Beverly Hills Rehabilitation Centre

Based on observation, interview, and record review, the facility failed to ensure one of ten sampled residents (Resident 37) received Balsalazide Disodium (medication used to treat ulcerative colitis [a condition which causes swelling and sores in the lining of the colon [large intestine] and rectum]) 750 milligrams (mg, a unit of measurement) with meals as ordered.This failure had the potential for Resident 37 to experience an upset stomach and pain.Findings:During a review of Resident 37's admission Record, the admission Record indicated the facility admitted Resident 37 on 7/18/2025, with diagnoses including peritoneal abscess(a localized collection of pus within the abdominal cavity),other specified disorders of the peritoneum ( a range of conditions affecting the thin lining of the abdominal cavity), ulcerative colitis(a chronic inflammatory bowel disease that causes ulcers in the lining of the large intestine), acute duodenal ulcer with both hemorrhage and perforation (a sudden severe sore in the upper part of the small intestine that is both bleeding and has created a hole),…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 facility staff Certified Nursing Assistant 1 (CNA 1) maintained the necessary qualifications for employment at the facility. This failure had the potential to result for CNA 1 not to have the knowledge and qualifications necessary to care for the facility's residents and placed the residents at risk for harm.Findings:During a review of CNA 1's timecard (a record, either physical or digital, that tracks an employee's work hours, including start and end times, breaks, and overtime) dated [DATE] to [DATE], the timecard indicated CNA 1 worked at the facility as a CNA on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE]. [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE].During a review of CNA 1's timecard dated [DATE] to [DATE], the timecard indicated CNA 1 worked at the facility as a CNA on [DATE], [DATE], and [DATE].During a concurrent interview and record review on [DATE] at 9:23 AM, with the Director of Staff…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 call light (a device that alerts healthcare providers that the patient needs assistance) was within reach for two of 28 sampled residents (Resident 25 and Resident 164)This deficient practice had the potential to result in delay in meeting Resident 25's and Resident 164's needs for assistance. Findings: 1.During a review of Resident 25’s admission Record, the admission Record indicated the facility admitted the resident on 9/17/2024 with diagnoses including diabetes mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing), osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage), hypertension (HTN - high blood pressure), metabolic encephalopathy (a condition where the brain's function is impaired due to chemical imbalances in the body, often caused by an underlying illness or organ dysfunction), muscle weakness, and failure to thrive (a state of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, facility failed to ensure one of four sampled residents (Resident 1)'s medications were not left at bedside after administering and documented according to facility's policy and procedures (P&P) titled, Administering Medications.This deficient practice increased the risk for accidents, unintended complications from receiving more or less than the required medications dose and jeopardized resident's health and safety by failing to administer necessary medications in accordance with the physician order.Findings:During a review of the admission Record, Resident 1 was admitted to the facility on [DATE] with diagnosis including type II Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), difficulty in walking and muscle weakness (weakening, shrinking, and loss of muscle)During a review of the Minimum Data Set (MDS - resident assessment tool) dated 6/30/2025 indicated Resident 1's cognitive (mental action or…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 one of four exit doors on the resident floors armed with an alarm that would sound when it was being opened. The failure had the potential to lead to a resident elopement (the act of leaving a facility unsupervised and without prior authorization) or accident. Findings: During an observation on 5/12/25 at 12:32 pm on the north side of the facility ' s 1st floor, to the left of room [ROOM NUMBER], a exit door to the stairwell was observed with signage CAUTION ALARM IS ON EMERGENCY EXIT ONLY and signage in red OF EMERGENCY EXIT ALARM WILL SOUND IF DOOR IS OPENED. During the same observation a tall staff member with black scrubs was observed opening the door and entering the stairwell without an alarm sounding or the staff using a key to deactivate the alarm. During a concurrent observation and interview on 5/12/25 at 12:33 pm, with Certified Nursing Assistant (CNA) 1 the exit door to the stairwell next to room [ROOM NUMBER] was observed.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility staff failed to ensure resident received appropriate treatment and services to prevent urinary tract infection (UTI- an infection in the bladder/urinary tract) for two of two sampled residents (Resident 2 and Resident 3) by failing to ensure resident's indwelling urinary (foley) catheters (a hollow tube inserted into the bladder to drain or collect urine) were placed below the level of the bladder at all times. This deficient practice had the potential to result or resulted in urinary tract infections for the residents. Findings: 1. A review of the admission Record indicated Resident 2 was admitted to the facility on [DATE] with diagnoses including benign prostatic hyperplasia (BPH - is a condition that occurs when the prostate gland enlarges, potentially slowing or blocking the urine stream) and obstructive and reflux uropathy (a condition where urine flow is blocked within the urinary tract causing urine to backflow upwards into the kidneys…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure resident assessment and documentation were complete concerning resident's death for one of three sampled residents (Resident 1) by failing to implement facility's policy and procedure (P&P) titled, Death of a Resident when Resident 1 expired on [DATE]. This deficient practice resulted in incomplete assessment and documentation for Resident 1 required per facility's policy and procedure upon death. Findings: A review of the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including acute on chronic diastolic (congestive) heart failure (CHF-a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), -chronic obstructive pulmonary disease (COPD - a group of lung diseases that block airflow and make it difficult to breathe) and respiratory failure (condition in which your blood does not get enough oxygen or has too much carbon dioxide). A review 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 maintain an infection control measure and prevention by failing to 1. Ensure the staff wear a gown to have a complete personal protective equipment (PPE-mask, gown, eye protection, gloves) before providing close-contact care for resident on Enhanced barrier precautions during high contact resident care activities. 2. Perform proper hand hygiene including changing gloves in between procedure while doing treatment care for three of three sampled residents (Resident 1, 2, and 3) per facility policy. These deficient practices have the potential to result in the spread of disease and infection to other residents, visitors, and staff. Findings: 1. A review of the admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis including hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (loss of the ability to move in one side 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 interview, and record review, the nursing staff failed to revise a care plan for at risk of bleeding and hospitalizations for one of four sampled residents (Resident 1), who had bleeding and emesis (the action or process of vomiting) on several occasions. This deficient practice had the potential to place Resident 1 at risk for recurrent bleeding and hospitalizations. Findings: A review of the admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis including hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (loss of the ability to move in one side of the body) following unspecified cerebrovascular disease (CVD - a group of conditions that affect the blood vessels and blood flow in the brain and spinal cord) affecting left dominant side, chronic respiratory failure (condition in which your blood does not get enough oxygen or has too much carbon dioxide) and type II diabetes mellitus…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure proper care for