Cheviot Hills Post Acute

Based on observation, and interview, the facility failed to observe and maintain their infection control measures for one of four sampled residents (Resident 72) when Resident 70's nebulizer (a small electric machine that turns liquid medication into fine mist) tubing and mask was on Resident 72's night stand not stored in a plastic bag or labelled with a the residents name/date according to facility's policies and procedures (P&P), titled Infection Prevention and Control Program, reviewed 10/20/2025, and Administering Medication through a small Volume (Handheld) Nebulizer reviewed 10/2025. This deficient practice had the potential to cause infection and/or hospitalization for Resident 72.Findings: A review of Resident 72's admission Record indicated the facility admitted Resident 72 on 8/7/2025 with diagnoses including COPD, hypertension (HTN-high blood pressure), and diabetes (DM -a disorder characterized by difficulty in blood sugar control and poor wound healing). A review of Resident 72's Minimum Data Set (MDS - resident assessment tool) dated 2/12/2026, indicated Resident 72…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a resident's clinical record was maintained in accordance with accepted professional standards and practice that are accurate, by failing to document rehabilitative care (a set of medical and therapeutic interventions designed to help individuals regain, maintain, or improve physical, mental or cognitive abilities lost due to injury, illness, surgery or disability) in the Restorative Administrative Record for one out of two sampled residents (Resident 9) according to facility's policy and procedures (P&P) titled Charting and Documentation dated, 10/20/2025. This deficient practice had the potential to result in a lack and/or a delay in communication between the staff and cause an interruption in the provision of Restorative care/intervention for Resident 9.Findings: A review of Resident 9's admission record indicated the resident was originally admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included hypertension…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that a call button was within reach for one of five sampled residents (Resident 38) according to the facility's policy and procedures (P&P) titled, Call System Resident dated reviewed 10/20/2025. This deficient practice had the potential to result in delay of necessary care including emergency response for Resident 38.Findings: A review of Resident 38's admission Record indicated Resident 38 was admitted to the facility on [DATE], with medical diagnoses that included: Muscle weakness (a lack of physical or muscle strength, throughout the body), anemia (lower than normal amount of red blood cells in the body), and Type 2 diabetes (a disease characterized by elevated levels of blood sugar). A review of Resident 38's Minimum Data Set (MDS - resident assessment tool), dated 12/26/2025, indicated Resident 38's cognition (the mental ability to make decisions of daily living) was moderately impaired. The MDS indicated Resident 38 required…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to develop and implement an individualized person-centered care plan for one of the three sampled residents (Resident 2) who was assessed to have dry skin to the face and Bilateral Lower Extremeties (BLE- both legs) upon admission. This deficient practice had the potential to result is further dryness, skin break, and infection.During a review of the admission record for Resident 2 indicated Resident 2 was admitted to the facility on [DATE] with diagnoses including sequelae of cerebral infarction are the long-term problems or lasting effects that occur after a stroke (brain tissue death from blocked blood flow), diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), and heart failure (the heart can't pump enough oxygen-rich blood to meet the body's needs). During a review of Resident 2's initial admission assessment dated [DATE] at 8:47 pm, the assessment indicated under the body check section that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to ensure that one out of three sampled residents (Resident 2) who had dry skin to the face and both legs was assessed by a licensed nurse with a specific skill set within their scope. This deficient practice had the potential to result in skin breakdown and infection.During a review of the admission record for Resident 2 indicated Resident 2 was admitted to the facility on [DATE] with diagnoses including sequelae of cerebral infarction are the long-term problems or lasting effects that occur after a stroke (brain tissue death from blocked blood flow), diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), and heart failure (the heart can't pump enough oxygen-rich blood to meet the body's needs). During a review of Resident 2's initial admission assessment dated [DATE] at 8:47 pm, the assessment indicated under the body check section that Resident 2 had excessive dry skin noted to the face and BLE…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 observations, interviews, and record reviews, the facility failed to provide necessary services to maintain good personal hygiene and grooming to one out of three sampled residents (Resident 1), by failing to ensure Resident 1 did not have excessive dry skin to the face and overgrown toenails. This deficient practice placed Residents 1 at risk for skin infections, skin breakdown, and poor self-perception.Findings: During a review of Resident 1's admission record, the admission record indicated the facility admitted the resident on 3/21/2025 with diagnoses that included Type 2 Diabetes Mellitus (a disease in which your body does not produce enough insulin needed to control sugar levels in the blood), other sequelae of cerebral infarction (the long-term health problems or disabilities that remain after someone has a stroke), and dysphagia (difficulty swallowing). During a review of Resident 1's Body Check dated 3/21/2025 at 8:47 pm, the body check indicated Skin intact upon assessment. Excessive dry skin noted to the face and BLE [both lower legs]. During a review of Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure an accurate assessment in the Minimum Data Set (MDS- a federally mandated resident assessment tool) was done for one of three sampled residents (Resident 1). This deficient practice had the potential to affect the resident's plan of care and delivery of services. Cross reference with F656 Findings: During a review of Resident 1's admission Record, the record indicated the resident was admitted to the facility on [DATE] with diagnoses including: heart failure (a condition where the heart weakened and cannot pump enough blood to meet the body's needs , cellulitis, muscle weakness, morbid (severe) obesity (excessive amount of body fat), hypertension (high blood pressure), obstructive sleep apnea (a sleep disorder where breathing repeatedly stops and starts during sleep due to a blockage of the upper airway). During a review of Resident 1's History and Physical (H&P) dated 5/2/25, the H&P indicated the resident during her hospital…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to develop a care plan for OSA (Obstructive Sleep Apnea. It is a sleep disorder where the airway repeatedly collapses during sleep, causing breathing to stop or become shallow) for one of three sampled residents (Resident 1). This failure resulted in no plan of care for Resident 1's OSA and had the potential to affect continuity and delivery of care. Cross reference with F641 Findings: During a review of Resident 1's admission Record, the record indicated the resident was admitted to the facility on [DATE] with diagnoses including; heart failure (a condition where the heart weakened and cannot pump enough blood to meet the body's needs , cellulitis, muscle weakness, morbid (severe) obesity (excessive amount of body fat), hypertension (high blood pressure), obstructive sleep apnea (a sleep disorder where breathing repeatedly stops and starts during sleep due to a blockage of the upper airway). During a review of Resident 1's History and Physical (H&P) dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review for one of three sampled residents (Resident 2), the facility failed to develop a care plan for the left foot treatments. This deficient practice had the potential to led to the development of redness to the left heel. Findings: A review of Resident 2's admission record indicated the facility admitted this [AGE] year-old male on 2/3/2025 with diagnoses including peripheral vascular disease (PVD - a slow progressive narrowing of the blood flow to the arms and legs), Type 2 diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), atherosclerosis (chronic disease where sticky substances build up in the inner lining of the arteries) of right leg with gangrene (dead tissue caused by infection or lack of blood flow), atherosclerosis of aorta (largest blood vessel in the body), atherosclerotic heart disease, hypertensive heart disease (heart issues related to high blood pressure), presence of coronary angioplasty implant and graft…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review for one of three sampled residents (Resident 2), the facility failed to monitor skin and report redness on Resident 2's left heel to the attending physician (AP). This deficient practice placed Resident 2 at risk of developing a pressure injury (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence) to the left heel. Findings: A review of Resident 2's admission record indicated the facility admitted this [AGE] year-old male on 2/3/2025 with diagnoses including peripheral vascular disease (PVD - a slow progressive narrowing of the blood flow to the arms and legs), Type 2 diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), atherosclerosis (chronic disease where sticky substances build up in the inner lining of the arteries) of right leg with gangrene (dead tissue caused by infection or lack of blood flow), atherosclerosis of aorta (largest blood vessel in the…

