Minimum Data Set (MDS, a resident assessment tool) dated 5/30/25…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 properly use the low air loss mattress (LAL, specialized mattress that prevents pressure ulcers [damage to an area of the skin caused by constant pressure on the area for a long time], according to the professional standard of practice for one of the two sampled residents (Resident 1). During observation on 6/27/25 at 9:20 a.m., Resident 1 had a blue reusable pad ( chux) while lying on the LAL mattress. This deficient practice had the potential to affect Resident 1's comfort level and delay healing of Resident 1's pressure ulcer. Findings: During a review of the admission Record indicated the facility admitted Resident 1 on 11/21/24 with diagnoses including dementia (a progressive state of decline in mental abilities), hypertension (high blood pressure) and depression. During a review of Resident 1's Care Plan initiated on 11/22/24 indicated Resident 1 had saccrococcyx (lower back and tail bone) pressure injury. The Care Plan goal included Resident 1 will have no complications related to the saccrococcyx…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 medications were administered as ordered by the physician for one of two sampled residents (Resident 1). For Resident 1, the facility failed to document medications were administered as soon as given and failed to document the reasons why the medications were not administered.These deficient practices resulted in the facility failing to determine if the medications were administered to Resident 1, prevent the potential for medication errors, medication duplication and delay in care and treatment to meet the needs of Resident 1. Findings:During a review of the admission Record indicated the facility admitted Resident 1 on 11/21/24 with diagnoses including dementia (a progressive state of decline in mental abilities), hypertension (high blood pressure) and depression. During a review of the History and Physical dated 2/15/25 indicated Resident 1 does not have the capacity to understand and make decisions. During a review of the Minimum Data Set (MDS, a resident assessment tool) dated 5/30/25 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 develop individualized person-centered care plan (a plan of care that summarizes a resident's health conditions, specific care and services facility staff need to provide a resident to promote healing and prevent a worsening of a condition, and current treatments) to meet the residents needs for three of six sampled residents (Resident 25, Resident 28 and Resident 45) as evidenced by: 1. Failing to create a care plan with goals and interventions for Resident 25's pressure ulcers (also known as a pressure injury, a localized area of damaged skin or tissue caused by prolonged pressure on the skin). 2. Failing to develop a care plan with person centered interventions for antidepressant medication use (medication to treat depression [a mood disorder that causes a persistent feeling of sadness and loss of interest]) for Resident 28. 3. Failing to create a care plan with goals and interventions for Resident 45's refusal of bolus (a way to send formula…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to monitor for behaviors and side effects (an effect of a drug or other type of treatment that is in addition to or beyond its desired effect) of antipsychotic medication (medication used to treat certain mental/mood disorders) for two of five sampled residents (Resident 8 and Resident 23) by failing to: 1. Monitor Resident 8 for behaviors and side effects of risperidone (Risperdal, an antipsychotic medication used to treat mental illness). 2. Monitor Resident 23 for side effects and behavioral episodes for the use of risperidone and valproic acid (a medication used to treat seizures [a burst of uncontrolled electrical activity between brain cells that caused temporary abnormalities in muscle tone or movements] and bipolar disorder [a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration]). These deficient practices have the potential to result in increased risk of taking unnecessary medication 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 observation, interview, and record review, the facility failed to ensure a safe and sanitary environment and safe food storage practices were followed in the kitchen by failing to: 1. Ensure a bag of carrots and a bag of frozen corn was labeled and dated in the freezer. 2. Ensure a plastic bag full of personal clothing and shoes belonging to staff was not stored in the dry food storage area during the initial kitchen visit. 3. Ensure a staff member`s jacket and hat were not hanging on the shelf in the dry food storage area during a follow up visit of the kitchen. These deficient practices had the potential to place the facility residents at risk for foodborne illness (illness caused by food contaminated with bacteria, viruses, and other toxins) and the growth of harmful bacteria and cross contamination (transfer of harmful bacteria from one place to another). Findings: During an initial kitchen tour on 12/13/2024 at 6:10 PM with [NAME] 1, the surveyor observed a bag of frozen carrots and a bag of frozen corn without a label and date in the freezer. [NAME] 1 stated all food…