one of one sampled resident (Resident 1)'s peripheral intravenous (PIV-a small, flexible tube placed into a small vein for intravenous therapy such as medication fluids) line and site by failing to ensure labeling with date on the PIV site; assessing/ monitoring PIV site with proper documentation and timely removal of PIV when IV therapy has been discontinued for Resident 1. These deficient practices had the potential to place residents at risk for developing infections at the IV site which could also lead to sepsis (a serious condition resulting from the presence of harmful microorganisms in the blood or other tissues and the body's response to their presence, potentially leading to the malfunctioning of various organs, shock, and death). Findings: A review of the admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis including hemiplegia…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 comprehensive assessment was completed after one sampled resident (Resident 1) had a fall on 10/20/2024. Resident 1 had a bruise and a cut on the right eye, but there was no documentation from the staff regarding the injury. This deficient practice placed Resident 1 at an increased risk for a delay in treatment. Findings: A review of the admission Record indicated Resident 1 was admitted to the facility on [DATE], with diagnoses including dementia, difficulty walking, muscle weakness, and history of falling. A review of the history and physical dated 10/17/2024, indicated Resident 1 did not have the capacity to understand and make decisions. A review of Resident 1's Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 10/21/2024, indicated Resident 1 had an active diagnosis of dementia, severe cognitive impairment (problems with ability to remember, understand, or make decisions) and needed maximum assistance with bed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to follow infection prevention and control practices and implement interventions to prevent and control the spread of infections in the facility by failing to: a. Fit test (a test protocol conducted to verify that a respirator is both comfortable and provides the wearer with the expected protection) one of three Licensed Vocational Nurses (LVN 1) for the correct N95 mask (a respiratory protective device designed to achieve a very close facial fit and very efficient filtration of airborne particles). b. Ensure eight of eight staff members (Director of Nursing [DON], Infection Prevention Nurse [IPN], Registered Nurse Supervisor [RNS] 1, LVN 1, LVN 3, Certified Nursing Assistant [CNA] 1, CNA 2, and the Desk Nurse [DN]) wore the correct designated N95. c. Implement the facility ' s Policy and Procedures (P&P) titled admission Criteria dated January 2024. Two of three residents (Resident 1 and Resident 2) did not have a documented consent/refusal…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to develop a person-centered care plan timely for three of 29 sampled residents (Residents 117, Resident 51, and Resident 136). Resident 117, who was receiving occupational therapy (OT, rehabilitative profession that provides services to increase and/or maintain a person's capability to participate in everyday life activities) services, did not have a care plan for OT treatment. Resident 51 did not have a care plan for the Hoyer Lift during transfer and Resident 136 did not have an Out On Pass care plan. These deficient practices caused an increased risk in accidents leading to harm and there was a lack of individualized care effecting the services provided to the residents. Findings: a. A review of Resident 117's admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses including brachial plexus (network of nerves in the shoulder) disorders, muscle weakness, and difficulty walking. A review of Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure three of three sampled residents (Resident 144, Resident 39 and Resident 294), who received dialysis (process of removing waste products and excess fluid from the body) treatment received care and services in accordance with the professional standards of practice, by failing to: -Document Resident 294's assessment in the dialysis communication record. -Communicate with the resident's dialysis center about Epogen (a medication to treat anemia caused by chronic kidney disease) being administered during dialysis treatment for Resident 39 and Resident 294. Findings: a. A review of Resident 144's admission record indicated the facility admitted the resident on 7/9/2024 with diagnoses including end stage renal disease (ESRD - loss of kidney function in which the kidneys no long work to meet the body's needs) and dependence on renal dialysis (the process of removing waste products and excess fluid from the body using a machine when 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 have an effective pest control program when a fly was observed in the kitchen area. This deficient practice had the potential for residents at the facility to be at risk for food borne illness (illness caused by food contaminated with bacteria, viruses, parasites, or toxins). Findings: During a concurrent observation and interview with the Dietary Director (DD) in the kitchen on 7/17/2024 at 11:18 AM, a fly was observed flying around during tray line. The DD stated, How did that get in here? The DD stated if a fly was in the kitchen, the fly could bring bacteria and the residents could have an infection. During an interview on 7/18/2024 at 2:20 PM, the Maintenance Supervisor (MS) stated having insects or rodents in the facility could be an infection control problem. The MS stated the residents or staff could have an allergic reaction and if a fly was in the food or water, the food or water could become contaminated. A review of the facility's policy and procedure (P&P) titled, Pest Control, dated January…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 an advance directive acknowledgement form (a 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) was complete and in the resident's medical chart for one of seven sampled resident (Resident 133). This deficient practice had the potential to result in the facility not honoring the resident's medical decisions regarding end-of-life treatment. Findings: A review of Resident 133's admission Record indicated the facility admitted Resident 133 on 6/5/2024 with diagnoses including cerebrovascular disease (a condition that affect blood flow to your brain), myocardial infraction (a condition that happens when one or more areas of the heart muscle don't get enough oxygen), and diabetes Type II (a long-term medical condition in which the body does not use insulin [a hormone that lowers the level of sugar in the blood] properly). A review of Resident 133's Minimum Data Set (MDS- 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 provide a bed hold notification (holding or reserving a resident's bed while the resident is absent from the facility for therapeutic leave or hospitalization) in writing, at the time of transfer to the hospital for one of three sampled residents (Resident 61). This deficient practice denied Resident 61 or the Responsible Party (RP) of being informed of the resident's right to have the facility hold and reserve his bed while absent from the facility. Findings: A review of Resident 61's admission Record (Face Sheet) indicated the facility originally admitted the resident on 5/29/2024, and readmitted on [DATE], with diagnoses including anemia, urinary tract infection (UTI) and chronic kidney disease (kidneys are damaged and cannot filter blood as well as they should). A review of Resident 61's Bedhold Notification form, dated 5/29/2024 indicated the form had two sections, the first was To be Completed upon Admission and the second was To be Completed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 update one of 29 sampled residents (Resident 56) physical therapy (PT, a rehabilitation profession that restores, maintains, and promotes optimal physical function) and occupational therapy (OT, rehabilitative profession that provides services to increase and/or maintain a person ' s capability to participate in everyday life activities) care plans to reflect changes in the PT and OT services. This deficient practice had the potential for Resident 56 to receive incorrect services and minimize the facility's ability to review the effectiveness of PT and OT services. Findings: A review of the admission Record indicated Resident 56 was admitted to the facility on [DATE] with diagnoses including cerebral edema (swelling in the brain), muscle weakness, difficulty walking. A review of the Physician's History and Physical Examination dated 12/11/23 indicated Resident 56 did not have the capacity to understand and make decisions. A review of Minimum Data Set…

