California Post Acute

Based on interview and record review, the facility failed to ensure the drug regimen of two of five sampled Residents (Resident 7 and Resident 11) were free of unnecessary psychotropic medications (types of medication that affects brain activity and is used to treat mental health disorders) medication by: Failing to ensure the gradual dose reduction (GDR, a method used to slowly and carefully decrease the dosage of a medication over time) for risperidone (Risperdal, a medication used to treat schizophrenia [a mental illness that is characterized by disturbances in thought]) was performed in February 2025 for Resident 7.Failing to ensure an informed consent form (a formal conversation and a signed document that acknowledges the resident's understanding and agreement to the medication treatment plan) for alprazolam (Xanax, a medication used to treat anxiety [a feeling of fear, dread, and uneasiness]) was signed by the Responsible Party (RP, an individual who is responsible for handling a resident's finances and medical care) for Resident 11. This failure had the potential to 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 develop and implement a comprehensive person-centered care plan (a plan of care that summarizes a resident's health conditions, specific care and services facility staff need to provide a resident to promote healing and prevent a worsening of a condition, and current treatments) to meet the resident's needs for three of 14 sampled residents (Resident 3, Resident 10, and Resident 11) as evidenced by: Failing to specify Resident 3's significant personal interests and activities to support coping with auditory hallucinations (when someone hears sounds or voices that are not there).Failing to reduce environmental noise while cleaning Resident 10. Failing to develop a comprehensive person-centered care plan for Resident 11's diagnosis of dementia (a progressive state of decline in mental abilities). These failures had the potential for Resident 3, Resident 10, and Resident 11 to receive inadequate care and services needed. Findings:During a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that three of five sampled employees' (Licensed Vocational Nurse 8 [LVN8], Treatment Nurse [TN], and for Interim Director of Nursing [IDON]) files were complete with a performance evaluation, skills competency checklist, and Basic Life Support (BLS, life saving techniques for someone experiencing breathing of heart emergencies) certification.This failure had the potential to result in the staff underperforming, which could affect the residents' care. Findings: During a concurrent interview and record review on [DATE] at 11:21 AM with the Director of Staff Development (DSD), LVN 8's employee file was reviewed. The employee file did not have a BLS certification, skills competency checklist (a list used to assess someone's proficiency in specific skills) and performance evaluation (a process used to give employees feedback on their job performance) for 2024. DSD stated LVN 8 was hired on [DATE]. DSD stated the BLS and skills competency checklist…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 adequate medication supply for Resident 40 when alogliptin benzoate (a medication used to treat type 2 diabetes [a condition where the body either does not produce enough insulin or does not properly use the insulin] 12.5 milligrams (mg, unit of measurement) oral tablets were not available for administration. Maintain a narcotic count (refers to the systematic process of counting and documenting the amount of controlled substances at specific times to ensure accurate inventory and prevent misuse or diversion) without discrepancy for Resident 65 when the narcotic count sheet for buprenorphine-naloxone (a medication that treats opioid use disorder) 8-2 mg sublingual (situated or applied under the tongue ) film indicated 18 films available and the medication count revealed 17. These failures had the potential to result in Resident 40 developing elevated blood glucose (too much sugar in the blood) levels and disruption in her…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to: Administer medication according to the physician order when: Resident 4 received MiraLax (a medication used to facilitate bowel movements) oral powder 17 grams (gm, unit of measurement) per scoop in 7 ounces of water. Resident 4 received acetaminophen (a medication used to relieve pain and reduce fever [elevated body temperature above the normal range]) two 325 milligrams (mg, unit of measurement) tablets for pain. Resident 40 did not receive alogliptin benzoate (a medication used to treat type 2 diabetes (a condition where the body either does not produce enough insulin [define] or does not properly use the insulin) 12.5 mg oral tablets. Preform blood sugar level monitoring prior to insulin administration when Resident 40 received 50 units of insulin glargine subcutaneous solution. These failures had the potential to result in Resident 4 experiencing constipation (a condition characterized by infrequent, hard, or difficult bowel…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 the temperature in the medication refrigerator between 36 degrees Fahrenheit (F, a temperature scale) to 46 degrees F when the thermometer indicated 21 degrees F. Dispose Resident 66's medication within 90 days of discharge when a lidocaine (a medication used to numb a specific area of the body) 5% patch was in the medication storage room. Discard medications inside the medication waste bin when tablets were on the bin rim and accessible. Implement accurate medication labeling when insulin lispro (a medication used to control blood sugar in people with diabetes [a condition where the body does not produce or use insulin properly]) 3 milliliter (mL, unit of measurement) injection for Resident 20 did not include a pharmacy medication label. Maintain one of two medication carts free from expired medications when glucagon (used for emergency treatment of very low blood sugar) 1 milligram (mg, unit of measurement) injection for…

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

Based on observation, interview and record review, the facility failed to ensure the standardized recipes for lunch menu were followed on 7/21/2025 by failing to ensure pureed diets (foods that do not require chewing and are easily swallowed. All food should be smooth and pureed to the consistency of pudding.) were prepared in accordance with the international Dysphagia Diet Initiative (IDDSI - a framework made up of levels and describes food textures and drink thickness) Level Four (pureed foods and extremely thick drinks). This failure had the potential to result in meal dissatisfaction and increased choking risk for residents on pureed diet.During an observation of the tray line (tray line-a system of food preparation, in which tray move along an assembly line) service for lunch on 7/21/2025 at 11:30AM, the pureed meat, pureed corn and potato looked thin and loose consistency. During the serving of the pureed food, the pureed food spread out flat on the plate and didn't hold its shape.During a concurrent interview and taste test of the pureed food with Dietary Supervisor (DS) and…