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

Based on observation, interview, and record review, the facility failed to ensure dietary cooks followed the menu and used a recipe for lunch on 12/9/2024. This deficient practice the potential for the food to be prepared incorrectly and could make the residents sick. Cross refence F812 Findings: 1. During an initial kitchen observation on 12/09/24 at 7:44 AM with the Dietary Supervisor (DS), the following were noted of the walk-in refrigerator: a container of cooked ground beef dated that it was cooked for 12/09/24; container of mixed vegetables dated 12/8/24; cooked chicken dated 12/9/24; mashed potatoes dated 12/8/24; cooked rice dated 12/09/24; cooked tofu unlabeled with a date of 12/9/24; and cooked pork dated 12/9/24. 2. During an observation of the food recipe binder on 12/09/24 at 8:32 am with DS, there was no recipe for the lunch that the Dietary Cooks were preparing. Dietary [NAME] 1 was priparing chicken noodle casserole. During a concurrent interview DS stated, the menu for today's (12/9/24) lunch is upstairs in my office. When asked how the Cooks are cooking the…

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

Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen. These failures had the potential to result in harmful bacteria growth that could lead to foodborne illness (illness caused by food contaminated with bacteria, viruses, and other toxins) for 89 of 89 medically compromised residents who received food from the kitchen. Cross refence F803 Findings: 1. During an initial kitchen observation on 12/09/24 at 7:44 AM with the Dietary Supervisor (DS), the following were noted of the walk-in refrigerator: a container of cooked ground beef dated that it was cooked for 12/09/24; container of mixed vegetables dated 12/08/24; cooked chicken dated 12/09/24; mashed potatoes dated 12/8/24; cooked rice dated 12/09/24; cooked tofu unlabeled with a date of 12/09/24; and cooked pork dated 12/09/24. 2. During an observation of the food recipe binder on 12/09/24 at 8:32 am with DS, there was no recipe for the lunch that the Dietary Cooks were preparing. Dietary [NAME] 1 was preparing chicken noodle…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 staff promote dignity while assisting one of 20 sampled residents (Residents 66) during meals; by not feeding the resident at eye level to maintain face-to-face contact with the residents. This deficient practice had the potential to result in feelings of decreased self-esteem and self-worth for Residents 4. Findings: A review of Resident 66's admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses that included metabolic encephalopathy (condition in which brain function is disturbed either temporarily or permanently due to different diseases or toxins in the body), paralytic syndrome following cerebral infarction (a condition where paralysis occurs as a result of a stroke (cerebral infarction),), hypertension (abnormally high blood pressure), contracture of left and right knee (a permanent tightening of the muscles, tendons, and other tissues in the knee that limits the joint's range 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 record review and staff interviews, the facility failed to complete and submit the annual comprehensive Minimum Data Set (MDS, a resident assessment tool) assessment within the regulatory timeframe for one of 18 sampled residents (Resident 40). This deficient practice had the potential to negatively affect the provision of necessary care and services for the affected residents. Findings: A review of Resident 40's admission record indicated the facility originally admitted the resident on 11/3/2023 and readmitted the resident on 5/17/2024 with diagnoses that included epilepsy, bipolar disorder (a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration) and hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (mild or partial weakness or loss of strength on one side of the body)?. A review of Resident 40's MDS dated [DATE], indicated Resident 40's was totally dependent upon staff for all activities of daily…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 conduct a Preadmission Screening and Resident Review (PASRR- is a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care) level 1 assessment for one of four residents (Resident 50) diagnosed with mental illness. This deficient practice had the potential for inappropriate placement and management of Resident 50. Findings: A review of Resident 50's admission Record indicated Resident 50 was admitted to the facility on [DATE] with diagnoses that included schizophrenia (a serious mental health condition that affects how people think, feel and behave) and major depression (a mood disorder that causes a persistent feeling of sadness and loss of interest and can interfere with daily activities) A review of a PASARR letter dated 12/27/2023, indicated Resident 50 was negative for PASRR Level I Screen, and therefore, the resident did not need PASRR Level II screening. A review of physician orders…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that a Pre-admission Screening Resident Review level I (PASRR-an evaluation to determine if an induvial has a serious mental illness, intellectual disability, developmental disability, or related condition) was obtained and maintained in the residents chart for three of three sampled residents (Residents 1, 2, and 74). This deficient practice had the potential to negatively affect the appropriated care and services rendered and required for the residents. Cross reference F726 Findings: a. A review of Resident 1's admission Record indicated the facility re-admitted Resident 1 on 1/16/2024 with diagnoses including bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), anxiety (a feeling of worry, unease, or nervousness), and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest) A review of Resident l's Minimum…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to: 1. The Director of Nursing (DON) was knowledgeable on how prevent medication/narcotics and did not maintain a log/records of medications/narcotics (controlled medications used to treat moderate to severe pain) collected for disposal by a medication waste management company. 2. Staff were knowledgeable in completing and submitting the correct complete Preadmission Screening and Resident Review (PASRR -is a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care) level 1 (screening involves completion of an evaluation to determine if an individual has, or is suspected of having a PASSR condition such as, a serious mental illness, intellectual disability, developmental disability, or related condition) and level 11 (If the Level 1 screening indicates a potential PASRR condition, a more comprehensive Level 2 evaluation is conducted to confirm the diagnosis and determine appropriate care needs)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 social services to one out of 20 sampled residents (Resident 244) by failing to follow up on an order for orthopedic (musculoskeletal specialist) evaluation appointment. This deficient practice had the potential for delay in the delivery of care and services. Findings: A review of Resident 244's admission record indicated, Resident 1 was admitted originally admitted to the facility on [DATE] with diagnoses that included fracture of upper and lower end of right fibula (a break in both the upper and lower parts of the fibula bone in the lower leg), gout (a type of joint inflammation that occurs when uric acid (chemical waste product created when the body breaks down purines) builds up in the body and forms needle-shaped crystals in the joints), hyperlipidemia (abnormally high levels of lipids, or fats, in the blood), malignant neoplasm (a cancerous tumor that grows into nearby tissue and spread to other parts of the body) of prostate (gland in…