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

Based on observation, interview, and record review, the facility failed to ensure that residents were provided a communication device or board with the language that the resident was able to understand for one of one sampled resident (Resident 133). This deficient practice prevented the resident from communicating with the staff and had the potential to delay receiving the care/treatment the resident needed. Findings: A review of Resident 133's admission Record indicated the facility admitted Resident 133 on 6/5/2024 with diagnoses including cerebrovascular disease (a condition that affect blood flow to your brain), myocardial infraction (a condition that happens when one or more areas of the heart muscle don't get enough oxygen), and diabetes type two (a long-term medical condition in which the body does not use insulin [a hormone that lowers the level of sugar in the blood] properly). A review of Resident 133's Minimum Data Set (MDS- standardized assessment and care planning tool) dated 6/9/2024, indicated that the resident had moderately impaired cognition (a moderate damaged…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 obtain a physician's order for a low air loss mattress (LALM) and to maintain the correct setting of a LALM for one of three sampled residents (Resident 128). This deficient practice had the potential to result in the failure of delivery of necessary care to maintain the skin integrity (the health of skin) of Resident 128. Findings: A review of Resident 128's admission Record indicated that the facility admitted Resident 128 on 4/26/2024 and readmitted her on 5/3/2024 with diagnoses including polyneuropathies (a condition when multiple peripheral nerves became damaged), type 2 diabetes (a long-term medical condition in which the body does not use insulin [a hormone that lowers the level of sugar in the blood] properly), and pressure ulcer of right hip unspecified stage (areas of damaged skin and tissue caused by sustained pressure that reduces blood flow to vulnerable areas of the right hip). A review of Resident 128's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 5/9/2024,…