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

Based on observation, interview and record review, the facility failed to ensure safe and sanitary food storage and food preparation in the kitchen when:1.One medium size tray of previously prepared tuna salad was stored in the walk-in refrigerator over three days, exceeding storage period for prepared salad. Six bunches of bananas that were very soft, brown in color and peeled open were stored in the dry storage area with no date. A peeled banana was touching the wall, there were stains on the wall and on the floor under the shelves. One can opener blade was dirty with dried brown residue and when the blade was worn and dented with the potential to harbor harmful bacteria.2.One Dietary Aide (DA1) working in the dishwashing area did not wash hands when removing clean and sanitized dishes from the dish machine.3.Food brought to residents from outside of the facility, were stored in the resident's food refrigerator with no date and not monitored for the expiration date. There was one container of potato salad that was expired and stored in the resident's food refrigerator. These…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 was maintained in a sanitary manner. By failing to ensure one large trash bin was covered and two recyclable trash bins were not overfilled with boxes and left uncovered.This deficient practice had the potential for harborage and feeding of pests.During a concurrent observation of the facility's trash area and interview with the dietary supervisor (DS) on 7/21/2025 at 9:00AM, one large trash bin that was observed not covered and two recyclable trash bins were observed overfilled with boxes and uncovered. A cat was observed around the trash area in the parking lot. The DS stated trash bins had to be covered to prevent the feeding of animals and attracting flies. The DS proceeded to cover the lid of the large trash bin.During an interview with Maintenance Supervisor (MS) on 7/21/2025 at 9:10AM, the MS stated trash was picked up twice a week. The MS stated cardboard boxes had to be broken down to allow more space in the bins and to cover the lids. The MS stated trash…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility did not maintain privacy for one of five sampled residents (Resident 21) due to broken window blinds that were visible from the main street in Resident 21's room. This failure had the potential to result in Resident 21 being exposed to people outside of the roomFindings: During a review of Resident 21's Face sheet (admission Record) dated 7/21/2025, the Face sheet indicated Resident 21, a [AGE] year old female, was admitted to the facility on [DATE], with diagnosis that included heart failure (a condition where the heart does not pump blood as well as it should making it hard for the body to get the oxygen and nutrients needed) and muscle weakness (a condition where the muscles do not have as much strength as before). During a review of Resident 21's Minimum Data Set (MDS, a resident assessment tool used for screening of clinical and functional status), dated 7/12/2025, the MDS indicated Resident 21 had an occasional bowel incontinence episode. During a concurrent…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 Resident 61's primary physician (MD 1), for one of three sampled residents (Resident 61), by failing to: 1. Ensure the licensed nurses (in general) informed MD 1 that General Acute Care Hospital 1 (GACH 1) could not accept Resident 61 on [DATE] for dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney[s] have failed) and experiencing shortness of breath (SOB) and weakness.2. Ensure licensed nurses (in general) informed MD 1 and initiated a change of condition (COC, internal form) when Resident 61 was not transferred out to GACH 1.These failures resulted Resident 61 did not receive dialysis care and services and did not receive medical interventions for the SOB and weakness. On [DATE] at 4:30 AM, Certified Nursing Assistant 5 (CNA 5) and Licensed Vocational Nurse 3 (LVN 3) found Resident 61 unresponsive (not reacting or moving at all) with no pulse (the number of times the 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 provide mandatory information on Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNFABN: a Skilled Nursing Facility [SNF] must issue this notice to a resident when it believes that Medicare may not cover their care or stay. The SNF must provide the notice to the resident before providing the non-covered care.) appeal process in a timely manner for one of three randomly selected residents (Resident 42). This deficient practice denied Resident 42 the right to accept or decline non-covered specific skilled services or file an appeal. Placing Resident 42 at risk for unexpected financial burden/crisis.Findings:During a review of Resident 42's admission Record, the admission Record indicated the facility re-admitted the resident on 8/20/2023 with diagnoses that included muscle weakness, dysphagia (difficulty swallowing), chronic obstructive pulmonary disease (COPD, a chronic lung disease causing difficulty in breathing), type 2 diabetes mellitus (DM, a disorder characterized by difficulty in blood sugar…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure the Minimum Data Set (MDS, a resident assessment tool) was created and transmitted to the Centers for Medicare and Medicaid Services (CMS, a federal agency that administers the Medicare program, among other health-related programs like Medicaid and the Children's Health Insurance Program) for one of 10 sampled residents (Resident 24), when Resident 24 was discharged from the facility on 6/17/2025.This failure had the potential to result in delayed discharge care for Resident 24.Findings:During a review of Resident 24's admission Record, the admission Record indicated the facility admitted the resident on 1/16/2025 with diagnoses that included urinary tract infection (UTI, an infection in the bladder/urinary tract), dysphagia (difficulty swallowing), muscle weakness and transient cerebral ischemic attack (TIA, a temporary blockage of blood flow to the brain).During a review of Resident 24's quarterly MDS assessment dated [DATE], the quarterly MDS…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure Resident 40 maintained clean and intact skin in the perineal area (area between the anus and the external genitalia) when Resident 40 developed Moisture-Associated Skin Damage (MASD, a type of skin damage that occurs when prolonged exposure to moisture, such as urine, weakens the skin's protective barrier, leading to inflammation, breakdown, and potential infection).This failure resulted in Resident 40 developing MASD in the perineal area and experiencing discomfort and pain in the affected area due to skin breakdown and exposure to urine and feces.Findings:During a review of Resident 40's admission Record (a document that collects essential information about a resident when they enter a healthcare facility), dated 7/25/2025, the record indicated Resident 40, a [AGE] year-old female, admitted to the facility on [DATE] with a diagnosis that included left above the knee amputation (the surgical removal of a leg above the knee joint),…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 apply resting hand splints to both hands for one of 14 sampled residents (Resident 56). This deficient practice has the potential to led for worsening contracture (a condition where muscles, tendons, and skin tighten, leading to a reduced range of motion) and a decrease in right hand mobility for Resident 56. Findings: During a review of Resident 56's Face Sheet (admission record) indicated Resident 56 was admitted to the facility on [DATE] with diagnoses that included fracture of the right femur (a break in the thigh bone), diabetes mellitus (a disorder characterized by difficulty in blood sugar control and poor wound healing), and osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage). During a review of Resident 56's Minimum Data Set (MDS, a resident assessment tool), the MDS indicated Resident 56 requires supervision and maximal assistance to complete activities of daily living. During a review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement the fall risk care plan for one of 14 sampled residents (Resident 5) when Resident 5 was not frequently visually monitored to prevent a fall. This failure had the potential to result in Resident 5 experiencing excessive bleeding and serious injury from a fall. Findings: During a review of Resident 5's Face Sheet (admission record) indicated Resident 5 was admitted to the facility on [DATE], with diagnoses that included necrotizing fasciitis (a serious bacterial infection that destroys tissue under the skin), generalized muscle weakness, lower leg osteomyelitis (inflammation of bone or bone marrow, usually due to infection), and chronic ulcers (open sores or wounds on the skin) of the right and left feet. During a review of Resident 5's Minimum Data Set (MDS, a resident assessment tool), the MDS indicated Resident 5 has impairments to both feet and requires supervision and assistance to complete activities of daily living. During…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure one of two sampled residents (Resident 55) received the appropriate treatment and services needed to maintain and prevent gastrostomy tube (a surgical procedure to insert a tube through the abdomen and into the stomach used for feeding, usually via a feeding tube) complications. By failing to label the resident's tube feeding container and syringe with an open date. This failure placed Resident 55 at risk for gastrointestinal (the digestive system) complications such as infection, diarrhea (frequent loose bowel movements), nausea (sensation of feeling the urge to vomit), and vomiting (forceful expulsion of stomach contents though the mouth). Findings:During a review of Resident 55's admission Record, the admission Record indicated the facility admitted the resident on [DATE] with diagnoses that included dysphagia (difficulty swallowing) and gastrostomy. During a review of Resident 55's Minimum Data Set (MDS, a resident assessment…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to ensure dietary preferences were honored for one of five sampled residents (Resident 21) when the resident received food that was listed on the meal ticket as a disliked food. This failure had the potential to result in Resident 21 experiencing a loss of autonomy in choosing meals. Findings: During a review of Resident 21's Face sheet (admission Record) dated 7/21/2025, the Face sheet indicated Resident 21 was admitted to the facility on [DATE], with diagnosis that included heart failure (a condition where the heart does not pump blood as well as it should making it hard for the body to get the oxygen and nutrients needed) and muscle weakness (a condition where the muscles do not have as much strength as before). During a review of Resident 21's Minimum Data Set (MDS, a resident assessment tool used for screening of clinical and functional status), dated 7/12/2025, the MDS indicated Resident 21 required assistance with food setup. During an interview on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections when: Resident 5 did not have an order for enhanced barrier precautions (EBP- are an infection control strategy used in healthcare settings, particularly skilled nursing facilities, to reduce the spread of multidrug-resistant organisms (MDROs). Resident 1 did not have proper signage before entering the isolation room. These failures had the potential to result in the spread of infection and placed the residents, staff and visitor at risk to become infected and seriously ill, leading to hospitalization or death. Findings: 1. During a review of Resident 5's Face Sheet (admission record) indicated Resident 5 was admitted to the facility on [DATE], with diagnoses that included necrotizing fasciitis (a serious bacterial infection that destroys…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 follow their infection control policy for storage of clean laundry. During observation, on 7/1/25 at 10:32 a.m. and at 1:38 p.m., two laundry carts that contained the clean linen for the residents were in the facility's parking lot.This deficient practice had the potential for the clean linen to be contaminated with dust and allergens that can potentially affect the health and safety of the residents. During observation and concurrent interview on 7/1/25 at 10:32 a.m. two laundry carts with clean linen and towels were observed in the parking lot of the facility. The linen carts were observed to be covered with plastic. The Maintenance Supervisor (MS) stated the carts contain clean linen. MS stated the laundry carts were placed in the parking lot because there was no space inside the facility.During an interview on 7/1/25 at 1:35 p.m. the interim director of nursing (DON) stated the clean linen should not be placed in the parking lot. The DON stated even if the carts were covered with plastic, . it is…

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

Based on interview and record review the facility failed to implement their Policy in reporting unusual occurrences for one of three sample residents (Resident 1). The facility failed to report to the state survey agency (SSA) when Resident 1 eloped (the act of leaving a facility unsupervised and without prior authorization) on 5/18/25. This deficient practice resulted in a delay in the investigation of the elopement of Resident 1 and to ensure Resident 1 was safe. Findings: During a review of the admission Record indicated the facility admitted Resident 1 on 5/14/25 with diagnoses including encephalopathy (a disease that affects the function or structure of the brain) and anoxic brain damage (serious types of brain injuries characterized by a lack of oxygen to the brain). During a review of Resident 1 ' s History and Physical (H&P, a comprehensive formal assessment by a healthcare provider) dated 5/17/25 indicated Resident 1 required close supervision at all times when out of bed to ensure safety secondary to impaired cognition and poor safety awareness. The H&P 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to prevent elopement (the act of leaving a facility unsupervised and without prior authorization) for one of three sampled residents (Resident 1). Resident 1 who was identified as an elopement risk, the facility failed to provide one-to-one sitter (staff member that provide one-to-one care and observation to ensure resident ' s safety) to prevent elopement. This deficient practice resulted in Resident 1 eloping from the facility on 5/18/25 at 11 a.m., exposing Resident 1 to danger while out in the community. Findings: During a review of the admission Record indicated the facility admitted Resident 1 on 5/14/25 with diagnoses including encephalopathy (a disease that affects the function or structure of the brain) and anoxic brain damage (serious types of brain injuries characterized by a lack of oxygen to the brain). During a review of the Progress Notes admission summary dated [DATE] at 9:53 p.m., indicated safety measures were implemented due to Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to develop and implement a care plan for nutrition for one of five sampled residents (Resident 1). For Resident 1, the facility failed to develop and implement a care plan to address Resident 1 ' s nutritional and hydration needs. This deficient practice had the potential for the facility not to address Resident 1 ' s hydration and nutritional needs. Findings: During a review of the admission Record indicated the facility admitted Resident 1 on 12/30/24 with diagnoses including Parkinson ' s disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), muscle weakness, and heart failure (lifelong condition in which the heart muscle can't pump enough blood to meet the body's needs for blood and oxygen). During a review of Resident 1 ' s Minimum Data Set (MDS, a resident assessment tool) dated 1/3/25 indicated Resident 1had mild cognitive impairment. Resident 1 was dependent on toileting hygiene,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to evaluate the nutritional and hydration (maintain adequate amount of fluid in the body) needs of one of five sampled residents (Resident 1). For Resident 1, the facility failed to ensure: 1. Resident 1 ' s intake (amount of fluid entering the body) and output (amount of liquid leaving the body) were monitored as ordered by the physician on 2/8/25. 2. The registered dietitian (RD) evaluates Resident 1 ' s nutritional needs regularly. 3. Resident 1 was given a fortified diet as recommended by the RD on 1/20/25. These deficient practices had the potential for the facility not to be able to meet the hydration and nutritional needs of Resident 1. Findings: During a review of the admission Record indicated the facility admitted Resident 1 on 12/30/24 with diagnoses including Parkinson ' s disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), muscle weakness, and heart failure (lifelong…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 adequate staffing for one of 5 sampled residents (Resident 2). Resident 2 stated on 5/3/25 and 5/4/25 she called for assistance to have her pull ups changed during the night shift. Resident 2 stated she did not get the assistance she needed timely. This deficient practice resulted in Resident 2 not provided the necessary services timely affecting Resident 2 ' s psychosocial and physical well-being. Findings: During a review of the admission Record indicated the facility admitted Resident 2 on 4/5/25 with diagnoses including muscle weakness and difficulty in walking. During a review of the Minimum Data Set (MDS, a resident assessment tool) dated 4/12/25 indicated Resident 2 was cognitively intact. Resident 2 was dependent (helper does all the effort) on toileting hygiene, needed maximal assistance (helper does more than half the effort) with oral hygiene, shower/bathe self, upper/lower body dressing, putting on/taking off footwear, personal hygiene and set up with eating. During a review of Resident 2 ' s Care Plan…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to follow physician orders to evaluate resident ' s nutritional and fluid needs for one of five sampled residents (Resident 1). For Resident 1, the facility failed to: 1. Assess, monitor and evaluate Resident 1 ' s nutritional needs regularly and as needed. 2. Monitor Resident 1 ' s intake and output as ordered by the Resident 1 ' s primary physician. 3.Discuss and meet with the weight variance interdisciplinary team (IDT, professionals from different discipline, as appropriate, will work together to provide the greatest benefit for the resident) to discuss Resident 1 ' s nutritional needs. These deficient practices had the potential for the facility not to meet Resident 1 ' s nutritional needs to maintain Resident 1 ' s highest practicable well-being. Findings: During a review of the admission Record indicated the facility admitted Resident 1 on 1/17/24 and readmitted on [DATE] with diagnoses including dysphagia (difficulty in swallowing), gastrostomy…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 interventions to prevent complications for residents who were receiving enteral (form of nutrition that is delivered into the stomach as a liquid) through the gastrostomy tube (GT, a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems) for one of five sampled residents (Resident 1). For Resident 1, the facility failed to follow physician order to: 1.Always keep Resident 1 ' s head of the bed elevated at 30 degrees and higher during feeding and for one hour after feeding has stopped. 2.Check the tube placement before initiation of formula, medication administration and water flushing at least every eight hours. These deficient practices had the potential for Resident 1 to have aspiration pneumonia (food, liquid, or other material enters a person's airway and eventually the lungs [breathing organ] by accident). Findings: During a review of the 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 interview and record review the facility failed to ensure the medical records were kept accurate for one of five sampled residents (Resident 1). For Resident 1, the facility failed to accurately reflect in Resident 1 ' s medical record that a care meeting was held between the facility and Resident 1 ' s responsible parties (RPs) on 2/27/25. This deficient practice resulted in inaccurate and incomplete medical record for Resident 1. Findings: During a review of the admission Record indicated the facility admitted Resident 1 on 1/17/24 and readmitted on [DATE] with diagnoses including dysphagia (difficulty in swallowing), gastrostomy (GT, a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems), and dementia (a progressive state of decline in mental abilities). During a review of the Minimum Data Set (MDS, a resident assessment tool) dated 2/14/25 indicated Resident 1 had severely impaired cognitive skills. Resident 1…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to provide treatment and care in accordance with professional standard of practice for one of three sampled residents (Resident 1). For Resident 1 who reported on 12/8/24 that he had a fall on 12/8/24 at 4 a.m., the facility failed to: 1.Assess Resident 1 immediately after he reported that he had a fall. 2.Notify Resident 1's physician immediately after Resident 1 reported he had a fall on 12/8/24. 3.Ensure the Magnetic Resonance Imaging (MRI, test that produces clear images of the organs and structures inside the body to diagnose a variety of conditions) ordered by the physician on 12/9/24 was carried out as ordered. These deficient practices had the potential for Resident 1 not to receive necessary treatment timely for possible injuries resulted from the fall. Findings: During a review of the admission Record, the Record indicated the facility originally admitted Resident 1 on 9/18/21 and re-admitted on [DATE] with diagnoses including respiratory failure…