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

Based on observation and interview, the Director of Nursing (DON) failed to store, and discard controlled and non-controlled medications according to the facility's policy and procedures titled Discarding and Destroying Medications. These failures had the potential for diversion of medications. Cross Reference F726 Findings: During an observation in the DON's office and concurrent interview on 12/10/24 at 10:21 am with the DON, the facility's [NAME] President of Operations and Nurse Resource were sitting in the DON's office with the door open. Large blue and white bucket with unlocked screw on top that did not lock was noted/observed. The medications (tablets) in the waste containers were whole, intact, and retrievable. The medications were tablets not mixed in any solution/gel to disolve the disposed medications/narcotics. The medications could easily be poured out from the blue and white container. The DON stated that he shares his office with the Assistant Director of Nursing (ADON). DON stated he disposes of the narcotics with the pharmacist once a month. DON stated 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 and interview, the facility failed to provide food that accommodates resident allergies, intolerances, and preferences. This deficient practice resulted in the Resident waiting over two hours for an alternative meal. Findings: A review of Resident 294's admission Record indicated Resident 294 was admitted to the facility on [DATE], with medical diagnoses that included: hypertension (high blood pressure) and muscle weakness (a lack of physical or muscle strength, throughout the body). A review of Resident 294's doctor's assessment titled History and Physical (H&P) dated 12/8/2024 Resident 294's cognition (the mental ability to make decisions of daily living) was intact, and resident can make decisions for medical care; however, needs assistance to perform some of her activities of daily living. During observation on 12/09/24 at 8:42 am., Resident 294 was looking at her food on the plate and was not eating it. A cup with oatmeal on the resident's breakfast tray looked very strange and watery.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 a homelike environment by the inability of the facility to ensure a pest free environment for one of three residents, Resident 294. This deficient practice resulted in Resident 294 being bitten by a spider and also had the potential for facility wide infestation of spiders. Findings: A review of Resident 294's admission Record indicated Resident 294 was admitted to the facility on [DATE], with medical diagnoses that included hypertension (high blood pressure) and muscle weakness (a lack of physical or muscle strength, throughout the body). A review of Resident 294's Doctor's assessment titled History and Physical (H&P) dated 12/8/2024 Resident 294's cognition (the mental ability to make decisions of daily living) was intact, and resident can make decisions for medical care; however, needs assistance to perform some of her activities of daily living. During a witnessed observation and concurrent interview with Certified Nursing…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement its' policy and procedure (P&P) by failing to ensure prompt physician notification of one of the three sample residents (Resident 2) when Resident 2 had chills on 10/18/2024 at 3:47 pm and 10/18/2024 at 11:49 pm. As a result of this deficient practice, Resident 2 was found to have Altered Mental Status (AMS -a change in mental function that stems from illnesses, disorders and injuries affecting your brain)and was transferred to General Acute Care Hospital (GACH) where she was diagnosed with sepsis (a life-threatening blood infection), Urinary Tract Infection (UTI- an infection in the bladder/urinary tract). Findings: During a review of the admission record indicated Resident 2 was i admitted to the facility on [DATE] with diagnoses that included sepsis, and diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 2 ' s History and physical (a term…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 Certified Nursing Assistant 2 (CNA 2) did not assist CNA 1 with the care for one of four residents (Resident 1) after Resident 1 refused for CNA 2 to provide/assist with Resident 1's care. This deficient practice violated Resident 1's right to make an informed decision regarding who will provide nursing care to Resident 1 prior to performing nursing care. Findings: During a review of Resident 1's face sheet (front page of the chart that contains a summary of basic information about the resident), indicated Resident 1 was admitted to the facility on [DATE] and was re-admitted on [DATE] with diagnoses including encephalopathy (brain dysfunction that can appear as confusion, memory loss, personality changes and/or coma in the most severe form), pressure ulcer of the sacral region, Stage 4 (skin damage spreads to the muscle, bone, or joints), contracture of the right and left ankles and multiple muscle sites (a stiffening/shortening 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 observations, interviews and record reviews, the facility failed to protect the resident's right to be free from abuse for one of three Residents (Resident 1). As a result, on 4/5/24 Resident 2 punched Resident 1 (Resident 2's roommate) in the face, resulting in a cut to Resident 1's lip. Findings: A review of Resident 1's Face Sheet indicated the resident was admitted to the facility on [DATE], with diagnoses that included unspecified dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life). A review of Resident 1's History and Physical (H&P) dated 1/30/24, indicated, Resident 1 did not have the capacity to understand and make decisions. H&P indicated Resident 1 was yelling, unable to calm down, and lashing out at individuals both staff and family. During a review of Resident 1's Minimum Data Set (MDS; a standardized assessment and care screening tool) dated 2/2/24, indicated Resident 1 did not have intact cognition (mental…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record reviews, the facility failed to obtain a physician ' s order for behavior monitoring and implement behavior monitoring for signs and symptoms of dementia ((loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life) for one of three Residents (Resident 1). As a result, on 4/5/24 Resident 2 punched his roommate (Resident 1) in the face, resulting in a cut to Resident 1 ' s lip. Cross Reference F600 Findings: A review of Resident 1 ' s Face Sheet indicated the resident was admitted to the facility on [DATE], with diagnoses that included unspecified dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life). A review of Resident 1 ' s History and Physical (H&P) dated 1/30/24, indicated, Resident 1 did not have the capacity to understand and make decisions. H&P indicated Resident 1 was yelling, unable to calm down, and lashing out 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.