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

Based on observation and interview, the facility failed to store the following food brought in by visitors in accordance with the facility's policy by not labeling items with the resident's name and the date it was brought to the facility: a. Three cartons of Almond Breeze. b. One plastic container of string cheese. c. One plastic bottle of Gatorade. d. One carton of Ensure original. e. One plastic container of clover honey. This deficient practice had the potential to result in the risk of food borne illness (illness caused by food contamination with bacteria, viruses, parasites, or toxins). Findings: During a concurrent observation and interview on 12/15/24 at 10:23 a.m., with Registered Nurse 1 (RN 1), while in the medication storage room, the designated residents' refrigerator was observed with the following items: three cartons of Almond Breeze, one plastic container of string cheese, one plastic bottle of Gatorade, one carton of Ensure original, and one plastic container of clover honey. These items had no resident's name or date it was brought to the facility. RN 1 stated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure a resident's oral status was assessed comprehensively for one of one sampled resident (Resident 40). This deficient practice may result in a failure to meet Resident 40's oral health needs. Findings: During a review of Resident 40's admission Record, the document indicated that the facility admitted Resident 40 on 11/28/2024 with diagnoses including acute kidney failure (a condition in which the kidneys are damaged and cannot filter blood well), atrial fibrillation (a heart condition that causes an irregular and often abnormally fast heart rate), and anemia (a condition that develops when your blood produces a lower-than-normal amount of healthy blood cells). During a review of Resident 40's Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated 12/5/2024, the document indicated that the resident had intact cognition (undamaged mental abilities, including remembering things, making 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 interview and record review, the facility failed to ensure one of three sampled residents (Resident 25), who had pressure ulcers (also known as a pressure injury, a localized area of damaged skin or tissue caused by prolonged pressure on the skin), was assessed quarterly using the Braden scale assessment (a tool used to assess a patient's risk of developing pressure ulcers). This deficient practice caused an increased risk in assessing a significant change to Resident 25's skin integrity. Findings: During a review of Resident 25's admission Record, the admission Record indicated the facility admitted the resident on 7/13/2024 with diagnoses that included a displaced communicated fracture of the shaft of the right fibula (an injury where the bone in the lower leg, specifically the middle section (shaft), has broken into multiple pieces causing a visible deformity and likely requiring surgical intervention), difficulty in walking, and anemia (a condition where the body does not have enough healthy red…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to ensure the Minimum Data Set (MDS - a resident assessment tool) was transmitted timely to the Centers for Medicare and Medicaid Services (CMS) system for one of one sampled resident (Resident 3). This deficient practice had the potential to result in delayed services for the resident. Findings: During a review of Resident 3`s admission Record, the admission Record indicated the facility originally admitted the resident on 4/13/2005, and readmitted on [DATE], with diagnoses including dementia (a progressive state of decline in mental abilities), type two diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). During a review of Resident 3's MDS dated [DATE], The MDS indicated that the resident`s cognitive skills (brain's ability to think, read, learn, remember, reason, express thoughts,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 set the resident's Low Air Loss Mattress (LALM - a pressure-relieving mattress used to prevent and treat pressure injuries) to the correct setting for one of one sampled residents (Resident 23) investigated under the pressure ulcer/injury (localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device) care area. This deficient practice had the potential to place the resident at risk for discomfort and the development of pressure ulcers/injuries. Findings: During a review of Resident 23's admission Record, the document indicated the facility admitted Resident 23 to the facility on 3/5/2024 and readmitted the resident on 7/5/2024 with diagnoses including idiopathic neuropathy (a nerve condition that affects the body's automatic function), major depression (a mood disorder that causes a persistent feeling of sadness and loss of interest and can interfere with your daily activities of living), and anxiety (persistent and excessive worry that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that one of three sampled residents (Resident 35) received the necessary care and services to prevent accidents and falls by failing to: 1. Revise Resident 35`s fall care plan (a plan of care that summarizes a resident's health conditions, specific care needs, and current treatments) after Resident 35 fell on 7/31/2024 and 10/16/2024. 