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

Based on interview and record review the facility failed to obtain informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding risks, benefits and alternatives offered) for one of two sampled residents (Resident 1) before starting Resident 1 on quetiapine fumarate (Seroquel: antipsychotic medication) 150 milligrams (mg., metric unit of measurement, used for medication dosage and/or amount). This deficient practice resulted in Resident 1 being administered an antipsychotic without knowing the risks and benefits of taking the quetiapine fumarate and alternative treatment available. Findings: During a review of the admission Record indicated the facility admitted Resident 1 on 11/1/23 with diagnoses including adjustment disorder with mixed anxiety and depressed mood and muscle weakness. During a review of Resident 1 ' s Care Plan initiated on 11/2/23 indicated Resident 1 was taking an antipsychotic medication, Seroquel. The care plan goal indicated Resident 1 would be free from discomfort or adverse (negative) reactions related to…

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

Based on interview and record review the facility failed to provide indication and monitoring for adverse reaction when resident was started on psychotropic medication (any drug that affects behavior, mood, thoughts, or perception such as an antipsychotic) for one of two sampled residents (Resident 1), by failing to ensure: 1.The physician order for the Seroquel (antipsychotic medication) included the indication for the use of (reason why the medication is being ordered for the resident) and targeted behavior and manifestation. 2. Resident 1 was monitored for adverse (negative) reactions that included lethargy. These deficient practices resulted in Resident 1 receiving Seroquel unnecessarily and had the potential for Resident 1 to have adverse effects from the Seroquel. Findings: During a review of the admission Record indicated the facility admitted Resident 1 on 11/1/23 with diagnoses including adjustment disorder with mixed anxiety and depressed mood and muscle weakness. During a review of Resident 1 ' s Care Plan initiated on 11/2/23 indicated Resident 1 was taking an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to review, revise and update the care plans quarterly addressing risk for fall, incontinence, and activities of daily living (ADL) for one of four sampled residents (Resident 1). This deficient practice had the potential for Resident 1 to have recurrent falls, urinary tract infections (UTI- an infection in parts of the urinary system kidneys, bladder and or urethra), or decline in functional ability. Findings: A review of Resident 1's admission record indicated the resident was re-admitted to the facility on [DATE], with diagnoses including history of generalized muscle weakness, cognitive communication deficit (a person's inability to think learn, remember, use judgement, and make sound decisions), and chronic kidney disease (a damage to the kidneys and they are not functioning as they should). A review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care screening tool) dated 11/15/2024, indicated Resident 1 was moderately confused,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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), who was incontinent (having no or insufficient voluntary control over urination or defecation) and dependent on staff for toilet transfer, was properly monitored with evaluation of the resident's bladder habits (volume, or quality of stream). There was no monitoring of Resident 1's continence status at regular intervals (a check and change strategy) to restore continence to the extent possible. As a result, on 11/28/2024 approximately at 11:30 PM, Resident 1 tried to go to the bathroom by himself and fell. Resident 1 was transferred to the General Acute Care Hospital (GACH) for further evaluation where he was diagnosed with a displaced intertrochanteric (the area between the greater and lesser bone, where hip and thigh meet) fracture (a partial or complete break in a bone) of right femur (the thigh bone, the longest and strongest bone in the body), initial encounter for closed fracture. Cross Reference…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews the facility failed to ensure one out of three sampled residents (Resident 1) were free from physical abuse (an act where one person uses their body to inflict intentional harm or injury upon another person) from staff by failing to acknowledge and investigate allegations, assess monitor, and implement allegations of Resident 1 being slapped by Certified Nursing Assistant (CNA) 1 This deficient practice had the potential to result in the continued physical abuse to Resident 1 and resident sin the facility. Findings: During a review of Resident 3's admission record indicated Resident 3 was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses including diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), major depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), and hypertension (HTN-high blood pressure). During a review of a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to: 1. Ensure Certified Nursing Assistant (CNA) 2 did not release a hoyer lift (a medical device use to transfer patients with limited mobility from one place/surface to another) control quickly when transferring one of four sampled residents (Resident 2). 2. Inspect the hoyer lift for any malfunction or operational concerns before using it to transfer dependent residents including Resident 2. These deficient practices resulted in the hoyer lift control hitting Resident 2 in the face and the resident sustaining a bruise (an injury appearing as an area of discolored skin on the body, caused by a blow or impact rupturing underlying blood vessels) to the right eye, and had the potential for further injuries to the residents. Findings: During a review of the admission record for Resident 2 indicated Resident 2 was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses including chronic obstructive pulmonary…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 three sampled Certified Nurse Assistants (CNA 1, 2, and 3) had a completed annual performance evaluation when providing care to Resident 1. This deficient practice violated the facility's Performance Evaluations policy and had the potential for Resident 1 to not receive appropriate services. Findings: A review of Resident 1's admission Record indicated the resident was originally admitted to the facility on [DATE] with diagnoses including adjustment disorder (a group of symptoms, such as stress, anxiety, feeling sad or hopeless, and physical symptoms that can occur after you go through a stressful life event) with mixed anxiety (a mental condition characterized by excessive apprehensiveness about real or perceived threats), and depressed mood. A review of the Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 8/7/2024 indicated Resident 1 was cognitively intact. During a phone interview on 10/28/2024 at 10:36 AM, CNA 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.