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 b. A review of Resident 19's admission Record indicated the facility admitted the resident on 6/5/24 with diagnoses including muscle weakness (decrease in muscle strength), difficulty in walking, and osteoarthritis (a degenerative joint disease, in which the tissues in the joint break down over time). A review of Resident 19's Physical Therapy Care Plan dated 6/6/2024, indicated a goal for the resident for wheelchair mobility to be improved. The Care Plan indicated interventions for wheelchair mobility training but did not include ensuring foot rests must be applied during wheelchair use. A review of Resident 19's Decreased Functional Mobility Care Plan dated 6/6/2024, indicated a goal for the resident to improve activities of daily living (ADL) skills. The Care Plan indicated interventions for wheelchair mobility but did not include ensuring foot rests must be applied during wheelchair use. A review of Resident 19's MDS dated [DATE], indicated the resident had severe cognitive impairment (ability to think,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 there was an emergency drug supply (E-Kit) usage or administration log. The facility also failed to ensure there was wastage documentation of a controlled drug removed from the E-Kit. These deficient practices had the potential of drug diversion and / or medication errors. Findings: On 7/16/2024 at 2:04 PM during an observation and a concurrent interview in the medication room at the nursing station on the first floor, Licensed Vocational Nurse (LVN) 1 did not know of an administration log or binder for the E-kit. LVN 1 stated nurses fill out the emergency drug kit slip and place it in the E-kit after removing a medication from the kit. During an interview on 7/16/2024 at 2:12 PM, Registered Nurse Supervisor (RN) 1 stated nurses would turn in the yellow slip to Assistant Director of Nursing (ADON). On 7/16/2024 at 2:15 PM during an interview, the ADON presented a Ziploc bag containing a stack of yellow emergency drug kit slips (the yellow carbon copy indicated it was facility record), stacked, approximately about…

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

Based on observation, interview, and record review, the facility failed to maintain proper storage of medications for one of 10 sampled residents (Resident 76), when a bottle of Vitamin C (a nutrient that is vital to the body's healing process) was at the bedside. This deficient practice had the potential for Resident 76 to take medications without the supervision of staff. Findings: A review of Resident 76's admission Record indicated the facility admitted the resident on 5/17/2024 with diagnoses including anxiety (feelings of fear, dread, and uneasiness that may occur as a reaction to stress), muscle weakness (decrease in muscle strength), 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). A review of Resident 76's Minimum Data Set (MDS - a standardized resident assessment and care screening tool) dated 7/3/2024, indicated the resident's cognition was intact with an active diagnoses of anxiety disorder, depression, and muscle weakness. A review of Resident 76's Nursing…

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

Based on observation, interview, and record review, the facility failed to store food in accordance with professional standards of practice by not labeling several food items with received date or use by date and failed to ensure safe and clean sanitary coffee cups were served to residents in accordance with professional standards for food service safety. These deficient practices had the potential for residents in the facility to be at risk for food borne illness (illness caused by food contamination with bacteria, viruses, parasites, or toxins). Findings: a. During a concurrent observation and interview on 7/15/24 at 8:15 AM, the Dietary Director (DD) observed one bag of mozzarella cheese, one block of white cheese, and one block of cheddar cheese without a received date. The DD observed one bag of shredded cheese without a use by date. The DD observed one container of tomatoes, one container of green and red bell peppers, one container of lemons, and one container of oranges without a received or use by date. The DD stated there should have been a label with a received date and a…

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

Based on observation, interview, and record review, the facility failed to ensure the trash stored in the dumpster areas were maintained in a sanitary manner. a. Two of four garbage dumpsters were overfilled with plastic bags and a cardboard box. b. One of four garbage dumpsters had the lid open. c. One of four garbage dumpsters lid was broken and cut in half. These deficient practices had the potential for harborage and feeding of pests. Findings: During a concurrent observation and interview with the Housekeeping Director (HD) on 7/17/2024 at 12:07 PM, there were two dumpsters outside of the kitchen back exit that were over filled with trash bags. One dumpster had the lid propped open with trash overflowing and another dumpsters lid could not close because the dumpster was overflowing with trash bags. There was a foul odor with flies flying around the dumpster. The HD stated the dumpsters should have been closed and not overflowing with trash. The HD stated if the dumpsters were not closed, the smell would attract flies and there could be an infection control issue because 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 provide rehabilitative therapy services for two of seven sampled residents (Residents 136 and 117). Resident 136 did not receive a speech therapy (ST, profession that identifies, assesses, and treats speech, language, cognitive communication, and swallowing disorders) evaluation timely and the Occupational therapy (OT, rehabilitative profession that provides services to increase and/or maintain a person's capability to participate in everyday life activities) services were provided to Resident 117 without renewing an active physician's order for continuation of OT services. These deficient practices had the potential for a delay of therapy services and provision of therapy services without physician's approval. Findings: a. During an observation and interview in Resident 136's room, on [DATE] at 1:22 PM, Resident 136 was sitting at the edge of the bed with bedside table in front. Resident 136 was able to eat lunch independently. A review…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the hospice residents binder had a copy of the Certification of Terminal Illness (CTI) for one sampled resident (Resident 8). This deficient practice resulted in failure to comply and coordinate with Hospice services. Findings: A review of Resident 8's admission Record indicated the resident was re-admitted to the facility on [DATE], with diagnoses including multiple sclerosis (disabling disease of the brain and spinal cord that causes the nerves to deteriorate or become permanently damaged) and pressure ulcer (an injury that breaks down the skin and underlying tissue, also known as bedsore or pressure sore). A review of the Physician's Order, dated 6/3/2024, indicated to admit Resident 8 to a hospice agency on a routine level of care for Stage IV pressure injury (deep wound reaching the muscles, ligaments, or bones) and protein calorie malnutrition. A review of the hospice and facility contract, dated 6/6/2024, indicated hospice…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program by not providing supplies for hand hygiene in the occupational therapy (OT, rehabilitative profession that provides services to increase and/or maintain a person's capability to participate in everyday life activities) gym for staff to perform hand hygiene before and after donning (putting on) and doffing (taking off) protective personal equipment (PPE, protective gloves, gowns, facemasks, and other equipment designed to protect the wearer from the spread of infection or illness) under enhanced barrier precautions (EBP, (intervention designed to reduce transmission of infectious organisms). The facility also failed to label oxygen tubing with date when it was changed for Resident 12. These deficient practices had the potential to cause complications associated with oxygen therapy for the residents. These deficient practices had the potential to spread infections among facility staff,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 licensed nursing staff failed to offer the influenza as required or appropriate to one of five sampled residents (Resident 12). This deficient practice placed Resident 12 at increased risk of acquiring and/or transmitting the flu and pneumonia to other residents in the facility. Findings: A review of Resident 12's Immunization History Report, dated 9/19/2023, indicated Resident 12 last received the flu vaccine on 9/1/2020. A review of Resident 12's admission Record indicated the resident was originally admitted to the facility on [DATE] and re-admitted to the facility on [DATE], with diagnoses including heart failure (condition in which the heart muscle is unable to pump enough blood to meet the body's needs for blood and oxygen), end stage renal disease (loss of kidney function in which the kidneys no long work to meet the body's needs) and Stage IV pressure ulcer (deep wound reaching the muscles, ligaments, or bones). A review of Resident 12's Minimum Data Set (MDS- a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to offer the Coronavirus Disease (COVID-19) vaccination to two of five sampled residents (Resident 12 and 132). This deficient practice placed Resident 12 and Resident 132 at a higher risk of acquiring and transmitting the COVID-19 to other residents in the facility. Findings: a. A review of Resident 12's admission Record indicated the resident was readmitted to the facility on [DATE], with diagnoses including acute respiratory failure, Schizophrenia (a serious mental disorder in which people interpret reality abnormally) and atrial fibrillation (a-fib - an irregular and often rapid heart rhythm). A review of Resident 12's Minimum Data Set (MDS- a standardized assessment and screening tool) dated 9/8/2023, indicated the resident had severely impaired cognition (never/rarely made decisions) and the resident was totally dependent on staff for transfer, dressing, eating, toilet use and personal hygiene. A review of Resident 12's History and Physical, 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 sample residents (Resident 1) was free from medication errors. This failure resulted in Resident 1 receiving a discontinued medication gabapentin (medication used for seizures or nerve pain) 100 mg (milligrams) that was not removed from the medication cart. Findings: A review of Resident 1 ' s admission Record dated 3/27/24, indicated Resident 1 was admitted to the facility on [DATE], with diagnoses including aftercare following joint replacement surgery, primary osteoarthritis (protective cartilage around joint wears down causing, joint swelling, pain, tenderness bone spurs [extra bits of bone form around the joint]) of left knee, legal blindness, difficulty walking and muscle weakness. A review of Resident 1 ' s Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 2/4/24 indicated Resident 1 had moderately impaired cognition (ability to think, understand and make daily decisions) and required limited…