2. Assess Resident 35 accurately when developing fall risk assessments. These deficient practices placed Resident 35 at an increased risk for recurrent falls. Findings: During a review of Resident 35`s admission Record, the admission Record indicated the facility originally admitted Resident 35 on 4/8/2024, and readmitted the resident on 11/11/2024, with diagnoses that included depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), lack of coordination (not able to move different parts of the body together well or easily), reduced (less) mobility, and unsteadiness on feet.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 latanoprost eye drops (a medication that required refrigeration and used to treat glaucoma) were stored in the refrigerator per the manufacturer's requirements for one resident (Resident 10) in one of one inspected medication carts (Medication Cart 1). The deficient practice had the potential to result in an increased risk that Resident 10 could have received medication that had become ineffective or toxic due to improper storage possibly leading to health complications. Findings: During a concurrent observation and interview on 12/15/2024 at 3:03 PM of Medication Cart 1 with Licensed Vocational Nurse (LVN 1) the following medications were found stored in a manner contrary to the manufacturer's requirements: 1). One unopened bottle of latanoprost eye drops (medication used to treat glaucoma, a condition in which increased pressure in the eye can lead to a gradual loss of vision, and ocular hypertension, a condition which causes increased pressure in the eye) for Resident 10 was found stored at room…

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

Based on observation, interview, and record review, the facility failed to implement its policy and procedure titled, Installation of Eye Drops (putting eye drops into residents' eyes) by failing to ensure Licensed Vocational Nurse 1 (LVN 1) washed and dried her hands thoroughly before treating each eye while administering eye drops to one (Resident 24) out of five residents investigated during a review of the infection control task. This deficient practice had the potential to cause cross contamination (unintentional transfer of bacteria/germs or other contaminants from one surface to another) infection (occurs when harmful microorganisms, such as bacteria or viruses enter the body and multiply) between Resident 24's eyes. Findings: During a review of Resident 24's admission Record, the admission Record indicated that the facility initially admitted Resident 24 on 11/26/2024 with diagnoses that included chronic systolic heart failure (a long-term condition in which a heart cannot pump blood well enough to meet the body needs), essential hypertension (high blood pressure), 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 provide range of motion (ROM, activity aimed at improving movement of a specific joint) exercises as ordered by the physician for two of three sampled residents (Resident 2 and Resident 3). For Resident 2 and Resident 3, the facility failed to: 1. Ensure the restorative nursing assistants (RNA, assist recovering residents to regain physical and cognitive capabilities through mobility and exercises) provided ROM exercises to Resident 2 and Resident 3 daily five times a week as ordered by the physician. Resident 2 and Resident 3 did not receive ROM exercises on 11/5/24, 11/7/24 and 11/12/24. 2. Create care plan that would address the restorative needs of Resident 2 and Resident 3. These deficient practices had the potential for Resident 2 and Resident 3 to develop decreased ROM and contractures (a stiffening/shortening at any joint, that reduces the joint's range of motion). Findings: 1. During a review of the admission Record for Resident 2, the admission record indicated the facility admitted Resident 2 on 7/12/24 with…

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

Based on interview and record review the facility failed to develop a person-centered care plan after a change in condition (CIC - clinically important deviation from a patient ' s baseline in physical, cognitive, behavioral, or functional domains that, without intervention, may result in complications or death) for one of four sampled residents (Resident 1). On 8/20/24, Resident 1 alleged that a person came into Resident 1 ' s room and placed a hand over Resident 1 ' s mouth. The facility failed to create a care plan that will address Resident 1 ' s allegations and the interventions and services that would be provided to Resident 1. This deficient practice had the potential for the facility not to meet the needs of Resident 1. Findings: During a review of the admission Record indicated the facility admitted Resident 1 on 8/15/24 with diagnoses including cerebrovascular disease (condition that affect the blood flow in the brain) with hemiplegia (paralysis that affects only one side of the body) and hemiparesis (weakness in one side of the body) of the right side, diabetes (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 interview and record review the facility failed to provide the necessary social services for one of four sampled residents (Resident 1). For Resident 1, the facility failed