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 2/2023 through 12/2023 for 78 of 78 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. Findings: A review the facility ' s LVN Job Description dated 12/26/2023, indicated the purpose of this position is to provide nursing care to residents under the supervision of a physician and/or registered nurse and within the scope…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 advance directives (written statement of a person's wishes regarding medical treatment made to ensure those wishes are carried out should the person be unable to communicate them to a doctor) were updated in the clinical records five out of five sampled residents (Resident 4, Resident 17, Resident 32, Resident 35, and Resident 60) by failing to maintain documentation of the residents' advance directives acknowledgement form in the residents' clinical records. This deficient practice had the potential to cause conflict with the residents' wishes regarding health care Resident 4, Resident 17, Resident 32, Resident 35, and Resident 60. Findings: A review of Resident 4's admission Record indicated Resident 4 was initially admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that include metabolic encephalopathy (damage or disease that affects the brain), schizophrenia (mental illness that affects how a person feels 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, for three of three sampled residents (Resident 17, Resident 66, and Resident 281), the facility failed to develop a comprehensive care plans for: 1. Chronic (ongoing) right knee pain for Resident 66 2. Antipsychotic medications (medications used to treat menlla illness) for Resident 281 3. Coffee ground emesis (vomit that looks like coffee grounds which is a sign of internal [inside] bleeding) for Resident 17 This deficient practice had a potential for Resident 17, Resident 66, and Resident 281 to not receive appropriate care and treatment. Findings: 1. A review of Resident 17's admission Record indicated Resident 17 was initially admitted to the facility on [DATE] and was readmitted on [DATE], with diagnoses that included encephalopathy (damage or disease that affects the brain), dementia (loss of cognitive functioning-thinking, remembering, and reasoning) and Parkinson's disease (progressive disorder that affects the nervous system [includes the brain and spinal cord] 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, interviews, and record review, the facility failed to ensure designated nursing staff would restock the Automated Drug Delivery System (ADDS, the facility used the brand, Cubex) within 48 hours of receiving the emergency medications supplies from the pharmacy. This deficient practice had the potential of drug diversion and/or delay in providing care to residents. Findings: During an interview on 11/15/23 at 9:38 AM, the licensed vocational nurse (LVN 1) stated the facility had 1 nursing station, 1 medication room inside the nursing station, & 3 medication carts. During an observation inside the medication room with the assistant director of nursing (ADON) on 11/16/23 at 11:17 AM, there was a linen cart stored inside the med room. On the counter to the left of the medication room entrance, there were 3 boxes next to an Automated Drug Delivery System, called Cubex. Each box had a delivery receipt taped on the top. During a concurrent interview, ADON stated those boxes contained controlled substances (C2, narcotics and/or other classified medications) to be…