Based on interview and record review, the facility failed to protect the resident's right to be free from verbal abuse for one of three sampled residents (Resident 1), when Licensed Vocational Nurse (LVN) 1 told Resident 1, Don't make me get my belt. This deficient practice had the potential for Resident 1 to experience emotional distress (negative or uncomfortable feelings), loss of dignity (the quality or state of being worthy of honor or respect), and feeling unsafe in the facility. Findings: A review of Resident 1's admission Record indicated the facility re-admitted the resident on 3/29/2023 with diagnoses including metabolic encephalopathy (permanent brain damage that causes severe confusion and forgetfulness), schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly), cerebral infarction (stroke, loss of blood flow to a part of the brain), and insomnia (trouble falling asleep, staying asleep, or getting good quality sleep). A review of Resident 1's Minimum Data Set (MDS, a federally mandated resident assessment tool) dated 9/13/2024,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement its Personal Property policy by failing to update the residents inventory list monthly for four of four sampled residents (Residents 1, 2, 3, and 4). This deficient practice resulted in Resident 1 having a lighter at his bedside and starting a fire on 10/2/2024 at about 2 AM, and had the potential for other residents to have prohibited items at bedside. Findings: a. A review of Resident 1's admission Record indicated the resident was originally admitted to the facility on [DATE] with diagnoses including cerebral infarction (a condition that occurs when blood flow to the brain is blocked, damaging brain tissue), paraplegia (loss of movement and/or sensation, to some degree, of the legs), anxiety (a mental condition characterized by excessive apprehensiveness about real or perceived threats), schizophrenia (a mental illness that is characterized by disturbances in thought), and bipolar disorder (mood swings that range from the lows of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement its Unusual Occurrence Reporting policy by failing to report a fire that occurred on 10/2/2024 at 2AM, as required by current law and / or regulations within 24 hours of the incident for one of four sampled residents (Resident 1). This resulted in a delay of an onsite inspection by the Department of Public Health to ensure the unusual occurrence was investigated timely and could lead to a delay in prevention of further hazards for Resident 1. Findings: A review of Resident 1's admission Record indicated the resident was originally admitted to the facility on [DATE] with diagnoses including cerebral infarction (a condition that occurs when blood flow to the brain is blocked, damaging brain tissue), paraplegia (loss of movement and/or sensation, to some degree, of the legs), anxiety (a mental condition characterized by excessive apprehensiveness about real or perceived threats), schizophrenia (a mental illness that is characterized by…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the environment was free of accident hazards for one of four sampled residents (Resident 1), who was a smoker. On 10/2/2024 at about 2 AM, Resident 1 used a lighter to spark a fire in his room. This deficient practice caused an increased risk in resident safety. Findings: A review of Resident 1's admission Record indicated the resident was originally admitted to the facility on [DATE] with diagnoses including cerebral infarction (a condition that occurs when blood flow to the brain is blocked, damaging brain tissue), paraplegia (loss of movement and/or sensation, to some degree, of the legs), anxiety (a mental condition characterized by excessive apprehensiveness about real or perceived threats), schizophrenia (a mental illness that is characterized by disturbances in thought), and bipolar disorder (mood swings that range from the lows of depression to elevated periods of emotional highs). A review of Resident 1's Smoking assessment dated [DATE]…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the assessment entry for special treatments, procedures, and programs in the Minimum Data Set (MDS- a federally mandated resident assessment tool) was accurately documented to reflect the resident's use of oxygen for two of three sampled residents (Resident 2 and 3). This deficient practice had the potential to negatively affect Resident 2 and 3's plan of care and delivery of necessary care and services. Findings: a. A review of Resident 2's admission Record indicated the resident was originally admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing). A review of the Physician's Order dated 3/22/2024, indicated Resident 2 received oxygen at two liters per minute via nasal cannula, to keep O2 (oxygen) saturation above 88-90% for COPD and as needed, for shortness of breath or wheezing. A review of Resident 2's MDS dated [DATE], indicated the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide necessary respiratory care services for two of three sampled residents (Resident 1 and 2). For Resident 1 who had a diagnosis of chronic respiratory failure and for Resident 2 who had diagnosis of chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), the facility failed to ensure the resident received two liters of oxygen per minute as ordered by the physician. The facility also failed to change the oxygen tubing, change the oxygen humidifier bottle (a device used to make supplemental oxygen moist), and clean the external oxygen concentrator filter every Sunday as ordered by the physician for Resident 1 and 2. These deficient practices had the potential for the residents to develop a respiratory infection and / or cause complications associated with oxygen therapy. Findings: a. A review of Resident 1's care plan initiated on 9/15/2021 indicated the resident had oxygen therapy related…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 vital signs (measurement of the most basic functions including the heart rate, breathing rate, temperature, and blood pressure) were monitored and recorded every shift based on professional standards of practice for one of four sampled residents (Resident 1). For Resident 1 who had a temperature of 101 degrees (normal temperature is between 97 degrees Fahrenheit [F, unit of measurement] to 99 degrees F) on 8/7/24, the facility failed to ensure the complete vital signs were obtained and documented accurately every shift. This deficient practice resulted in Resident 1 ' s medical record incomplete and not accurately documented. Findings: During a review of the admission Record indicated the facility admitted Resident 1 on 7/20/24 with diagnoses including acute respiratory failure (serious condition that makes it difficult to breathe on your own) and hypertension. During a review of the Minimum Data Set (MDS, standardized care and screening tool) dated 7/26/24 indicated Resident 1 had short- and long-term 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 call lights were answered timely for two of five sampled residents (Resident 3 and Resident 4). The facility failed to answer the call lights timely and attend to the needs of Resident 2 and Resident 3 promptly when they called for assistance. These deficient practices resulted in Resident 2 and Resident 3 stating that they felt frustrated when they call for assistance and no comes to help them timely. Findings: 1. During a review of the admission Record indicated the facility admitted Resident 3 on 5/29/24 with diagnoses including generalized muscle weakness and pain in the left shoulder. During a review of the Care Plan initiated on 5/31/24 indicated Resident 3 had activities of daily living (ADLs) self-care deficit, needs assistance with bed mobility, transfer, dressing, toilet use, personal hygiene, and bathing. The care plan goal indicated Resident 3 will be able to regain more independence with the ADLs. The care plan…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 a copy of the medical record as a requested for one of five sampled residents (Resident 5) within 48 hours. On 8/1/24, Resident 5 ' s legal representative sent a request for copies of Resident 5 ' s medical record to the facility by electronic facsimile (eFax, process of sending and receiving faxes over the internet instead of using the fax machine and telephone connection). The facility failed to provide the records timely as requested by Resident 5 ' s legal representative. This deficient practice resulted in facility failing to give Resident 5 the right to have copies of her medical record. Findings: During a review of the admission Record indicated the facility admitted Resident 5 on 11/8/23 with diagnoses including quadriplegia (paralyzed from the neck down or in all four limbs due to disease or injury) and generalized muscle weakness. During a review of the Minimum Data Set (MDS, standardized care and health screening tool) dated 5/7/24 indicated Resident 5 was cognitively (mental ability to make decision of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to implement its policy and procedures (P&P) on abuse for two of five sampled residents (Resident 1 and Resident 2). For Resident 1 and Resident 2, the facility failed to report within 2 hours, to the state survey agency (SSA) when on 8/5/24, Resident 1 stated Resident 2 was arguing with him and called Resident 2 a pedophile (a mental disorder in which an adult has sexual fantasies about or engages in sexual acts with a prepubescent [before puberty] child) and derogatory (disrespective/of low opinion) language. This deficient practice resulted in: 1. Resident 2 stating that Resident 1 threatened his life and felt bad, upset, angry, and scared. 2. Delayed investigation to ensure Resident 1, and Resident 2 were safe. Findings: 1. During a review of the admission Record indicated the facility admitted Resident 1 on 6/17/24 with diagnoses including paraplegia (paralysis in lower part of the body) and anxiety disorder. During a review of the 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 interview and record review the facility failed to ensure there was adequate supply of medications and administer the medication timely as ordered by the physician for one of five sampled residents (Resident 1). For Resident 1, the facility failed to ensure there was adequate supply of Norco (medication given for moderate to severe pain) 10-325 milligrams (mg., unit of measurement) as needed and failed to administer the Norco 10-325 mg. as ordered by the physician. This deficient practice resulted in Resident 1 was not given the Norco on 8/9/24, 8/10/24, and 8/11/24 because the facility had run out of Norco. Resident 1 stated he continued to have pain on his right leg and right hip. Findings: During a review of the admission Record indicated the facility admitted Resident 1 on 6/17/24 with diagnoses including paraplegia (paralysis in lower part of the body) and anxiety disorder. During a review of Resident 1 ' s Care Plan initiated on 6/19/24, indicated Resident 1 has chronic pain related to (that included) wound and swelling in the lower limbs. The Care Plan goal included…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 update and revise the Care Plan to meet the individual needs for one out of three sampled residents (Resident 1). By failing to revise Resident 1 ' s care plan after Depakote Tablet (a medication used to treat certain psychiatric disorders by restoring the balance in the brain) was increased from 375 milligram (mg-unit of measurement) to 500 mg on 07/23/2024. This deficient practice had the potential to prevent Resident 1 from receiving care to address their specific needs, which could lead to a decline in physical health. Findings: A review of Resident 1 ' s admission Record indicated the facility admitted the resident on 12/10/2020 and readmitted the resident on 10/13/2023 with diagnoses including chronic obstructive pulmonary disease (a group of diseases that cause airflow blockage and breathing-related problems), schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves), impulse disorder (it is a condition that makes it difficult for someone to control their actions 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 ensure one of three sample residents (Resident 1) had the call light within reach. This failure resulted in Resident 1's inability to call staff for assistance due to inability to see. Cross referenced with F656 and F641. Findings: During a review of Resident 1's admission Record, dated 8/1/2024, indicated Resident 1 was admitted to the facility on [DATE], with a diagnoses of glaucoma (a group of eye diseases that can cause vision loss and blindness by damaging a nerve in the back of your eye), bipolar disorder (a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration), and paraplegia (inability to deliberately control or move your muscles of the legs and lower body, typically caused by spinal injury or disease). During a review of Resident 1's Minimum Data Set (MDS - a standardized assessment and care screening tool) indicated Resident 1 had adequate vision and did not wear corrective…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of three sample residents (Resident 1) had an accurate assessment reflective of Resident 1 ' s diagnosis of glaucoma. This failure had the potential to cause Resident 1 to obtain an injury, experience weight loss due to inability to see the food and worsening vision. Cross referenced with F558 and F656 Findings: During a review of Resident 1's admission Record, dated 8/1/2024, indicated Resident 1 was admitted to the facility on [DATE], with a diagnoses of glaucoma (a group of eye diseases that can cause vision loss and blindness by damaging a nerve in the back of your eye), bipolar disorder (a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration), and paraplegia (inability to deliberately control or move your muscles of the legs and lower body, typically caused by spinal injury or disease). During a review of Resident 1's Minimum Data Set (MDS - a standardized assessment and care screening…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure care plan was developed for one of three sample residents (Resident 1) addressing the resident's diagnoses of glaucoma (a group of eye diseases that can cause vision loss and blindness by damaging a nerve in the back of your eye). This failure had the potential to cause Resident 1 to experience worsening vision. Cross referenced with F558 and F641 Findings: During a review of Resident 1's admission record, dated 8/1/2024, indicated Resident 1 was admitted on [DATE], with a diagnosis of glaucoma, bipolar disorder (a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration), and paraplegia (inability to deliberately control or move your muscles of the legs and lower body, typically caused by spinal injury or disease). During a review of Resident 1's Minimum Data Set (MDS - a standardized assessment and care screening tool) indicated Resident 1 has adequate vision and does not wear corrective lenses.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 arranging suitable and reliable transportation of the designated resident to and from the dialysis (a procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly) center for one of three sampled residents (Resident 1). As a result, Resident 1 missed dialysis appointment on 6/25/24, 6/27/24,7/2/24 and family member (FM) had to call transportation to take Resident 1 back to the facility on 7/13/24. This deficient practice had the potential for Resident 1 to build up waste products inside the body, placing the resident at risk for hospital admission or even death. Findings: A review of the admission Record indicated the facility admitted Resident 1 on 6/7/23 with diagnoses including end stage renal disease (kidneys no longer work to meet the body's need requiring a regular course of dialysis or kidney transplant) and dependence on renal dialysis. A review of the Physician Order dated 6/12/23 at 1:13 p.m., indicated an order for Resident 1 to go for dialysis on Tuesdays at…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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: -Discard expired acetaminophen (a medication used to treat mild to moderate pain) from one of two inspected medication carts (Medication Cart 2) which was going to be administered to Resident 265. -Ensure one expired insulin pen (an injection device used to deliver medication that controls blood sugar) belonging to Resident 46 was discarded from one of two inspected medication carts (Medication Cart 1). -Ensure two unopened insulin pens belonging to Residents 14 and 31 were stored in the refrigerator according to the facility's policy in one of two inspected medication carts (Medication Cart 1). These deficient practices placed Resident 265 at risk for experiencing pain, and Residents 46, 14, and 31 were at risk for developing hyperglycemia (too much sugar in your blood). Findings: A review of Resident 265's admission Record indicated the facility admitted the resident on [DATE] with diagnoses including aftercare following a joint…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 for food service safety by not labeling: a. one peach pie with a received date. b. three boxes of blueberry muffins with a received date. c. one bag of pasta noodle with a received date d. one bag of hamburger bread with a use by date. e. one bag of tortilla with a use by date. f. one block of cheddar cheese with a use by date. g. one plastic bag of mozzarella cheese with a use by date. h. one bag of chocolate chips with a use by date. i. one bag of marshmallows with a use by date. These deficient practices had the potential for residents in the facility to be at risk for food borne illness (caused by food contaminated with bacteria, viruses, parasites, or toxins). Findings: During a concurrent observation and interview on 7/1/2024 at 8:30 AM, the [NAME] observed a peach pie box, three blueberry muffins and a bag of pasta noodle was not labeled with a received date. The [NAME] observed a bag of hamburger bread, a bag of tortilla, a block of…