to provide social services to Resident 1 who made allegation on 8/20/24 that a person went into her room and placed a hand to cover Resident 1 ' s mouth. This deficient practice had the potential to affect Resident 1 ' s psychosocial well-being and ensure that Resident 1 felt safe. Findings: During a review of the admission Record indicated the facility admitted Resident 1 on 8/15/24 with diagnoses including cerebrovascular disease (condition that affect the blood flow in the brain) with hemiplegia (paralysis that affects only one side of the body) and hemiparesis (weakness in one side of the body) of the right side, diabetes (a condition that happens when the blood sugar [blood glucose] is too high), and anxiety disorder. During a review of the Nurse Progress Notes dated 8/20/24 at 11 p.m. indicated the licensed vocational nurse (LVN) overheard Resident 1 talking on the phone with Resident 1 ' s family…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 maintain medical records that were accurate and concise for one of four sampled residents (Resident 1). On 8/21/24 at 7 a.m., the Nurses Progress Notes indicated Resident 1 alleged that a staff member physically assaulted Resident 1. The registered nurse supervisor (RNS 1) stated Resident 1 ' s allegation that a staff member physically assaulted Resident 1 was wrong. This deficient practice resulted in the inaccurate medical record for Resident 1. Findings: During a review of the admission Record indicated the facility admitted Resident 1 on 8/15/24 with diagnoses including cerebrovascular disease (condition that affect the blood flow in the brain) with hemiplegia (paralysis that affects only one side of the body) and hemiparesis (weakness in one side of the body) of the right side, diabetes (a condition that happens when the blood sugar [blood glucose] is too high), and anxiety disorder. During a review of the Nurse Progress Notes dated 8/20/24 at 11 p.m. indicated the licensed vocational nurse (LVN) overheard Resident 1…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Amended on 4/22/2025 Based on interview and record review, the facility failed to protect the resident's right to be free from physical abuse (deliberate, aggressive, or violent behavior with the intention to cause harm) for one of two sampled residents (Resident 1), when on 6/26/2024 Resident 2 hit Resident 1 on the nose causing pain and redness to the nose. Resident 1 was subjected to abuse and psychosocial (mental health) harm by Resident 2, while under the care of the facility. Findings: A review of Resident 2's admission record indicated the facility admitted the resident on 1/19/2024 with diagnoses including Parkinson's disease (brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination), psychosis (a mental disorder, collection of symptoms that affect the mind, where there has been some loss of contact with reality) and anxiety disorder. A review of Resident 2's Behavior Problem Care Plan, initiated 3/7/2024, indicated the…

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

Based on interview and record review, the facility failed to developo a care plan (a document outlining a detailed approach to care customized to an individual resident's need) for psychotropic (a medication that affects behavior, mood, thoughts, or perception) medication for one of four sampled residents (Resident 2). This deficient practice had the potential to result in Resident 2 not receiving the appropriate care and to experience adverse (harmful) side effects which could result in injury. Findings: A review of Resident 2's admission Record indicated the facility admitted the resident on 7/18/2024 with diagnoses including unspecified psychosis (a mental disorder characterized by a disconnection from reality) schizoaffective disorder (a mental health problem where you experience psychosis as well as mood symptoms), and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest and can interfere with your daily activities of living). A review of Resident 2's Physician's Orders dated 7/18/2024, indicated the resident was to receive the following:…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 informed consent (a communication between a patient and physician that results in the patient's authorization or agreement to undergo a specific medical intervention or treatment) for an increase in the dosage of Fluvoxamine Maleate [a medication used to treat depression (a mood disorder that causes a persistent feeling of sadness and loss of interest and can interfere with your daily activities of living), with side effects that include nausea, diarrhea, tremors, seizures, fast heartbeat, insomnia (trouble sleeping), and restlessness] for one of four sampled residents (Resident 1). This deficient practice had the potential to result in Resident 1 not being informed about the medications Resident 1 was receiving and had the potential to cause the resident to experience adverse (harmful) side effects of the medication. Findings: A review of Resident 1's admission Record indicated the facility admitted the resident on 5/31/2024 with a diagnoses including depression. A review of Resident 1's Physician's Order 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 interview, and record review, the facility failed to ensure one of five