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

Based on observation, interviews, and record review, the facility failed to ensure the medication error rates was not five (5) percent (%) or greater during medication administration observations. During the 29 opportunities of medication administration observations conducted, there were 6 errors, thus, the error rate was at 20.7%. Five of 6 errors were due to nurses crushing medication without physician orders, for Residents 67 and 14. The remaining 1 of 6 errors was due to the administration of the incorrect dosage form: Resident 21 had an order for aspirin (a medication to reduce risk of blood clots forming) oral capsule 81 milligrams (mg, an unit to measure mass), however, aspirin enteric coated (delay release coating to reduce stomach irritation) 81 mg tablet was administered. These deficient practices had the potentials of significant medication errors that may or may not affect the residents' health conditions. Findings: During an observation on 11/15/23 at 9:20 AM, the licensed vocation nurse (LVN 1) was preparing four medications for Resident 21. One of the 4 medications…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 practices in the kitchen when: 1.Personal soda bottles were stored in the facility reach in refrigerator. 2.Three containers of fruit stored in the reach in refrigerator had no date and label. 3.Cook1 did not wash hands after removing soiled gloves and returned to food preparation area to cook food. 4. Cook1 prepared raw chicken in the food preparation sink and then used the same sink to wash raw vegetables. These deficient practices had the potential to result in harmful bacteria growth and cross contamination (transfer of harmful bacteria from one place to another), leading to foodborne illness in 70 out of 78 residents who received food from the kitchen. Findings: 1. During a concurrent observation and interview in the kitchen on 11/14/23 at 7:35AM, there were two (2) plastic soda bottles stored in the reach in refrigerator. Dietary staff (DA1) stated those soda bottles belonged to staff, and they (soda bottles) had been there since yesterday. DA1…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 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: 1. Resident's room air-conditioning ventilator had an excess of dirt particles. 2. Meal trays were observed in the parking lot next to trash and linen barrels. 3. A shower room had human feces on the floor and dirty linens on top of the dirty linen barrel. These deficient practices could result in the spread of infections to residents and staff. Findings: 1. A review of Resident 67's admission record indicated the resident was admitted on [DATE] with medical history including pneumonia (lung infection), protein-calorie malnutrition, gout (painful form of arthritis), dysphagia (inability to swallow), muscle weakness, and hypercholesterolemia (high cholesterol). A review of Resident 67's Minimum Data Set (MDS, a standardized assessment and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure nursing staff responded to residents call lights promptly for one of three sampled residents (Residents 39). This deficient practice had the potential not to meet the needs of Resident 39. Findings: A review of Resident 39's admission record indicated Resident 39 was admitted to the facility on [DATE], with diagnoses that included hypothyroidism (a condition in which the a small, butterfly-shaped gland located at the front of your neck under your skin does not make enough thyroid hormone), hypertension (high blood pressure), protein malnutrition (state of inadequate intake of food (as a source of protein, calories, and other essential nutrients) and long term current use of anticoagulants (blood-thinning medications used to prevent blood clots in the body). A review of Resident 39's Minimum Data Set (MDS - a standardized assessment and care screening tool) dated 09/16/2023, indicated Resident 39 was able to understand others 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 notify the residents representative of a change in condition for one of three sampled residents (Resident 17) in accordance with the facility's policy and procedures (P&P) titled change in condition (COC- a change in the resident's health or function) Notification of, with effective date of 8/25/2021. This deficient practice resulted in violation of resident's representatives right to be notified of a change in condition for Resident 17. Findings: A review of Resident 17's admission Record indicated Resident 17 was initially admitted to the facility on [DATE] and was readmitted on [DATE], with diagnoses that included encephalopathy (damage or disease that affects the brain), dementia (loss of cognitive functioning-thinking, remembering, and reasoning) and Parkinson's disease (progressive disorder that affects the nervous system [includes the brain and spinal cord] and the pats of the body controlled by the nerves (cables that carry electrical impulses…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of 21 sampled residents (Resident 75) was kept clean and free of odors by failing to provide personal hygiene, and incontinent care. This deficient practice resulted in Resident 75 feeling frustrated and embarrassed and the potential for odors, infection, unkempt matted hair, dry/broken skin, and poor hygiene. Findings: A review of Resident 75's admission Record indicated the resident was admitted to the facility on [DATE], with diagnoses that included pressure ulcer (PU) of left buttock (skin and soft tissue injuries that form as a result of constant or pressure exerted on the skin)., stage 4 (an objective description of the severity of PUs.), pressures ulcer to right buttock stage 3, hypertension (high blood pressure), muscle weakness, hyperlipidemia (describe elevated lipid (fat) levels within the body, and atrial fibrillation (an irregular and often very rapid heart rhythm). A review of the Minimum Data Set (MDS) 