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

Based on interview and record review, the facility failed to provide protection from abuse by a family member for one of three sampled residents (Resident 1). Resident 1 reported to the facility staff and police that her Family Member slapped her in the face on 2/26/2024 and the next day the Family Member returned to the facility and was found in Resident 1's room. This deficient practice placed the resident at increased risk for further abuse from the Family Member. Findings: A review of the admission record, dated 8/7/2023 indicated Resident 1 was admitted to the facility with diagnoses including encephalopathy (a change in the way your brain works or a change in your body that affects your brain), essential hypertension (abnormally high blood pressure, not the result of a medical condition), chronic pain syndrome (causes pain and other symptoms in certain parts of your body, usually in your extremities). A review of the Minimum Data Set (MDS - a comprehensive assessment and care screening tool) dated 2/6/2024, indicated Resident 1 had no evidence of acute change in mental status.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed ensure transportation to hemodialysis (is the process of removing excess water, solutes, and toxins from the blood in people whose kidneys can no longer perform these functions naturally) treatments for one of three sampled residents (Resident 3). This deficient practice resulted in Resident 3 missing six of the ten ordered Saturday dialysis treatments ordered starting 1/6/24. Findings: A review of Resident 3's admission Record dated 3/5/24 indicated Resident 3 was admitted to the facility on [DATE], with diagnoses including, end stage renal disease (a condition in which the kidneys lose the ability to remove waste and balance fluids), type II diabetes mellitus (DMII, a condition where your body has trouble controlling the level of sugar in the blood), hypertension (high blood pressure), difficulty walking, and muscle weakness. A review of Resident 3's Minimum Data Set (MDS a standardized assessment and care screening tool) dated 12/29/23 indicated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of four sampled residents (Resident 1) was free from a psychotropic medication (drug that affects how the brain works and causes changes in mood, awareness, thoughts, feelings, or behavior). This failure resulted in Resident 1 receiving ordered medication Divalproex Sodium (medication used to treat seizures and also the manic [an abnormally elevated, extreme changes in mood, behaviors, activity and energy levels] phase of bipolar disorder [mental illness that causes extreme mood swings with emotional highs and lows]) Oral Tablet Delayed Release 125 milligrams (mg, unit of measurement). Findings: A review of Resident 1's admission Record dated 2/28/24, indicated Resident 1 was admitted to the facility on [DATE], with diagnoses including dementia (loss of memory, language, problem-solving and other thinking abilities severe enough to affect daily life), sleep disorder (problems with the quality, timing, and amount of sleep), major depressive…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 answer the nursing station telephone on second floor in a timely manner. This failure resulted in the caller hanging in up before the call was answered and potentially delaying care. Findings: During an observation on 1/8/24 at 3:45 pm, no staff are observed behind the nursing station on the second floor, and the nursing station telephone rang 17 times before the caller hanging up the unanswered phone call. The telephone display screen indicated it was a General Acute Care Hospital (GACH) that was calling. During an interview on 1/18/24 at 1:15 pm, with the Director of Nursing (DON), the DON stated the ward clerk or licensed staff are tasked with answering the telephone at the nursing station and forwarding to appropriate staff. The DON further stated, it is important to answer the phone because in case of emergency, interventions can be provided. During a review of the facility ' s policy and procedures titled Resident Rights, revised August 2023, indicated resident ' s right to: . communication with 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 ensure pressure injury (pressure ulcer/ injury or bed sore, an injury to the skin that develops over bony areas of the body from prolonged pressure to the area) precautions were followed for one of three sampled residents (Resident 1). By failing to: 1. Failing to accurately assess the resident ' s risk for pressure sore ' s upon admission on [DATE]. 2. Failing to develop a care plan for pressure sore on admission to the facility on [DATE]. 3. Follow care plan intervention for pressure reducing mattress started on 10/29/24 for decline in pressure sore. This failure resulted in a worsening of Resident 1 ' s sacrococcygeal pressure injury from stage two (partial thickness loss of dermis [top layer of skin] presenting as an open sore with a pink or red wound bed) pressure injury, to a stage three (full thickness tissue loss, with exposure of subcutaneous [deepest layer of skin made up of connective tissue and fat] up to the muscle facia (tissue 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 ensure the call lights were functioning properly for three of five sampled residents (Residents 3, 4 & 5). This failure resulted in Residents 3, 4 and 5 not having a properly functioning call light to use in case they needed to call staff for assistance. Findings: A review of Resident 3's admission Record, dated 12/15/23, the admission Record indicated, the resident was admitted to the facility on [DATE] with diagnoses including myocardial infarction (heart attack), metabolic encephalopathy (disorder of the brain due to a chemical imbalance in the body), and adult failure to thrive (syndrome of global decline that occurs in older patients as an aggregate of frailty, cognitive impairment, and functional disability, complicated by medical comorbidities and psychosocial factors). A review of Resident 3 ' s Minimum Data Set (MDS, a standardized assessment and screening tool), dated 11/8/23, the MDS indicated, Resident 3 had severe memory…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 plan of care for peripherally inserted central catheter (PICC, a long, thin tube that's inserted through a vein in the arm and passed through to the larger veins near the heart ) was followed for one of five sampled residents (Resident 2) by failing to ensure the PICC line dressing remained intact. This failure had the potential to result in Resident 2 being exposed to PICC line infection. Findings: A review of Resident 2's admission Record, dated 12/15/23, the admission Record indicated, the resident was admitted to the facility on [DATE] with diagnoses including infection of the skin and subcutaneous (deepest layer of skin made up of fat and connective tissue) tissue, muscle weakness, osteoarthritis (degenerative joint disease) of bilateral (both sides) knees, and osteomyelitis (infection in the bone) of vertebra (spine bone) in thoracic (mid back) region. A review of Resident 2 ' s Minimum Data Set (MDS, a standardized…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of five sampled residents (Resident 2) was given a physician ordered Zolpidem Tartrate (medication used for insomnia [sleep disorder]) timely. This failure resulted in Resident 2 having to wait until the early morning hours (3:25 am) to receive the medication she had requested at her bedtime (11:00 pm). Findings: A review of Resident 2's admission Record, dated 12/15/23, the admission Record indicated, the resident was admitted to the facility on [DATE] with diagnoses including infection of the skin and subcutaneous (deepest layer of skin made up of fat and connective tissue) tissue, muscle weakness, osteoarthritis (degenerative joint disease) of bilateral (both sides) knees, and osteomyelitis (infection in the bone) of vertebra (spine bone) in thoracic (mid back) region. A review of Resident 2 ' s Minimum Data Set (MDS, a standardized assessment and screening tool), dated 11/8/23, the MDS indicated, Resident 2 had mild memory issues, 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 develop a comprehensive and resident-centered care plan regarding a resident ' s actual fall for one of five sampled residents (Resident 1). This deficient practice had the potential to place Resident 1 at risk for subsequent falls and possible injury. Findings: A review of Resident 1's admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included polyneuropathy (simultaneous malfunction of many peripheral nerves throughout the body), muscle weakness, difficulty in walking, and bilateral primary osteoarthritis (a degenerative joint disease, in which the tissues in the joint break down over time) of the hip. A review of Resident 1's fall risk assessment, dated 7/13/2023, indicated Resident 1 had a score of 22. Any score between 16-42 indicated a resident was a high risk for fall. A review of the Interdisciplinary Conference Note, dated 7/25/2023, indicated Resident 1 was at risk for accidents and falls. A…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to implement the facility's policy and procedure during a change in a resident's condition or status to inform resident's responsible party for one of six sampled residents, Resident 1. This deficient practice violated the resident and responsible party the right to be notified and participate in the changes to the plan of care. Findings: During a review of Resident 1's admission Record indicated Resident 1 was originally admitted on [DATE] and readmitted on [DATE] with diagnoses including sepsis (a life-threatening condition that arises when the body's response to infection causes injury to its own tissues and organs), hereditary and idiopathic neuropathy (an illness where sensory and motor nerves of the peripheral nervous system are affected), type II diabetes mellitus (DM - a chronic condition that affects the way the body processes blood sugar [glucose]), difficulty in walking, and muscle weakness. During a review of Resident 1's admission Record…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 meet professional standards of quality by failing to implement the facility's policy and procedure titled, Assessing Falls and Their Causes, to complete an incident report for resident falls . the incident report form should be completed by the nursing supervisor on duty at the time for one of six sampled residents, Resident 1. This deficient practice resulted in Resident 1's not receiving proper assessment and monitoring after he had an unwitnessed fall. Findings: During a review of Resident 1's admission Record indicated Resident 1 was originally admitted on [DATE] and readmitted on [DATE] with diagnoses including sepsis (a life-threatening condition that arises when the body's response to infection causes injury to its own tissues and organs), hereditary and idiopathic neuropathy (an illness where sensory and motor nerves of the peripheral nervous system are affected), type II diabetes mellitus (DM - a chronic condition that affects 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 six sampled residents (Resident 2), was transferred from the bed to a wheelchair using a two-person assist by using a Mechanical lift (sling lift, an assistive device that allows residents to be transferred between a bed and a chair, by the use of electrical or hydraulic power). This failure had the potential to place Resident 4 at risk for falls or injury possible fracture while being transferred from the bed to a wheelchair solely by Certified Nursing Assistant (CNA 1). Findings: During a review of Resident 2's admission Record indicated Resident 2 was originally admitted on [DATE] and readmitted on [DATE] with diagnoses including toxic encephalopathy (a disease in which the functioning of the brain is affected by some agent or condition-such as viral infection or toxins in the blood), hemiplegia and hemiparesis (loss of the ability to move in one side of the body) following cerebral infarction (lack of blood flow…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to offer and/or provide the pneumococcal (bacteria that