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

Based on observation, interview, and record review, the facility failed to maintain equipment in the kitchen when the freezer temperatures were above zero degrees Fahrenheit for approximately two weeks. This deficient practice had the potential to place the facility's residents at risk for food borne illness (caused by food contaminated with bacteria, viruses, parasites, or toxins) or contamination (process of making something dirty or poisonous, or the state of containing unwanted or dangerous substances). Findings: During an observation on the initial kitchen tour on 7/1/2024 at 8:12 AM, Freezer 1 indicated 28 degrees Fahrenheit. Food items in the freezer were frozen and did not show signs of thawing, including ice cream. During a return observation on 7/1/2024 at 12:47 PM, Freezer 1 indicated 12 degrees Fahrenheit. Food items in the freezer remained frozen. A review of the Maintenance Request Log indicated Freezer 1 and Freezer 2 required maintenance on 5/10/2024, 6/6, 6/7, 6/8, and 6/24/2024. A review of the Freezer Temperature Log indicated freezer temperatures were documented…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 space requirements of 80 square feet for each resident were met in multiple resident bedrooms. This deficient practice had the potential to result in inadequate space to provide safe nursing care and privacy for 38 Residents. Findings: A review of the admission record indicated the facility admitted Resident 34 on 6/23/2020 and re-admitted the resident to the facility on 9/30/2023, 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), atrial fibrillation (an irregular heartbeat that can lead to blood clots and increases the risk of stroke and other heart complications) and high blood pressure. A review of Resident 34's Minimum Data Set (MDS-comprehensive assessment and care screening tool) dated 6/4/2024, indicated Resident 34's cognition was moderately impaired. The MDS indicated Resident 34 was totally dependent upon staff for personal hygiene and required total assistance with transferring to 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 provide care in a manner that maintained or enhanced resident's dignity and respect for one sampled resident (Resident 44) by assigning to the resident Certified Nursing Assistant 1 (CNA 1), whom Resident 44 complained about. This deficient practice had the potential to affect Resident 44's self-esteem, self-worth, and the resident's sense of independence. Findings: A review of Resident 44's admission Record indicated the facility admitted the resident on 11/9/2022 with diagnoses that included encephalopathy (the group of condition that cause brain dysfunction [can appear as confusion, memory loss and personality change]), Parkinson's disease (a brain disorder that causes uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination), and seizures (a burst of uncontrolled electrical activity between brain cells that caused temporary abnormalities in muscle tone or movements). A review of Resident 44's History and Physical (H&P) dated 11/16/2023, indicated the resident did…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 two of three sampled residents (Resident 28 and Resident 51) had an Advance Directive (AD - written statement of a person's wishes regarding medical treatment made to ensure those wishes were carried out should the person be unable to communicate them to a doctor or to facility staff) on file as part of the resident's medical record. This deficient practice had the potential for the facility to not honor the resident's medical decisions regarding end-of-life treatment. Findings: a. A review of Resident 28's admission Record indicated the facility admitted the resident on 5/29/2024, with diagnoses including end stage renal disease (ESRD - medical condition in which a person's kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis or a kidney transplant to maintain life), dependence on renal dialysis (procedure to remove waste products and excess fluid from the body when the kidneys stop working properly), and muscle weakness (decrease in muscle strength). A…

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

Based on interview and record review, the facility failed to assess insertion site and document a signature for one of two sampled residents (Resident 27) by failing to ensure Resident 27's post-dialysis assessment was completed and the post-dialysis assessment was signed by a licensed nurse. These deficient practices had the potential for the facility to miss critical changes in the resident after dialysis treatment. Findings: A review of Resident 27's admission Record indicated the facility re-admitted the resident on 10/25/2023 with diagnoses including end stage renal disease (ESRD - medical condition in which a person's kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis or a kidney transplant to maintain life), chronic kidney disease (when the kidneys were damaged and could not filter blood the way they should), and morbid obesity (more than 80 to 100 pounds above their ideal body weight). A review of Resident 27's Physician's Order dated 10/25/2023, indicated to notify the dialysis center of any abnormalities noted…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 revise the care plan for two of the 16 sampled residents (Resident 34 and 55) investigated for care planning. Resident 55 's care plan for Quetiapine Fumarate (a psychotropic medication used to treat schizophrenia [a serious mental illness that affects how a person thinks, feels, and behaves]) was discontinued and Resident 34's alteration in skin integrity care plan had a change in the interventions for the management of the pressure injury. This deficient practice placed the residents at risk for inconsistent implementation of care plans which could lead to a lack of care or delay in delivery of care and services. Findings: a. A review of Resident 55's admission Record indicated the facility admitted the resident on 11/1/2023 with diagnoses including post-laminectomy syndrome (a condition characterized by chronic back pain following back surgery), and had a fusion of the spine (a surgery performed by an orthopedic surgeon [a surgeon who…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure one of two sampled residents (Resident 33), who had limited range of motion (ROM - the extent of movement of a joint) and/or limited mobility, received appropriate services to prevent or maintain further decline in the range of motion to all his extremities by failing to provide a handroll for his left hand. This deficient practice placed Resident 33 at risk for further decline and contracture formation. Findings: A review of Resident 33's admission record indicated the facility admitted the resident on 6/23/2020 with diagnoses including hemiplegia and hemiparesis, epilepsy and difficulty in walking. A review of Resident 33's History and Physical (H&P), dated 8/30/2023, indicated Resident 33 had left hemiplegia and the resident had the capacity to understand and make decisions. A review of Resident 33's Functional ROM and Voluntary Movement form, dated 10/29/2023, indicated the following: - the resident's functional range of motion…

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

Based on interview and record review, the facility failed to ensure one of five sampled residents (Resident 41) was free of unnecessary medication by failing to follow the physician's order to administer the resident's Norco (a pain medication) 5-325 milligrams (mg - unit of measurement) as needed (PRN) every six hours for severe pain. This deficient practice resulted in Resident 41 receiving Norco on 6/5/2024 for pain level rated at four and on 6/6/2024 for pain level rated at six, placing the resident at risk for receiving unnecessary medication. Findings: A review of Resident 41's admission Record indicated the facility admitted the resident on 5/26/2022 with diagnoses that included hereditary and idiopathic neuropathy (a painful nervous system disorder that interferes with normal nerve function), 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), and essential hypertension (a condition in which blood pressure is higher than normal). A review of Resident 41's Pain care plan…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 monitor for side effects of psychotropic medications (drugs that affect a person's mental state) for one of three sampled residents (Resident 26). This deficient practice had the potential to lead to Resident 26 to have adverse effects of medication (ie, become oversedated [excessively drowsy], have frequent falls, or experience tardive dyskinesia [a movement disorder which causes involuntary and repetitive movements, including those of the face, mouth, tongue, arms, or legs]. Findings: A review of Resident 26's admission record, dated 7/2/2024, indicated the facility admitted the resident on 12/5/2020 with diagnoses including metabolic encephalopathy (a disorder induced by another health condition like diabetes or kidney failure that causes brain dysfunction), major depressive disorder (a mood disorder that causes a persistent feeling of sadness), and acute kidney failure. A review of Resident 26's History and Physical, dated 5/16/2024, indicated the resident had fluctuating capacity to understand and make decisions. A…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the medication error rate was less than five percent. Two medication errors out of 26 total opportunities contributed to an overall medication error rate of 7.69% affecting one of four sampled residents (Resident 265) observed for medication administration performed by one of two Licensed Vocational Nurses (LVN 1). The facility failed to: -Ensure Resident 265 received polyethylene glycol powder (Miralax, a laxative medication which increased the number of bowel movements and softens the stool) per physician's orders. -Ensure Resident 265 did not receive expired acetaminophen (a medication used to treat mild to moderate pain). These deficient practices placed Resident 265 at risk for experiencing constipation (a condition that causes infrequent or uncomfortable bowel movements), pain and adverse medication effects. Findings: A review of Resident 265's admission Record indicated the facility admitted the resident on [DATE] with…