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 ensure one of seven sampled residents (Residents 79) received care and services by failing to assess, monitor, and document a set of vital signs prior to the resident's death. This deficient practice had the potential to result in delayed appropriate care and treatment. Findings: A record review of Resident 79's admission Record indicated Resident 79 was admitted on [DATE] with medical diagnosis including chronic obstructive pulmonary disease ( a lung disease causing restricted airflow), congestive heart failure (a chronic condition in which the heat does not pump blood as it should), atrial fibrillation (an irregular heart beat), dementia (a group of thinking and social symptoms that interferes with daily functioning ), major depressive disorder ( a mood disorder characterized by sadness), dysphagia (inability to swallow), pulmonary emboli (blood clots in the lungs), and gastroesophageal reflux disease (acid reflux). A review of Resident 79's Minimum…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure a 16 ounce (oz - unit of measurement ) bottle of Isopropyl 70% Alcohol (rubbing alcohol - a colorless, flammable [easily set on fire] liquid) was not left at the bedside for one of 21 sampled residents (Resident 6). This deficient practice had the potential to result in fire related hazards and death for all residents, staff, and guests in the facility. Findings: A review of Resident 6's admission Record, indicated, Resident 6 was originally admitted to the facility on [DATE] with a diagnoses that included neuropathy (nerve damage characterized by numbness, tingling and pain) type 2 diabetes (a long-term metabolic disease characterized by elevated levels of sugar in the blood), hypertension (high blood pressure), muscle weakness and difficulty walking. A review of Resident 6's the Minimum Date Set (MDS-a standardized assessment care screening tool) dated 8/14/2023, indicated Resident 6's cognition (the mental action or process 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 licensed nursing staff failed to assess the pain level (intensity) and manage pain for one of one sampled resident (Resident 20). This deficient practice resulted in Resident 20 experiencing unnecessary pain. Findings: A review of the Resident 20's admission record indicated the facility admitted Resident 20 on 5/16/2023 with a diagnosis that included, hypertension (high blood pressure), type 2 diabetes, (a long-term metabolic disease characterized by elevated levels of sugar in the blood), seizures (a sudden, uncontrolled burst of electrical activity in the brain that can cause changes in behavior, movements, feelings and levels of consciousness) and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). A review of Resident 20's Minimum Date Set (MDS-a standardized assessment care screening tool) dated 5/22/2023 indicated Resident 20's cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) was not…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 staffing information was posted and updated daily. As a result, the total number of staff and the actual hours worked by the staff was not readily accessible to residents and visitors. Findings: On 11/14/2023 at 11:00 AM., during an observation, the staffing information was not posted in the facility's Nursing Station On 11/15/2023 at 11:00 AM., during an observation, the staffing information was not posted in the facility's Nursing Station On 11/15/2023 at 1:00PM., during an observation and interview with Director of Nurses (DON), DON stated she did not know which staffing information should be posted daily. DON stated she would find out which form needs to posted daily. DON stated any posting should have been posted at the nurse's station. A review of the facility's policy and procedures titled, Posting Direct Care Daily Staffing Numbers dated 8/2022, indicated, the facility will post on a daily basis for each shift nurse staffing data, including the number of personnel responsible for providing…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of one sampled resident (Resident 6), received treatment and care in accordance with professional standards of practice to meet the resident's physical, mental, and psychosocial needs, by failing to assess the source of Resident 6's itchy skin and notifying the doctor of a change in Resident 6's skin condition. This deficient practice had the potential for Resident 6 to have unresolved skin itching that could result in skin infection and unnecessary hospitalization. Findings: A review of Resident 6's admission Record, indicated, Resident 6 was originally admitted to the facility on [DATE] with a diagnosis that included Neuropathy (nerve damage interferes with the functioning of the peripheral nervous system (PNS) characterized as Numbness, tingling and pain) type 2 diabetes ((a long-term metabolic disease characterized by elevated levels of sugar in the blood), hypertension( (high blood pressure), muscle weakness and difficulty walking. A…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement an antibiotic stewardship program (a coordinated program that promotes the appropriate use of drugs used to treat infections, including antibiotics) to monitor antibiotic use for two of two sampled residents (Resident 21 and 79). This deficient practice had the potential for inappropriate use of antibiotics, placing residents at higher risk of antibiotic resistance (taking antibiotics too often or for the wrong reasons can change bacteria so much that antibiotics don't work against them). Findings: A review of Resident 21's admission Record indicated the resident was admitted on [DATE] with medical history including urinary tract infection (bladder infection), sepsis (bacterial infection in the blood), type 2 diabetes (body's inability to process sugar), chronic kidney disease, dysphagia (inability to swallow), hypertension (elevated blood pressure). A review of Resident 21'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.