sampled residents (Resident 1) diagnosed with unspecified dementia (loss of cognitive functioning-thinking, remembering, and reasoning) and major depressive disorder (a mental health condition that causes a persistently low or depressed mood and a loss of interest in activities that once brought joy) severe with psychotic symptoms (a collection of symptoms, including delusions [false beliefs, for example, that people on television are sending them special messages or that others are trying to hurt them] and hallucinations [seeing or hearing things that others do not, such as hearing voices telling them to do something or criticizing them] which happen when a person experiences a disconnection from reality) with a court delegated durable power of attorney (POA – authorizes someone else to handle certain matters, such as finances or health care, on someone ' s behalf. If a power of attorney is durable, it remains in effect if the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide a safe, comfortable, and homelike environment by failing to ensure residents ' rooms were kept with comfortable sound levels maintained for two of six sampled residents (Resident 5 and Resident 6). This deficient practice placed Resident 5 and 6 an increased level of discomfort and inability to sleep during the night that had the potential to negatively impact the resident ' s quality of life. Cross Reference F656. Findings: 1. A review of Resident 5's admission Record indicated that Resident 5 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis including type 2 diabetes mellitus (DM-a chronic condition that affects the way the body processes blood sugar [glucose]) and depression (a mood disorder that causes persistent feeling of sadness and loss of interest). A review of Resident 5's Minimum Data Set (MDS - a comprehensive standardized assessment and care-screening tool) dated 6/6/2024, MDS indicated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement a comprehensive care plan (CP) that met the care/services based on the resident's individual assessed needs for three of seven sampled residents (Resident 1, Resident 5, and Resident 6) regarding Resident 5 and 6 ' s inability to sleep and complained due to Resident 1 ' s noise at nighttime. This deficient practice had the potential to result negative impact on residents ' health and safety, as well as the quality of care and services received. Cross Reference F584. Findings: 1. A review of Resident 5's admission Record indicated that Resident 5 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis including type 2 diabetes mellitus (DM-a chronic condition that affects the way the body processes blood sugar [glucose]) and depression (a mood disorder that causes persistent feeling of sadness and loss of interest). A review of Resident 5's Minimum Data Set (MDS - a comprehensive standardized assessment and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1) who was a smoker was assessed for their ability to smoke safely prior to being allowed to smoke independently while in the facility. This deficient practice had the potential for fire related accidents in the facility among residents, staff and visitors. Findings: A review of Resident 1's admission Record indicated that Resident 1 was admitted to the facility on [DATE] with diagnosis including nicotine dependence, cigarettes (involves physical and psychological factors that make it difficult to stop using tobacco, even if the person wants to quit), chronic obstructive pulmonary disease (COPD - a group of lung diseases that block airflow and make it difficult to breathe), unspecified dementia (loss of cognitive functioning-thinking, remembering, and reasoning), major depressive disorder (a mental health condition that causes a persistently low or depressed mood and a loss of interest in activities that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to have the call light (a mechanism used by residents to promptly communicate with staff) within reach for two of five sampled residents (Resident 2 and 3). This deficient practice had the potential to result in an accident and/or injury. Findings: A review Resident 2's admission Record dated 4/26/24 indicated Resident 2 was originally admitted to the facility on [DATE] with diagnosis including hypertension (high blood pressure), hemiplegia (paralysis of one side of the body) of the right dominant side, dementia (decline in abilities to remember, make judgments, think, or make decisions), atherosclerotic heart disease (damage or disease of the heart's large vessels). A review of Resident 2's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 2/4/24 indicated Resident 2 had severe cognitive (ability to think, understand and make daily decisions) impairment and was dependent on staff for eating, oral hygiene,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 had specific choices and treatments communicated through an Advance Directives and copies of the Advance Directives (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) were maintained in the Resident's clinical record for four of forty-three Residents (Resident 2 , 28, 38 and 56). This deficient practice had the potential to cause conflict with a resident's wishes regarding health care for Residents (2, 28, 38 and 56). Findings: a. A review