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

Based on observation, interview and record review, the facility failed to enforce its policy titled,Enhanced Barrier Precautions, by failing to: - ensure staff members wore a gown when providing direct care to one of five sampled residents (Resident 34), and - provide personal protective equipment (PPE ) immediately outside of the resident room. These deficient practices had the potential to transmit infectious microorganisms to the other residents in the facility Findings: A review of the admission record indicated the facility re-admitted Resident 34 to the facility on 9/30/2023, 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), atrial fibrillation (an irregular heartbeat that can lead to blood clots and increases the risk of stroke and other heart complications) and high blood pressure. A review of Resident 34's alteration in skin integrity care plan initiated 11/30/2023, indicated the resident had a Stage IV pressure injury to the right heel. The goal was to minimize the risk…

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

Based on observation, interview, and record review the facility failed to provide privacy for one of two sampled residents (Resident 1). For Resident 1, the facility failed to provide privacy when Resident 1 was transferred from the bed to the wheelchair using the Hoyer lift (a device that holds a person in hammock like sling to lift completely and transfer to another surface). This deficient practice resulted in exposing Resident 1 ' s body to everyone who passed by and had the potential to affect Resident 1 ' s dignity. Findings: A review of Resident 1's admission Record indicated the facility admitted Resident 1 on 3/6/23 with diagnoses including diabetes mellitus (group of diseases that affect how the body uses blood sugar (glucose) and left above knee amputee. A review of Resident 1's Minimum Data Set (MDS, standardized care and health screening tool) dated 2/14/24 indicated Resident 1 had moderately impaired cognitive skills (mental process used to engage in learning and thinking). Resident 1 was dependent (helper does all the effort) with toileting hygiene, shower, upper 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 implement the care plan for one of two sampled residents (Resident 1). For Resident 1 the facility failed to ensure that two persons were available when using the Hoyer lift (Device used to transfer a person) to transfer Resident 1 from the bed to the wheelchair. This deficient practice had the potential for Resident 1 to sustain injury. Findings: A review of Resident 1's admission Record indicated the facility admitted Resident 1 on 3/6/23 with diagnoses including diabetes mellitus (group of diseases that affect how the body uses blood sugar (glucose) and left above knee amputee. A review of Resident 1's Minimum Data Set (MDS, standardized care and health screening tool) dated 2/14/24 indicated Resident 1 had moderately impaired cognitive skills (mental process used to engage in learning and thinking). Resident 1 was dependent (helper does all the effort) with toileting hygiene, shower, upper and lower body dressing, putting on/taking off footwear, personal hygiene and set up (helper sets up or cleans up,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure the records were accurate for two of three sampled residents (Resident 1 and Resident 2). By failing to: 1. Ensure room changes were documented in Resident 1 and Resident 2 ' s medical record as indicated in the facility Policy titled Room Change/Roommate Assignment with a reviewed date of 1/18/24. 2. Follow up with Resident 1 and Resident 2 on how they were doing in the new environment. These deficient practices accurately reflect Resident 1 and Resident 2 ' s location and had the potential to cause a delay in care and services, anxiety, and depression. Findings: A review of Resident 1 ' s admission record indicated the facility admitted the resident on 11/1/23 with diagnoses including post laminectomy (surgery in which the surgeon removes part of the vertebral [back] bone) and a history of falling. A review of Resident 1 ' s Minimum Data Set (MDS, standardized care and health screening tool) dated 11/14/23 indicated the resident was cognitively…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 that the residents were informed in advance, of the risks and benefits of psychoactive medication (a drug that changes brain function and results in alterations in perception, mood, consciousness, or behavior) for one of 5 sampled residents (Resident 4). This deficient practice violated the resident's right to make an informed decision regarding the use of psychoactive medications. Findings: A review of Resident 4's admission Record indicated that the facility initially admitted Resident 4 on 9/11/2021 with a readmission date of 12/17/2021. Resident 4's diagnoses included chronic respiratory failure (a condition that occurs when the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body), chronic pain syndrome (a long lasting pain that persist beyond the usual recovery period), anxiety disorder(persistent and excessive worry that interferes with daily activities), major depression (a common and serious medical illness that negatively affects how you feel, the way you think and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to identify and appropriately address a hazardous object for one of five sampled residents (Resident 4) when on 4/5/2024 a [NAME] axe was founded under his mattress . This deficient practice had the potential to result in an injury to a residents or facility staff. Findings: A review of Resident 5's admission Record indicated that the facility initially admitted Resident 5 on 9/28/2023 with a readmission date of 10/24/2024. Resident 5's diagnoses included hemiplegia (one-sided muscle paralysis or weakness), hemiparesis (weakness or the inability to move on one side of the body, making it hard to perform everyday activities like eating or dressing), anxiety disorder (persistent and excessive worry that interferes with daily activities), chronic obstructive pulmonary disease (a group of diseases that cause airflow blockage and breathing-related problems), and major depressive disorder (a common and serious medical illness that negatively…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 administer medication timely as ordered by the physician for one of two sampled residents (Resident 1). For Resident 1, the facility failed to administer the Tamiflu (medicine used to treat the influenza (flu, a contagious respiratory [nose, throat, and lungs [breathing organ] in people two weeks of age and older who had the flu symptoms for no more than two days) 75 milligrams (mg. unit of measurement) by mouth two times a day on 12/18/23 at 9 p.m. and on 12/19/23 at 9 a.m. as ordered by the physician. This deficient practice resulted in Resident 1 stated he felt he was dying and had difficulty breathing. Finding: A review of Resident 1's admission Record indicated the facility admitted Resident 1 on 12/17/2021 with diagnoses including viral pneumonia (infection of the lungs caused by virus), chronic respiratory failure (serious illness that gets worse over time that include shortness of breath (SOB) or feeling like you can ' t get enough air) 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 maintain a full time Director of Nursing (DON- registered nurse [RN]) and that a Licensed Vocational Nurse (LVN) did not assume the role of Assistant DON (ADON) without the direct supervision of a DON for the months of 11/2023 and 12/2023 for 60 of 60 residents in the building. This deficient practice had the potential to result in the facility inability to establish nursing standard of practices, compliance with the Stated and Federal agencies, handle emergencies in the facility, complete incident reports, initiate investigations on incidents and complete necessary forms, manage the entire nursing department and assume the responsibility for resident care in the absence of a physician, and the assume the responsibility of an Administrator in the absence of an Administrator for 60 residents in the facility. Findings: A review the facility's Unit Manager LVN Job Description for and signed by ADON (licensed as an LVN), dated 5/25/2023, indicated, . under the supervision of the DON and the ADON, the unit manager…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 proper food handling and preparation practices to prevent foodborne illnesses by failing to: 1. Follow the therapeutic recipe (recipes designed to support the treatment of diseases and medical conditions) approved by a dieticianrequiring the broccoli stems thicker than one inch to be cut. 2. Ensure fish served to residents was maintained out of the Danger Zone (41- 135 degrees Fahrenheit [F], the temperature in which bacteria and microorganisms can row rapidly and cause food borne illnesses). On 12/6/2023 at 12:06 p.m. cooked fish was placed on a counter allowing the temperature to drop to 110 degrees F. 3. Use the recommended therapeutic diet scooper for portion sizes for two of three sampled residents (Residents 2 and 3). Residents 2 and 3 were served a double portion of risotto rice (Italian rice). These deficient practices had the potential to decrease nutritional value and allow the growth of pathogens which could lead to 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 administer Wegovy/Semaglutide (a diabetes medication used with diet and exercise to treat adults whose diabetes is not satisfactorily controlled) (0.25 or 0.5mg) subcutaneously (SC- administration of a medication beneath the skin by injection), inject 1mg(milligrams- one thousandth of a gram) /ml(one thousandth of a liter) SC one time a day every Tuesday for morbid obesity two injections of 0.5mg per manufacturer recommendation for one of three sampled residents (Resident 1). This deficient practice caused a short supply of the weekly dose leading to a late dose administration. Findings: A review of resident 1's admission Record indicated the facility originally admitted the resident on 9/18/2021 and readmitted the resident on 12/17/2021 with diagnoses includingviral pneumonia ( infection in the lungs caused by a virus), chronic pain (pain lasting longer than 3 months), anxiety(a feeling of worry, nervousness, or unease, typically about an imminent event or something with an uncertain outcome), 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to complete required annual competencies for one of two sampled cooks (Cook 2). This deficient practice may have led to [NAME] 2 not following therapeuticrecipes (recipes designed to support the treatment of diseases and medical conditions) when preparing lunch. Findings: A review of [NAME] 1's dietary competency checklist (a check list used to ensure staff has the knowledge and skills to perform assigned tasks) dated 4/6/2023 indicated cook 1 was competent in food preparation and service. During an interview on 12/6/2023 at 12:47 p.m. [NAME] 1 stated the previous dietary supervisor (DS) completed his (Cook 1's) annual competency this year. During an interview on 12/6/2023 at 12:47 p.m. [NAME] 2 was asked if an annual competency had been completed this year and stated she (Cook 2) could not remember the last time the competency checklist was done. During an interview on 12/6/2023 at 12:47 