can cause infections including pneumonia [PNA, inflammation of the lungs] and Coronavirus disease (COVID-19, a disease that is very contagious and spreads quickly) immunizations (protection against a disease through vaccination) for three of five sampled residents (Resident 1, Resident 2, and Resident 3). This failure had the potential for the residents to infected with pneumonia and COVID-19. Findings: 1.During a review of the admission Record indicated the facility admitted Resident 1 on 8/11/2023 with diagnoses including metabolic encephalopathy (condition in which the brain function is disturbed either temporarily or permanently due to different diseases) and muscle weakness. During a review of the Minimum Data Set (MDS, standardized screening and assessment tool) dated 8/14/22023, indicated Resident 1 had severely impaired decision-making regarding tasks of daily life. Resident 1 needed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 infection preventionist (IP, professionals responsible for the infection prevention and control program) complete 10 hours of continuing education (CE) on an annual basis. This failure had the potential for the IP to not be up to date with the latest infection control thus affecting the residents and staff in the facility. Findings: During a review of the IP certificate titled Nursing Home Infection Preventionist Training Course (Web-based), indicated the IP obtained the certificate on 2/21/2021. During an interview on 9/13/2023 at 9:40 a.m., the IP confirmed that her certificate for infection control was dated 2/21/2021. IP further confirmed and stated she did not complete the required 10 hours of annual continuing education (CE) and stated there are always changes with infection control practices. During an interview on 9/14/2023 at 11:53 a.m., the director of nursing (DON) stated the IP should complete 10 hours of CE to, . keep up to date with the changes in infection control. During 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to supervise and ensure activities of daily living (ADL- mobility, positioning, nutrition, personal hygiene, grooming, toileting, bathing and bowel and bladder) was provided for three of three sampled residents, (Residents 1, 2 , and 3). The facility determined Residents 1, 2, and 3 were dependent on staff for ADL. These deficient practice resulted in: 1. Residents 1, 2 and 3 remaining in wet or soiled incontinent briefs on 9/5/2023 during the 7 a.m. to 3 p.m. shift. 2. Residents 1 and 2 had an odor that smelled like urine on 9/5/2023 3. Resident 3 had brownish gray crust like substance was stuck all on the lips, mouth, and tongue on 9/5/2023. Findings: 1. A review of Resident 1's admission Record indicated the facility originally admitted Resident 1 on 2/27/2020, and readmitted the resident on 8/11/2023 with diagnoses including Non-ST-elevation myocardial infarction (NSTEMI - a type of heart attack that usually happens when your heart's need…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to notify the attending physician for one out of three sampled residents (Resident 1) of a change in skin condition requiring care and treatment orders. This deficient practice resulted in Resident 1 ' s stage I pressure ulcer (redness to skin that does not fade under pressure, indicating there is good blood flow return) worsening to a stage II (redness with possible blister or open sore due to direct pressure over the bony area) on sacral coccyx (lower back and mid buttocks) and Resident 1 not receiving treatment for the pressure ulcer from [DATE] to [DATE]. Placing the resident at risk for complications resulting from untreated or improperly treated pressure ulcers which could result in systemic infections that could lead to death. Cross Reference: F656, F686 Findings: A review of Resident 1 ' s admission record indicated the facility admitted the resident on [DATE] with diagnoses which included aphasia (difficulty speaking) following cerebral infarction…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure one out of three sampled residents (Resident 3 ' s) medical records had accurately documented assessment and treatment reflective of the resident ' s status during a cardiac arrest (when the heart suddenly and unexpectedly stops pumping). This deficient practice resulted in Resident 1 ' s medical records being inaccurate and missing vital information of treatment and services provided while attempting to revive the resident. Findings A review of the admission Record indicated the facility admitted Resident 3 on [DATE] with diagnoses including aphasia (difficulty speaking) following cerebral infarction (stroke), Diabetes Mellitus (a chronic, metabolic disease characterized by elevated levels of blood sugar), Alzheimer ' s disease (progressive mental decline due to generalized breakdown of the brain), and hypertension (high blood pressure). A review of the Minimum Data Set (MDS - an assessment and screening tool), dated [DATE], indicated 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 interview, and record review the facility failed to assess, develop, and implement and revise as indicated in the facility ' s policy and procedures an individualized (resident-specific) care plan for one out of three sampled residents (Resident 1) who had pressure ulcers. This deficient practice resulted in Resident 1 ' s stage I pressure ulcer worsening to a stage II and Resident 1 not receiving treatment for the pressure ulcer from 12/02/2023 to 12/06/2023. Placing the resident at risk for complications resulting from untreated or improperly treated pressure ulcers which could result in systemic infections that could lead to death. Cross reference: F580, F686 Findings: A review of Resident 1 ' s admission record indicated the facility admitted the resident on 11/12/2021 with diagnoses which included aphasia (difficulty speaking) following cerebral infarction (stroke), Diabetes Mellitus (an impairment in the way the body regulates and uses sugar [glucose] as a fuel), Alzheimer ' s disease (progressive mental decline due to generalized breakdown of the brain), and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide pressure ulcers/injuries (injuries to the skin and underlying tissue, primarily caused by prolonged pressure on the skin) care, and treatments for one of three sampled residents (Resident 1) by failing to: 1. Follow the facility ' s policy and procedures and provide Resident 1 with a low air loss mattress (LAL: mattress filled with air used to help prevent and treat pressure ulcers) to prevent further wound decline. 2. Obtain physician orders to treat Resident 1 ' s stage I pressure ulcer on [DATE]. This deficient practice resulted in Resident 1 ' s stage I pressure ulcer worsening to a stage II and Resident 1 not receiving treatment for the pressure ulcer from [DATE] to [DATE]. Placing the resident at risk for complications resulting from untreated or improperly treated pressure ulcers which could result in systemic infections that could lead to death. Cross Reference: F580, F656 Findings: A review of Resident 1 ' s admission record indicated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to: a. Administer medications as per physician ' s order, and accurately document and administered medication according to the facility ' s medication scheduled time for three of six sampled residents, (Residents 3, 5, and 6). b. Monitor and document heart rate prior to administering carvedilol (medication to lower blood pressure that can lower heart rate) for one of six sampled residents, (Resident 3). c. Check the blood pressure before giving amlodipine (medication used to lower blood pressure) and Metoprolol (medication to lower blood pressure that can lower heart rate) for one of six sampled residents, (Resident 5). These deficient practices had the potential to cause the residents blood pressure and heart rate to decrease leading to dizziness, confusion, weakness and possibly death. Findings: On 8/8/2023 at 4:32 p.m. the California Department of Public Health (CDPH) received a complaint regarding Resident 3 not receiving scheduled heart…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 a safe discharge plan to home for one of three sampled residents (Resident 1) in accordance with the facility ' s policy and procedures titled Discharge Summary and Plan dated October 2022. The facility discharged Resident 1 on 2/23/2023 at 6:30 PM. Resident 1 required one person assist with ambulating (walking) on level surfaces and assistance for safety at home. As a result, Resident 1 fell at home on 2/25/2023, and was admitted to a General Acute Care Hospital (GACH) with diagnoses including second degree burn (burn that effect the outer and inner layer of skin) to face due to scalding (extremely hot) food and ground level fall. Findings: A review of Resident 1 ' s admission record (face sheet) dated 1/31/2023, indicated the facility admitted Resident 1 on 1/31/2023 from a GACH with diagnoses that included fracture (broken bone) of left tibia (bone in the lower part of the leg), malignant neoplasm of female breast (breast cancer that has spread to other parts of the body), and acute embolism and thrombosis of deep…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure three of four sampled Residents (Resident 1, Resident 2, and Resident 7) had received timely ADL (activities of daily living) care and Resident 2 had ADLs performed daily. This deficient practice had the potential to cause impaired skin integrity, infection and psychosocial harm related to neglect. Findings: 1. A review of Resident 2's admission record (face sheet) indicated the facility admitted Resident 2 on 11/18/2022 with a readmission on [DATE] from the general acute care hospital (GACH) with diagnoses that included metabolic encephalopathy (brain disease, damage, or malfunction usually related to inflammation within the body), hemiplegia (weakness or unable to move one side of the body) following unspecified cerebrovascular disease (conditions that affect blood flow and the blood vessels in the brain) affecting right dominant side, dysphagia (difficulty with swallowing) and type 2 diabetes (a problem in the way the 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 implement its policy regarding Release of Information and provided 1 of 3 sampled residents (Resident 2) a copy of the requested medical records within 48 hours of receiving a written requested. This deficient practice violated the right of Resident 2 representatives to obtain a copy of the requested medical records within 48 hours. Findings: A review of Resident 2 ' s admission record (face sheet) indicated, Resident 2 was admitted to the facility on [DATE] with a readmission on [DATE] from the general acute care hospital with diagnoses that included metabolic encephalopathy (brain disease, damage, or malfunction usually related to inflammation within the body), hemiplegia (weakness or unable to move one side of the body) following unspecified cerebrovascular disease (conditions that affect blood flow and the blood vessels in the brain) affecting right dominant side, dysphagia (difficulty with swallowing) and type 2 diabetes (a problem in the way 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 develop and implement a comprehensive care plan for a left leg cast (rigid covers that keep the knee and lower keg still) for one of three sampled residents (Resident 1). This deficient practice had the potential to place the residents at risk for insufficient provision of care and services related to the use of a full leg cast and can lead to injury. Findings: A review of Resident 1 ' s admission Record indicated the facility admitted Resident 1on 7/1/2023 with diagnoses including rheumatoid arthritis (autoimmune [immune system attacking healthy cells in the body by mistake] and inflammatory [painful swelling] disease usually attacking many joints at the same time), difficulty in walking and generalized muscle weakness (decreased strength of the muscles). A review of Resident 1 ' s Minimum Data Set (MDS - a standard assessment and care screening tool) dated 7/8/2023, indicated Resident 1 was cognitively (mental ability to make decisions of daily living) intact. The MDS indicated Resident 1 required limited assistance for…