Based on observation, interview and record review, the facility failed to ensure the walk-in freezer was maintained in a good operating condition. The walk-in freezer had ice buildups inside, on the ceiling, floor, walls next to the door and the plastic door curtains (strip curtains used for temperature separation for door openings in refrigerators and freezers). There was ice buildup on the door and the parameters of the freezer door. Upon opening the door, a large thick chunk of ice fell to the floor and the freezer door was not closing tight. There were buildups of frost and ice crystals inside the food including ice crystals in the veggie patty and ice buildup in the bags of meat next to the entrance of the walk-in freezer. The freezer was operational in a manner that had the potential to affect food quality and /or increase the potential of growth of microorganism. This deficient practice the potential to cause foodborne illness due to the inappropriate storage of food and had the potential to negatively affect the health and wellbeing of 70 residents, who consumed food from…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 facility pest free (free of cockroaches and flies), maintain room cleanliness, prevent pest harborage areas, and maintain an effective pest control program. This deficient practice had the potential to place all 72 residents residing in the facility at risk of vector-borne diseases (Illness that results from infections transmitted to humans by insects, such as cockroaches) if cockroaches and flies spread in the facility. Findings: During an unannounced visit to the facility about a complaint regarding physical environment on 11/2/2023 at 11:50 a.m., Resident 3 was observed getting prepared by staff to get a shower. The floor in his room was observed to be covered in debris, his nightstand was covered in clutter from clothing items and other personal items. The drawers od his nightstand contained 2 jars of opened peanut butter, a packet of open crackers mixed with books. He stated that he observed a roach coming into his room…

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

Based on observation, interview, and record review, the facility failed to maintain the facility in good repair, at all times. This deficient practice had the potential to result in accidents and negatively affect the health and safety of all residents, staff, and visitors. Findings: On 9/1/2023, the California Department of Public Health (CDPH, the Department) made an unannounced visit to the facility to investigate a complaint about physical environment. During a concurrent observation and interview on 9/1/2023 at 9:36 a.m., with the facility Administrator (ADM) and Fire Department Inspector (FDI), the evaluator observed missing acoustical ceiling tiles (tiles used to cover ceilings) with cables/wires exposed and hanging on the ceiling in the basement corridor. The wooden membrane of the floor-ceiling assembly was also exposed. The ADM stated the facility had rainwater leaking into the basement due to the storm on 8/20/2023. The rainwater may have come into the patio and affected the basement. The FDI stated, in case of smoke or fire, the smoke had the potential to spread in the…