p.m. DS 1 had been employed as the DS since October 2023 and [NAME]…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 administer medication timely as ordered by the physician for one of two sampled residents (Resident 1). For Resident 1, the facility failed to administer the Spiriva (medication that makes breathing easier by relaxing the muscles in the lungs (breathing organ] and widening the bronchi [airways] inhalation 18 micrograms (mcg., unit of measurement) one time a day, at 9 a.m. as ordered by the physician. This deficient practice resulted in Resident 1 stated he had difficulty breathing, was scared, and had anxiety attack when he did not receive his Spiriva at 9 a.m. on 11/1/2023. Findings: During a review of the admission Record indicated the facility admitted Resident 1 on 12/17/2021 with diagnoses including viral pneumonia (infection of the lungs caused by virus), chronic respiratory failure (serious illness that gets worse over time that include shortness of breath (SOB) or feeling like you can't get enough air) and anxiety disorder. During a review of the Physician Telephone Order dated 6/9/2023, at 6:06 p.m., indicated an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Cross Reference F600, F609, and F557 Based on interview and record review the facility failed the Director of Social Services and Certified Nurse Assistant 2 (CNA 2) checked the belongings for one of three sampled residents (Resident 1), to ensure Resident 1 did not possess on himself or his belongings a blow torch (blowlamp - a portable device torch that shoots out extremely hot gasoline flame intensified by pressurized air) and incense. Resident 2 (Resident 1 ' s roommate) was on oxygen (odorless gas that is present in the air and necessary to maintain life) therapy. The facility had 57 Resident in house on. This deficient practice had the potential to result in fire related accidents and death for Residents 1 and 2 and all residents, staff, and guests in the facility. Findings: A review of Resident 2 ' s admission record, indicated Resident 2 was admitted to the facility on [DATE] with the most recent readmission to the facility on [DATE] with diagnoses that included viral pneumonia (an infection of the lungs…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Cross Reference F600 and F689 Based on interview and record review the facility failed to conduct an inventory for belongings of one of three sampled residents (Resident 1) in accordance with the facility ' s undated policy and procedures titled Personal Property. This deficient practice had the potential to not account for Resident 1 ' s belongings and compromise the safety of all residents in the facility related to possession of illegal contrabands (anything prohibited by law that is considered too dangerous or offensive) not limited to deadly weapon(s) and hazardous equipment(s) by Resident 1. Findings: A review of Resident 1 ' s admission record dated 8/30/2023, indicated Resident 1 was admitted to the facility on [DATE] from a General Acute Care Hospital (GACH) with diagnoses that included end stage renal disease(a condition in which the kidneys lose the ability to remove waste and balance fluids) with dependance on dialysis (a treatment to clean your blood when your kidneys are not able to), type 2…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Cross Reference F577 and F600 Based on interview and record review the facility failed to implement it abuse prevention policy and procedures by failing to report to the State Agency (SA) the unusual occurrence of a resident to resident altercation (negative and aggressive physical, sexual, or verbal interactions between long-term care residents) to two of three sampled residents (Resident 1 and 2) in accordance with the facility ' s undated policy and procedures titled Abuse Investigation and Reporting. This deficient practice resulted in Resident 2 experienced increased anxiety (an emotion characterized by feelings of tension, worried thoughts, and physical changes like increased blood pressure) with a potential for further resident to resident abuse/altercation. Findings: A review of Resident 1 ' s admission record, indicated Resident 1 was admitted to the facility on [DATE] from a General Acute Care Hospital (GACH) with diagnoses that included end stage renal disease (a condition in which the kidneys lose…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 reasonable accommodations by not placing the call light within reach for Residents 4, 5 and 40, and failed to answer Resident's 400's call light requesting for assistance in a timely manner within three minutes. These deficient practices had the potential to prevent the residents from receiving necessary care and services, which could negatively affect the residents' physical comfort and psychosocial well-being. Findings: a. A review of Resident 4's admission Record indicated the facility re-admitted Resident 4 on 10/27/2021, with diagnoses included but not limited to metabolic encephalopathy (when the brain function is affected by viral infection or toxins in the blood), hemiplegia and hemiparesis (weakness or paralysis of one side of the body) following cerebral infarction (brain damage due to a loss of oxygen to the area), left knee contracture (chronic loss of joint motion causing joint deformity and stiffness). A review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure residents had specific choices and treatments communicated through an Advance Directives and copies of the Advance Directives (written statement of a person's wishes regarding medical treatment made to ensure those wishes are carried out should the person be unable to communicate them to a doctor) maintained in the Resident's clinical record for three of 13 Residents (Resident 4 ,18 and 23). This deficient practice had the potential for Residents 4, 18 and 23 not be given the right to accept or refuse specific medical treatments and have those options honored. Findings: a. A review of Resident 4`s admission Record indicated the facility originally admitted the resident on 5/28/2021, and re-admitted on [DATE], with diagnoses including but not limited to, metabolic encephalopathy (problem in the brain caused by chemical imbalance in the blood), epilepsy (a disorder in which nerve cell activity in the brain is disturbed, causing seizures) 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 observations, interview, and record review, the facility failed to provide activities that reflect the choices of the resident including group activities and outdoor activities for three of 13 sampled residents (Resident 4, 5, and 18). This deficient practice had the potential for the residents to feel isolated in their rooms, to decrease physical, cognitive, sense of belonging, and emotional health. Findings: a. A review of Resident 4's admission Record indicated the facility re-admitted Resident 4 on 10/27/2021 with diagnoses including but not limited to metabolic encephalopathy (brain disorder resulting to infect caused by viral or toxins in the blood system) epilepsy (abnormal electrical activity in the brain marked by sudden, recurrent episodes of loss of consciousness or uncontrolled body shaking), hemiplegia and hemiparesis (weakness or paralysis of one side of the body) following cerebral infarction (brain damage due to a loss of oxygen to the area), left knee contracture (chronic loss of joint…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 interventions to ensure six of 13 sampled residents (Resident 4, 5, 12, 22, 36, and 48) received appropriate treatment and services to prevent further decline in mobility and range of motion (ROM, full movement potential of a joint) as evidenced by: a. The facility did not objectively assess all residents, including Resident 4, 5, 12, 22, 36, and 48, for ROM in both arms and legs on a quarterly basis. b. For Resident 4, the facility failed to provide active assistive range of motion (AAROM, use of muscles surrounding the joint to perform the exercise but requires some help from the therapist or equipment) to both arms per physician's order. The facility also failed to provide appropriate positioning of both legs to prevent contractures (chronic loss of joint motion associated with deformity and joint stiffness) and pressure sores (injuries to the skin and underlying tissue caused by prolonged pressure on the skin). c. For…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure Resident 4 and 46 who were on enteral feeding (way of delivering nutrition directly to your stomach) received appropriate treatment, care, and ensure feeding tube was labeled for two of six sampled residents by failing to ensure: a. The head of the bed was elevated per Physician's Orders while receiving feeding through a gastrostomy tube (G-tube, tube placed directly into the stomach for long-term feeding) for Resident 4. b. Gastric feeding tubing and flushing syringe was labeled with date and the time the formula was hung for (Resident 46). These deficient practices had the potential for Residents' needs not being provided and placed the Residents at risk to develop complications of enteral feeding such as aspiration (when food or liquid goes into your airway). Findings: a. A review of the admission Record indicated the facility re-admitted Resident 4 on 10/27/21, with diagnoses that included but not limited to metabolic…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 sufficiently train one of two Licensed Vocational Nurses (LVN 1, a healthcare professional on how to provides nursing care) and two of two Restorative Nursing Assistants (RNA, nursing aide program that helps residents to maintain their function and joint mobility) on how to provide care and services as evidenced by: a. LVN 1 crushed multiple medications together to administer via gastrostomy tube (g-tube, a tube inserted through the wall of the abdomen directly into the stomach) route. b. One of two RNAs did not provide adequate active range of motion (AROM, performance of ROM of a joint without any assistance or effort of another person) exercises to one of 32 residents (Resident 48) receiving RNA services for range of motion (ROM, full potential movement of a joint). c. Two of two RNAs did not have any documented training to provide AROM, active assistive range of motion (AAROM, use of muscles surrounding the joint to perform the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to: - Ensure one of five sampled residents (Resident 18) was free of therapeutic duplications (unintentionally using multiple medications at the same time to treat the same condition) or in excessive dose (higher than intended dose) of psychotropic medications (medications that affect brain activities associated with mental processes and behavior) between 2/13/22 and 3/9/22. -Ensure one of five sampled residents (Resident 44) was monitored for adverse effects (unwanted dangerous side effects of medications) and effectiveness of psychotropic medication therapy between 2/9/22, and 2/28/22. These deficient practices could have increased the risk that Residents 18 and 44 could have experienced adverse effects related to the use of psychotropic medications possibly causing a negative impact to the physical, mental, or psychosocial well-being. Findings: A review of Resident 18's admission Record dated 3/10/2022 indicated he was admitted to the facility on…