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

Based on interview, and observation, the facility failed to ensure one of three sampled Residents (Resident 7), had a functioning call light. This deficient practice had the potential for Resident 7 ' s needs not been met and could result in frustration, falls, injuries, and accidents. Findings: A review of Resident 7 ' s admission Record indicated the facility admitted Resident 7 on 7/10/2023 with diagnoses including difficulty in walking, history of falling, Parkinson ' s disease (brain disorder that causes unintended movements, such as shaking, stiffness, and difficulty with balance and coordination) and generalized muscle weakness (decreased strength of the muscles). A review of Resident 7 ' s Minimum Data Set (MDS - a standard assessment and care screening tool) dated 7/17/2023, indicated Resident 7 was cognitively (mental ability to make decisions of daily living) intact. The MDS indicated Resident 7 required extensive assistance for bed mobility, transfers, dressing, toilet use and personal hygiene. On 7/11/2023 at 10:25 a.m., during a concurrent facility tour observation and…

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

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety when: 1) Sanitizer concentration level in a sanitizer bucket in the kitchen was measured below 150 ppm (parts per million - usually describes the concentration of something in water or soil). 2) [NAME] 1 failed to wash hands prior to handling cleaned kitchen equipment after touching soiled kitchen equipment. These deficient practices had the potential to result in food-borne illness (any illness resulting from the spoilage of contaminated food, bacteria-germs, viruses, or parasites that contaminate food, as well as toxins [poisons]) in 100 of 104 residents who consumed the food prepared in the facility's kitchen. Findings: 1) During a concurrent observation and interview on 3/14/2022, at 8:43 a.m., with Dietary Supervisor (DS), in the kitchen, the DS measured the sanitizer bucket that was placed close to the food preparation sink multiple times, and the concentration was measured below 150 ppm. The DS…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, interviews and record review, the facility failed to employ sufficient staff with the needed competencies and skills sets to carry out the functions of the food and nutrition services when Dietary Aide 1 (DA 1) did not know how to manually wash dishes properly. This failure had the potential to result in unsafe and unsanitary food preparation and production, and a potential for food-borne illness in 100 of 104 residents who consumed the food prepared by the facility kitchen. Findings: During a concurrent observation and interview on 3/14/2022, at 9:00 a.m., with Dietary Aide 1 (DA 1) and Dietary Supervisor (DS), DA 1 demonstrated the manual dishwashing process with a plate and started at the pre-wash spray sink. He soaped the plate and rinsed it with the water spray, then he moved on to the left compartment of the 2-compartment sink to use the sanitizer dispenser. The DA 1 turned on the sanitizer dispenser and placed the plate under the sanitizer solution stream for 3 seconds, then he placed the plate on a dishwashing rack to dry it. The DS stated that DA 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 Based on observation, interview and record review, the facility failed to implement the facility's answering the Call light policy and procedures and ensure residents' call light device was within reach for three of 43 sampled residents (Residents 30, 64 and 66). This deficient practice had the potential to negatively impact the psychosocial (Social factors and individual thought and behavior) well-being of the residents or result in delayed provision of services for Residents 30, 64, and 66. Findings: a. A review of Resident 30's admission Record indicated the facility originally admitted Resident 30 on 11/24/2021, and was readmitted on [DATE], with diagnoses that included hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction (lack of blood flow resulting in severe damage to some of the brain tissue), encephalopathy (a disease in which the functioning of the brain is affected by some agent or condition-such as viral infection or toxins 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 facility failed to implement activities of daily living (ADLs) policy and procedures and ensure one of 21 sampled residents (Resident 57) was showered, groomed, and provided personal hygiene for 11 days from 3/4/2022 to 3/15/2022. This deficient practice resulted in Resident 57 not feeling uncomfortable and untidy. Findings: A review of admission Record indicated the facility originally admitted Resident 57 on 2/5/2022, and was readmitted on [DATE], with diagnoses that included congestive heart failure (a condition in which the heart does not pump blood as well as it should), epilepsy (a central nervous system (neurological) disorder in which brain activity becomes abnormal, causing seizures or periods of unusual behavior, sensations and sometimes loss of awareness), and muscle weakness. A review of Resident 57's Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated 2/23/2022, indicated Resident 57 had intact cognition (mental…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, for six of six sampled residents (Residents 2, 5, 20, 52, 58 and 64), the facility failed to ensure staff: 1. Implemented specialty mattress-pressure relieving devices policy and procedures 2. Understood how to operate and the significance for correct low air loss mattress (LAL-a mattress designed to prevent and treat pressure wounds) settings consistent with manufacturer's guide. Residents 2, 5, 20, 58 and 64) had severe cognitive (mental action or process of acquiring knowledge and understanding) impairment. These deficient practices increased the risk to develop pressure injury (bed sore-localized damage to the skin and or underlying soft tissue over bony prominence) and poor wound healing of the existing pressure ulcer for Residents 2, 5, 20, 52, 58 and 64 at. Findings: a. A review of admission Record indicated the facility originally admitted Resident 2 on 1/25/2018, and was readmitted on [DATE], with diagnoses that included pneumonia (PNA-infection 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 provide sufficient staffing to accommodate residents' needs by not answering the call light timely for six (6) of 43 sampled residents (Resident 29, 45, 56, 57, 83 and 240). This deficient practice resulted in residents not receiving needed services timely and efficiently, which could potentially lead to falls and/or injuries negatively affecting the health and the quality of life of the residents. Findings: a. A review of Resident 29's admission Record indicated the resident was admitted in the facility on 12/24/2021 with diagnoses including muscle weakness and difficulty in walking. A review of Resident 29's Minimum Data Set (MDS - a comprehensive standardized assessment and care-screening tool), dated 2/3/2022, indicated the resident had an intact cognition (mental action or process of acquiring knowledge and understanding) for daily decision-making. Resident 29 required limited to extensive assistance with activities of daily living…