of Resident 2's admission record indicated Resident 2 was originally admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety (a mental disorder in which a person loses the ability to think, remember, learn, make…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 therapeutic diets were served as prescribed by the physician for three of ten sampled residents (Residents 23, 25, and 41). These deficient practices had the potential to result in the risk for decreased nutritional intake and weight loss. Findings: a. A review of Resident 23's admission record indicated the facility readmitted the resident on 10/6/2022, with diagnoses that included unspecified dementia (short-term memory loss, confusion, personality, and behavior changes) and Type II diabetes mellitus (high levels of sugar in the blood). A review of Resident 23's Minimum Data Set (MDS - a standardized assessment and care screening tool) dated 8/9/2023, indicated Resident 23 had severely impaired cognition (never/rarely made decisions) and required supervision when eating, with extensive assistance for dressing, personal hygiene, and toilet use. The MDS indicated Resident 23 did not have a swallowing disorder and did not have any…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 safe and sanitary environment, including food storage practices in the kitchen, as evidenced by: -Observation of visible dirt and stains on the dish washing machine. -Failing to label and date an open bag of grapes and cilantro in the refrigerator and a bag of shredded cheese inside the freezer. These deficient practices 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 or infection. Findings: During the initial tour and observation of the kitchen on 1/23/2023 at 7:50 AM, with the Dietary Supervisor (DS), there was dirt which appeared to be wood dust on top of the dish washing machine. There were stains on the front and sides of the dish washing machine. During a concurrent interview, the DS stated, The dish washing machine is dirty. Staff normally perform the cleaning of the dish washer every afternoon. They must have missed cleaning it yesterday. The DS stated the potential…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to follow its Informed Consent, policy and procedure (a process by which residents or their responsible parties have the choice to accept or decline certain medication therapy or treatments once they are educated about the risks and benefits) for two of five sampled residents (Resident 22 and 25) by failing to: -Ensure the facility obtained Resident 22's signature for declination of the COVID-19 (Coronavirus disease 2019 is an infectious disease caused by virus that can result in different symptoms from mild to severe respiratory illnesses and is spread during close contact and through the air from person to person) vaccination. -Ensure the facility informed and obtained the Responsible Party's (RP) signature prior to administering the influenza (a high contagious viral infection of the respiratory passages) and COVID-19 vaccinations. These deficient practices violated Resident 22's right to make an informed decision regarding the COVID-19 vaccination…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 inform a Medicare and/or Medicaid eligible resident of changes made to services covered by Medicare and/or Medicaid prior to the last covered day for one of three sampled residents (Residents 50). This deficient practice had the potential to result in Resident 50 not being provided the information needed to decide to continue or refuse receiving the specific skilled services and have those options honored. Findings: A review of Resident 50's admission record indicated the facility admitted Resident 50 on 9/27/2023 with diagnoses including schizophrenia (chronic and severe mental disorder that affects how a person thinks, feels, and behaves), bipolar disorder (extreme mood swings that include mania [emotional highs] and depression which may lead to impaired functioning), and unsteadiness on feet. A review of Resident 50's recent quarterly Minimum Data Set (MDS- a standardized assessment and care screening tool) dated 10/2/2023 indicated Resident 50 was cognitively intact (decisions consistent and reasonable) and required…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to develop an individualized person-centered care plan to meet the residents' need for two of five sampled residents (Resident 30 and 38). For Resident 30 the facility failed to develop a care plan with goals and interventions for Urinary Tract Infection (UTI- an infection in any part of the urinary system). -For Resident 38, the facility failed to develop a care plan with goals and interventions when the resident refused to receive the influenza (a high contagious viral infection of the respiratory passages), and COVID-19 (Coronavirus disease 2019 is an infectious disease caused by virus that can result in different symptoms from mild to severe respiratory illnesses and is spread during close contact and through the air from person to person) vaccinations. These deficient practices had the potential to result in and lead to inadequate care of Residents 30 and 38. Findings: a. A review of Resident 30's admission record indicated Resident 30 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.