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

Based on observation, interview, and record review the facility failed to: -Ensure unopened insulin (a medication used to control high blood sugar) was stored in the refrigerator per the manufacturer's requirements or label open insulin stored at room temperature with an open date in two out of two medication carts (Medication Carts 1 and 2) affecting residents 12, 20, 34, 40, 46, and 151. -Remove expired medications from two out of two inspected medication carts (Medication Carts 1 and 2) affecting Residents 7, 34, 42, and 48. -Remove five vials of expired medications from the emergency kit (e-kit) in one of one inspected medication room. The deficient practices of failing to store or label medications per the manufacturers' requirements and remove expired medications from the medication carts and e-kit increased the risk that Residents 7, 12, 29, 34, 40, 42, 46, 48, and 151 could have received medication that had become ineffective or toxic due to improper storage or labeling possibly leading to health complications resulting in hospitalization or death. Findings: During an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide prescribed therapeutic diet (diet that is part of the treatment for a disease or clinical condition or to provide mechanically altered food) per physician's order for two of 13 sampled residents (Residents 5 and 12) These deficient practices had the potential to cause a decline in oral motor skills (use and function of the lips, tongue, jaw, teeth, and inner mouth structures for speech production and safe swallowing) and quality of life for both Resident 5 and 12. Findings: a. A review of the admission Record indicated the facility admitted Resident 5 on 12/1/2021 with diagnoses including but not limited to acute (recent) and chronic (long-term) respiratory failure (serious condition that develops when the lungs cannot get oxygen into the blood), dysphagia (difficulty swallowing), attention to gastrostomy (G-tube, a tube placed directly into the stomach for long-term feeding), metabolic encephalopathy (brain disorder resulting…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 facility staff adhered to facility`s infection control policy and procedures by failing to ensure: - Resident 44's indwelling catheter bag (inserted tube that drains urine from the bladder into a bag outside the body) was not touching the floor. -Infection Prevention Nurse conducted an infection control surveillance and antibiotic stewardship for all infections including respiratory infections. -Treatment Nurse (TN) 1 was wearing an N95 mask (a particulate-filtering face piece, respirator that meets the U.S. National Institute for occupational safety and Health [NIOSH] and filters at least 95% of airborne particles) properly to cover his nose and mouth in resident care area. These deficient practices had the potential to result in the spread of infection that could lead to serious harm and/or death to all residents and staff. a. A Review of Resident 44's admission Record, indicated the facility admitted the resident on 2/8/2022, with diagnosis that included but were not limited to right knee…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide care in a manner that maintained or enhanced dignity and respect by not standing over the resident while assisting him during meal for one of the 13 sampled residents (Resident 30). This deficient practice had the potential to affect resident's sense of self-worth and self-esteem. Findings: A review of Resident 30's admission Record indicated the resident was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses that included but were not limited to acute kidney failure (a condition in which the kidneys suddenly cannot filet waste from the blood), hypertension (elevated blood pressure), hemiplegia (paralysis to one side of the body) and hemiparesis (weakness or inability to use one side of the body). A review of Resident 30's Minimum Data Set (MDS, a standardized assessment and care -screening tool) dated 1/12/2020, indicated the resident's cogitative skills of daily decision making were severely impaired 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 obtain informed consent (a process by which residents or their responsible parties have the choice to accept or decline certain medication therapy or treatments once they are educated about the risks and benefits) prior to prescribing psychotropic medications (medications that affect brain activities associated with mental processes and behavior) or increasing their dose for two of five sampled residents (Residents 18 and 23). This deficient practice could have denied Residents 18 and 23 the right to be informed regarding the risks and benefits of psychotropic medication therapy possibly resulting in diminished overall physical, mental, and psychosocial well-being. Findings: A review of Resident 18's admission Record (a document containing resident diagnostic and demographic information), dated 3/10/2022, indicated he was admitted to the facility on [DATE] with diagnoses including insomnia (inability to sleep). A review of Resident 18's Order Summary…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 a bed hold (Holding or reserving a resident's bed while the resident is absent from the facility for therapeutic leave or hospitalization) notification at the time of transfer to the hospital for one of three sampled residents (Resident 47). This deficient practice denied Resident 47 information of the facility's bed hold policy and opportunity to hold or reserve her bed while absent from the facility. Findings: A review of Resident 47`s admission Record indicated the facility admitted the resident on 2/10/2022, with diagnoses including sepsis ( body`s extreme response to an infection), major depressive disorder (mood disorder that causes a persistent feeling of sadness and loss of interest), and Type II diabetes mellitus (a chronic condition that affects the way the body processes blood sugar [glucose]). A review of Resident 47's Minimum Data Set (MDS - a standardized assessment and care -screening tool) dated 2/21/2022, indicated the resident had severely impaired cognition (never/rarely made decisions). The MDS…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to follow through with the Preadmission Screening and Resident Review (PASRR) recommendation to obtain a PASRR level II evaluation for one of three sampled residents (Resident 12). This deficient practice had the potential to result in inappropriate placement and unidentified specialized services for Resident 12. Findings: A review of the admission record indicated the facility admitted Resident 12 on 6/12/2022, and readmitted on [DATE], with diagnoses that included but not limited to pneumonia (lung infection), and metabolic encephalopathy (problem in the brain that caused by a chemical imbalance in the blood). A review of Resident 12's PASRR completed on 2/11/2022, indicated the need for Level II PASRR evaluation. A review of Minimum Data Set (a standardized assessment and care - screening tool) dated 6/18/2021, indicated Resident 12 had severe impairment of cognitive skills for daily decision making. The MDS also indicated Resident 12 was receiving…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 care plan for range of motion for Resident 5 and indwelling catheter (a tube that drains urine from the bladder into a bag) for Resident 44 for two of 13 sampled residents. These deficient practices placed Resident 5 at risk for decline in motion and development of contractures (chronic joint stiffness associated with joint deformity and pain) and had the potential for Resident 44 to not receive appropriate care and treatment for the indwelling catheter. Findings: a. A review of Resident 5's admission Record indicated Resident 5 was admitted to the facility on [DATE], with diagnoses that included but not limited to acute (recent) and chronic (long-term) respiratory failure (serious condition that develops when the lungs cannot get oxygen into the blood), metabolic encephalopathy (brain disorder resulting from systemic illness like liver disease, kidney failure, or heart failure), and muscle weakness. A review of Resident 5'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, the facility failed to provide appropriate treatment and care to one of 13 sampled residents (Resident 22), who was assessed as a moderate risk for the development of pressure sores (injuries to the skin and underlying tissue caused by prolonged pressure on the skin). The facility did not adjust the low air loss mattress (LAL, special mattress used to heal pressure sores, which are injuries to the skin and underlying tissue caused by prolonged pressure on the skin) to Resident 22's appropriate weight. The facility also failed to change the bed despite Resident 22's requests. This deficient practice placed Resident 22 at risk for increased back pain and the development of pressure sores, impacting the resident's quality of life and lowering the resident's self-esteem. Findings: A review of the admission Record indicated the facility admitted Resident 22 on 6/22/2021 with diagnoses including Alzheimer's disease (progressive memory loss), nontraumatic ischemic infarction (restrictive blood supply) of the left upper arm muscle, 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 post an Oxygen in Use sign outside the doorway and inside resident room, for one of 13 sampled residents (Resident 5) to indicate the presence of oxygen in accordance with the facility's policy. This deficient practice had the potential to place Resident 5 at risk for oxygen deprivation (lack of oxygen) in the event of a power outage and placed the facility at risk for fire hazards. Findings: A review of the admission Record indicated the facility admitted Resident 5 on 12/1/2021 with diagnoses including but not limited to acute (recent) and chronic (long-term) respiratory failure (serious condition that develops when the lungs cannot get oxygen into the blood), dysphagia (difficulty swallowing), metabolic encephalopathy (brain disorder resulting from systemic illness like liver disease, kidney failure, or heart failure), and muscle weakness. A review of Resident 5's Physician's Order, dated 1/9/2022, indicated to provide oxygen at two liters per minute (2 L/min) via nasal cannula (tube placed in nostrils to…

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

Based on observation, interview, and record review, the facility failed to accurately account for the use of one dose of a controlled substance (medications with a high potential for abuse) for one resident (Residents 150) in one of two inspected medication carts (Medication Cart 2). This deficient practice increased the risk that Resident 150 could have received too much or too little medication due to lack of documentation possibly resulting in serious health complications requiring hospitalization. Findings: During an observation and concurrent interview of Medication Cart 2, on 3/8/22, at 11:42 AM., with the Licensed Vocation Nurse (LVN 2), the following discrepancy was found between the Controlled Drug Inventory (a log signed by the nurse with the date and time each time a controlled substance is given to a resident) and the medication card (a bubble pack from the dispensing pharmacy labeled with the resident's information that contains the individual doses of the medication): -Resident 150's Controlled Drug Inventory for oxycodone (a medication used to treat pain) 5 milligrams…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 confidential information for residents receiving rehabilitation services. This deficient practice had the potential to provide unauthorized access to residents' personal information. Findings: During an observation on 3/8/2022, at 7:53 AM., there was a computer screen on a desk in the rehabilitation room. The computer screen included but was not limited to the names of residents receiving Physical Therapy (PT, profession aimed in the restoration, maintenance, and promotion of optimal physical function), room numbers, and insurance information. There was no staff present in the rehabilitation room. During an interview on 3/8/2022, at 7:53 AM., the Director of Rehabilitation (DOR) walked into the rehabilitation room and stated the computer screen displayed resident information. The DOR stated staff should have logged off from the computer system prior to leaving the room to assist a resident. A review of the facility's policy and procedures titled, Confidentiality of Information and Personal Privacy,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 an antibiotic stewardship program (a coordinated program that promotes the appropriate use of drugs used to treat infections, including antibiotics), for antibiotic use protocol (official procedure or system of rules) for two of two sampled residents (Resident 46 and 47). This deficient practice had the potential to result in inappropriately prescribed antibiotics, and placed residents at higher risk of antibiotic resistance (when bacteria/germs change in some way that reduces or eliminates the effectiveness of drugs, chemicals, or other agents designed to cure or prevent infections). Findings: A review of the admission Record indicated the facility admitted Resident 46 on 2/3/2022, and readmitted with diagnoses of, but not limited to, history of heart failure (the heart cannot pump adequately), cerebral infarction (disrupted blood supply to the brain), peripheral vascular disease (a blood circulation disorder), and right leg amputation 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 call light was in functioning order for one of 13 sampled residents (Resident 23). This deficient practice had the potential to prevent Resident 23 from using the call light to alert staff for assistance. Findings: A review of Resident 23's admission Record indicated the facility admitted the resident on 6/30/2021 with diagnoses including but not limited to, diabetes mellitus Type II (a chronic condition that affects the way the body processes blood sugar [glucose]), hypertension (HTN - elevated blood pressure), and dysphagia (difficulty swallowing). A review of Resident 23's Quarterly Minimum Data Set (MDS- a standardized assessment and screening tool) dated 1/4/2022, indicated the resident was mildly cognitively impaired (some difficulty in new situations only) and required extensive assistance with one person assist for bed mobility, transfer, and toilet use. During an observation and interview on 3/8/2022, at 10:38 AM., Infection Prevention Nurse (IPN) observed and stated Resident 23's call…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 locked doors from 9 PM., to 5:30 AM., for resident safety. This deficient practice had the potential to place residents at risk for injury and theft. Findings: During an interview on 3/8/2022 at 2:35 PM., during Resident Council Meeting, the Council indicated the facility doors were unlocked and open at night. They indicated they were afraid a homeless person might come in. During an observation and interview on 3/11/2022, at 6:45 AM., Maintenance Supervisor (MS) stated the side door to the facility was open and unlocked at 6:45 AM. He stated the doors to the facility was supposed to always remain closed. A review on 3/11/2022, at 1:45 PM., indicated pictures of the doors unlocked and open on 3/10/2022, at 2 AM. During an interview on 3/11/2022, at 1:46 PM., Resident 35 stated he felt unsafe when the doors were unlocked. The resident stated he witnessed the facility doors being unlocked and open on different days including on 3/10/2022, at 2 AM. The resident stated he would like the facility to make…

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