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

Based on observation, interview and record review, the facility failed to: 1) follow portion size as written on the menu for residents on mechanical soft and pureed diet. 30 of 104 residents on mechanical soft and pureed diet received inaccurate portion. 2) follow menu as written for the secondary soup of the meal. Residents who preferred secondary soup of the meal received an unapproved substituted menu. This deficient practice had the potential for residents to receive wrong protein and caloric intake when not following the menu, which could result in undernutrition or overnutrition and further compromise their health and well-being Findings: 1) A review of the facility's document titled, Daily Cook's Menu, dated Spring Summer 2022, indicated food portioning as follows: a) regular portion for ground breaded fish should be served with a #10 scoop providing 3/8 cup; b) regular portion for ground steamed broccoli should be served with a #10 scoop providing 3/8 cup; and c) regular portion for pureed steamed broccoli should be served with a #10 scoop providing 3/8 cup or 3.25 oz…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 store, prepare, distribute, and serve food in accordance with professional standards for food service safety when: 1) Multiple food items in the designated refrigerators for resident food in all dining rooms were not labeled/dated per policy; 2) A cup of juice was stored in the refrigerator in a vacant resident room; 3) Resident food refrigerator in the dining room on the second floor was measured at 50°F. These deficient practices had the potential to result in food-borne illness (any illness resulting from the spoilage of contaminated food, bacteria-germs, viruses, or parasites that contaminate food, as well as toxins [poisons]) for the medically vulnerable residents. Findings: 1) During a concurrent observation and interview on 3/15/2022, at 10:01 a.m., with Housekeeping Supervisor (HS), in the dining room on second floor, the following items were observed in the refrigerator designated for resident food: a) two unlabeled and opened…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to maintain an infection control program designed to provide a safe and sanitary environment to help prevent the development and transmission of infections in the facility when: 1. Three (3) sampled staff members (Certified Nursing Assistant [CNA 2], Registered Nurse [RN 2], and CNA 4) did not use proper personal protective equipment (PPE-such as gloves, gown, mask, face shield) for rooms on contact isolation precautions (as everyone coming into a resident's room is asked to wear a gown and gloves). 2. A visitor did not take off PPE before exiting Resident 140's room in yellow zone (area designated for residents who are awaiting COVID-19 test results and may have symptoms of the infection) 3. A Licensed Vocational Nurse (LVN 6) failed to perform hand hygiene after removing a pair of soiled gloves used to remove soiled dressing for one of 21 sampled residents (Resident 59). These deficient practices had the potential to cause cross…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to implement the facility's assistance with meals, urinary catheter care, and quality of life-dignity policies and procedures to ensure residents were provided with care that promoted and or enhanced dignity and respect by failing to ensure: 1. Urinary catheters (a flexible tubes used to empty the bladder and collect urine) bags remained covered for four of five sampled residents (Residents 58, 59, 77, and 83) 2. Staff did not stand over residents while eating for two of five sampled residents (Residents 53 and 77). These deficient practices resulted in Resident 58 feeling embarrassed, and had the potential for psychosocial harm, lowered self-esteem, rushed feeling, and violated the right to be treated with dignity for Residents 53, 58, 59, 77, and 83. Findings: 1a. A review of Resident 58's admission Record indicated the facility originally admitted Resident 58 on 2/21/2022, with diagnoses that included diabetes mellitus (DM-a chronic…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure residents' medical records were updated to indicate that 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 discussed and written information were provided to the residents and/or responsible parties for three of 43 sampled residents (Residents 52, 64 and 66). This deficient practice violated the residents' and/or the representatives' right to be fully informed of the option to formulate advanced directives and had the potential to cause conflict with health care wishes for Residents 52, 64, and 66. Findings: a. A review of Resident 52's admission Record indicated the facility originally admitted Resident 58 on 12/23/2021, and was re-admitted on [DATE], with diagnoses that included diabetes mellitus (DM-a chronic condition that affects the way the body processes blood sugar [glucose]), multiple…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 repair a broken window screen and, provide a safe and homelike environment for two of 21 sampled residents (Residents 59 and 75) by failing to ensure the window screen is not broken and in functional (working) condition. This deficient practice had the potential to negatively impact the quality of life and increased risk for physical discomfort for Residents 59 and 75. Findings: a. A review of admission Record indicated the facility admitted Resident 59 on 2/21/2022, with diagnoses that included Type II diabetes mellitus (DM-a chronic condition that affects the way the body processes blood sugar [glucose]), metabolic encephalopathy (a disease in which the functioning of the brain is affected by some agent or condition-such as viral infection or toxins in the blood) and dysphagia (difficulty swallowing food or liquid). A review of Resident 59's Minimum Data Set (MDS - a standardized assessment and care-screening tool) dated 2/27/22,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 licensed nursing staff met professional standards of quality during medication pass for one of four sampled residents (Resident 47) when: 1. Potassium Chloride (KCL - a medicine used to prevent or treat low potassium levels in the body) 10 milliequivalents (mEq) extended release (ER) medication was crushed, not following the manufacturer's guidelines. 2. Resident 47's identification was not checked prior to medication administration. These deficient practices placed a potential risk to result in medication administration to the wrong resident and placed Resident 47 at risk for adverse reactions such as, severe, and uncontrollable bleeding and hyperkalemia (high level of potassium), which could lead to lower digestive tract conditions such as obstruction and perforation (a hole that develops through the wall of a body organ), abnormal heart rhythm, slow heart rate, muscle weakness or numbness. Findings: A review of admission…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 nasal cannula (NC-a device used to deliver supplemental oxygen placed directly on a resident's nostrils) was dated and replaced every seven days and that Licensed Vocational Nurse 8 (LVN 8) was knowledge when to exchange/replace NC for two of two sampled residents (Residents 2 and 68). This deficient practice placed Residents 2 and 68 at risk to develop respiratory infection. Findings: a. A review of Resident 2's admission Record indicated the facility originally admitted Resident 2 on 1/25/2018, and was readmitted on [DATE], with diagnoses that included pneumonia (PNA-infection that inflames air sacs in one or both lungs which may fill with fluid), aphasia (loss of ability to understand or express speech, caused by brain damage), and dysphagia (difficulty swallowing food or liquid). A review of Resident 2's Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated 2/21/2022, indicated Resident 2 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 observation, interview and record review, the facility failed to ensure medication error rates are not 5 percent or greater. During medication pass observation for Resident 47, a total of two medication errors were observed out of 29 opportunities, which resulted to a medication error rate of 6.9%. These deficient practices had the potentials to administrate the medications to wrong residents, to cause medications to loss their potency and to increase risks for harmful drug interaction, resulting negative impact on residents' health and well-being. Cross Reference: Ftag 658 Findings: A review of admission Record indicated Resident 47 was admitted to the facility on [DATE] with diagnoses including Parkinson's disease (a disorder in the brain that affects movement, often including tremors), encephalopathy (a disease in which the functioning of the brain is affected by some agent or condition-such as viral infection or toxins in the blood) and pneumonia (PNA-infection in lung). A review of Resident 47's…

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

Based on observation, interview and record review, facility failed to ensure: 1. medications requiring refrigeration were not stored in one of two inspected medication cart. 2. medications were stored and locked in the medication cart. These deficient practices of failing to store medications in a locked medication cart and per the manufacturer's requirement increased the risk for the residents receiving medications that had become ineffective or toxic due to improper storage, possible medication theft, and unapproved medication use, which could lead to health complications resulting in hospitalization or death. Findings: During a concurrent observation and interview on 3/12/2022 10:49 a.m., on Floor two Medication Cart two, with Licensed Vocational Nurse (LVN 4), Gabapentin (medication to prevent seizures or nerve pain) 250 milligrams (mg - a unit of measure for mass) per five milliliter (ml - a unit of measure for volume) for Resident 20 was found stored at room temperature and ibuprofen (pain medications) was also observed located on top of the medication cart unattended. Per…

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