Based on observation, interview, and record review, the facility failed to ensure residents received proper assistive devices to maintain hearing abilities by not providing both hearing aids for one of one sampled resident (Resident 18). This deficient practice had the potential to result in resident's needs not being provided and not being able to hear adequately during a conversation. Findings: A review of Resident 18's admission record indicated the facility re-admitted Resident 18 on 5/24/2021 with diagnoses that included hypertension (HTN - elevated blood pressure), glaucoma (a condition of increased pressure within the eyeball causing gradual loss of sight), and hearing loss to the left ear. A review of Resident 18's hearing assessment, dated 5/4/2023, indicated the resident had hearing loss significant enough to quality for hearing aids (HA- a device designed to improve hearing by making sound audible to a person with hearing loss). Resident 18 had greater hearing loss at higher frequencies in the left ear, meaning the resident had greater difficulty discriminating between…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 change the oxygen tubing for one of 21 sampled residents (Resident 38). This failure had the potential to result in a respiratory tract infection (an infection that affects the part of your body responsible for breathing) for Resident 38. Findings: During an observation on 1/23/2024 at 11:23 AM in Resident 38's room, there was an oxygen tube connected to the oxygen machine and to Resident 38 without a date. There was also an open equipment bag dated 1/7/2024. A review of Resident 38's admission record indicated Resident 38 was admitted to the facility 12/20/2023 with diagnoses including acute on chronic combined systolic (congestive), diastolic congestive heart failure (CHF- disease that causes the heart muscle to lose the ability to pump blood efficiently, and back pressure in the veins forces fluid to seep out and settle in the lungs and other tissues), and pneumonia (the air sacs may fill with fluid or pus). A review of the Minimum Data Set (MDS - a comprehensive assessment and care screening tool), dated…

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

Based on observation, interview, and record review, the facility failed to ensure one of one sampled resident (Resident 55) who was receiving hemodialysis (HD-a medical procedure to remove fluid and waste products from the body) had an emergency kit (supplies can be used to stop bleeding during emergency) at his bedside. This deficient practice had the potential to result in the resident to receive delayed interventions during accidental bleeding. Findings: A review of the admission record indicated the facility admitted Resident 55 on 10/18/2023, with diagnoses including end stage renal disease (ESRD, when kidneys are no longer able to work as they should to meet the needs of the body), dependence on renal dialysis (process of removing waste products and excess fluid from the body), and epilepsy (brain disorder that causes people to have recurring involuntary muscle movements, sensory disturbances and altered consciousness). A review of Resident 55's Physician's Orders, dated 12/23/2023, indicated Resident 55 required hemodialysis every Monday, Wednesday, and Friday at 4:15 AM. 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 post daily the Direct Care Service Hours Per Patient Day (DHPPD - refers to the actual hours of work performed per patient day by a direct caregiver) actual hours worked by licensed staff providing direct care to the residents per shift. As a result, residents and visitors did not know the accurate number of hours of staff working. Findings: During an observation on 1/23/2024 at 8:30 AM, the facility's posting of their DHPPD was observed. The facility did not have the DHPPD posted to indicate the actual direct care service hours for 1/22/2023 and / or 1/23/2023. During an observation on 1/24/2023 at 10:45 AM, the facility's posting of their DHPPD was observed. The facility did not have DHPPD posted to indicate the actual direct care service hours for 1/23/2024 and / or 1/24/2024. During an interview on 1/25/2024 at 10:14 AM, with Payroll (PR), the PR staff stated she was responsible for calculating and completing the DHPPD hours form. The PR staff stated she did not post the actual DHPPD hours for 1/23/2024,…

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 observation, interview and record review, the facility failed to ensure one of 21 sampled residents (Resident 45) was free of an unnecessary psychotropic (acting on the mind) medication. This deficient practice resulted in Resident 45 receiving Quetiapine (generic name Seroquel, a medication to treat mental and mood disorders) without a clinical indication or reason for use. Findings: A review of Resident 45's admission record indicated Resident 45 was originally admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included but not limited to schizophrenia unspecified (a mental disorder in which a person is disconnected from reality), epilepsy unspecified, intractable with status epilepticus (a disorder in which nerve cell activity in the brain is disturbed, causing seizures that are controlled) and essential hypertension (HTN - elevated blood pressure with no known cause). A review of Resident 45's Psychiatric consult notes from MD 2 dated 8/30/2023 indicated Resident 45 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.