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

Based on observation, interview, and record review, the facility failed to maintain the facility pest free (free of cockroaches and flies), maintain the kitchen area clean, prevent pest harborage areas, and maintain an effective pest control program. This deficient practice had the potential to place all 76 residents residing in the facility and receiving food or utensils from the kitchen at risk of vector-borne diseases (Illness that results from infections transmitted to humans by insects, such as cockroaches) if cockroaches and flies spread in the facility. Findings: On 9/1/2023, the California Department of Public Health (CDPH, the Department) made an unannounced visit to the facility to investigate a complaint about physical environment. During a concurrent observation and interview on 9/1/2023 at 9:48 a.m., with the facility Administrator (ADM) and Fire Department Inspector (FDI), the evaluator observed one live cockroach crawling on the wall along the corridor outside the electrical room. The ADM confirmed observation. The evaluator observed the Director of Staff Development…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure that 11 out of 17 sampled residents (Resident 1, 2,3,4,5,6,7,8,9,10,11) were provided a therapeutic diets (diet ordered by a physician as part of treatment for disease or clinical condition, or to eliminate or decrease specific nutrients in the diet, or to increase specific nutrients in the diet, or to provide food the resident is able to eat) as ordered by the physician. These deficient practices had the potential to prevent the residents from receiving benefit of the therapeutic diet. Findings: A review of Resident 2 ' s admission Record indicated the facility admitted the resident on 5/26/2022 with diagnoses including diabetes mellitus type 2 ((a chronic condition that affects the way the body processes blood sugar [glucose]), muscle wasting (thinning of the muscle mass) and dysphagia (difficulty swallowing). A review of Resident 2 ' s Minimum Data Set (MDS - assessment used as a care-planning tool), dated 7/6/2023 indicated the…

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

Based on observation, interview and record review, the facility failed to ensure one of 11 sampled residents (Resident 1) remains free of accident hazards by failing to ensure Resident 1 with dysphagia (inability to chew or difficulty swallowing) received a diet in the correct form per physician order. On 9/3/2023 at 5:24 p.m., Resident 1 was given a regular consistency diet (no food consistency/texture restrictions) instead of a prescribed puree diet (diet used in the dietary management of dysphagia with the food prepared moist, smooth, cohesive [sticking together] with no water separation and with consistency of a pudding). This failure had a potential to cause life threatening conditions such as choking, aspiration (inhaling small particles into the lungs), and death. Findings: During a review of Resident 1 ' s admission Record, indicated the facility admitted Resident 1 on 8/14/2023, with diagnoses including acute kidney failure (a condition in which the kidneys suddenly cannot filter waste from the blood), malnutrition (lack of sufficient nutrients in the body) and dysphagia.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 timely identify and provide the necessary treatment and services to prevent formation and progression of a pressure ulcer (PU, an injury to skin and underlying tissue due to prolonged pressure over a bony structure) to the sacrum (a triangular bone in the lower back formed from fused vertebrae and situated between the two hipbones of the pelvis) for one of three sampled residents (Resident 1), by failing to: 1. Evaluate Resident 1 ' specific risk factors and changes in Resident 1 ' s condition that might impact the development of a PU, 2. Redistribute pressure (such as repositioning) for Resident 1 in accordance with the facility's policy and procedures titled Preventative Intervention Guidelines. 3. Routinely assess and document the condition of Resident 1 ' s skin per facility wound and skin care program for any signs and symptoms of irritation or breakdown. Immediately report any signs of a developing pressure ulcer to the supervisor.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents was offered sufficient fluid intake to maintain proper hydration and health status by failing to Resident 1's eating and fluid intake was properly assessend and documented per facility's policy titled, Pressure Ulcer Risk Assessment. This deficient practice had the potential for Resident 1to be at a greater risk for Urinary Tract Infections (UTIs- common infections that happen when bacteria, often from the skin or rectum, enter the urethra, and infect the urinary tract) or dehydration (loss of water in the body). Cross Reference F686 Findings: A review of Resident 1's admission record (Facesheet) indicated the facility originally admitted Resident 1 on 5/12/2022 and readmitted on [DATE] with diagnoses including diabetes mellitus (elevated blood glucose[sugar] levels), essential hypertension (occurs when the force of blood is stronger than it should be normally which is not because of a medical…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 3), who had a history of fall, and was a high risk for falls, received care and services to prevent falls and injuries by failing to develop and implement a fall risk care plan. This deficient practice resulted in Resident 3 having a fall on 8/5/2023. Findings: A review of Resident 3's admission record (Facesheet) dated 8/7/2023, indicated Resident 3 was admitted to the facility on [DATE], with the diagnoses which included encephalopathy (is a general term that refers to brain disease, damage, or malfunction. The major symptom of encephalopathy is an altered mental state), thrombocytopenia (a condition in which the platelets (also called thrombocytes) are low in number, which can result in bleeding problems), and hypertension (when blood pressure is persistently high). A review of Resident 3's Minimum Data Set (MDS- a comprehensive assessment and care screening tool), dated 7/28/2023, indicated Resident 3…

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