Costa Del Sol Healthcare

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to initiate a care plan or have resident-centered interventions for three of six sampled residents (Residents 50, 8, and 16) when: 1. Resident 50's preference for an interpreter when communicating with doctors and healthcare staff was not included in his communication care plan. 2. Resident 8 did not have a care plan for the use of oxygen. 3. Resident 16 did not have a care plan for the use of oxygen. These deficient practices resulted in staff being unaware of Resident 50's preference for a Cambodian-speaking interpreter. These deficient practices had the potential for Resident 8 and 16 oxygen administration and potentially caused a delay and negatively affected the delivery of care. Findings: 1. During a review of Resident 50's admission Record, the admission Record indicated Resident 50 was originally admitted to the facility on [DATE] and most recently readmitted on [DATE]. Resident 50's admitting diagnoses included Parkinson's disease…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 residents received necessary respiratory care and services consistent with the resident's plan of care for three of 26 sampled residents (Resident 8, 16, 39). For Resident 8, who had a diagnosis of chronic obstructive pulmonary disease (COPD, a chronic lung disease causing difficulty in breathing), there was no assessment of the oxygen saturation (measurement of the amount of oxygen in the blood). For Residents 8, 16 and 39, the prescribed liters of oxygen were not administered to the residents per the physician's order. These deficient practices had the potential to cause a negative respiratory outcome and placed residents at risk of injury due to fire hazard. Findings: 1. During a review of Resident 8's admission Record, the admission Record indicated Resident 8 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including COPD and diabetes mellitus (DM-a disorder characterized by difficulty…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 licensed nursing staff failed to ensure the physician's orders to hold medications were followed, medications were administered timely, and medications administered were accurately documented for four of six sampled residents (Resident 5, 93, 84, and 89) when: 1. Resident 89's order to hold medications on scheduled dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) days was clarified with Nurse Practitioner (NP) 2. 2. Resident 93's newly prescribed dose of fluconazole (a medication used to treat fungal infections) was administered timely from 5/4/2025 to 5/6/2025. 3. Resident 93's Antibiotic (medication used to treat infection) Medication Count Sheet was accurate and complete to account for all 10 doses of Resident 93's ordered doses of fluconazole. 4. Resident 5's Pregabalin (a medication used to treat nerve pain) Medication Count Sheet was accurate and complete to account…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure two of three sampled residents (Resident 83 and Resident 87) were free from significant medication errors (one which causes the resident discomfort or jeopardizes his or her health and safety) by failing to: 1. Ensure licensed nurses held medications for Resident 83 and Resident 87 on scheduled hemodialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) days per the physician orders. The deficient practice had the potential to result in a hypotensive crisis (low blood pressure) leading to harm or hospitalization. Findings: a. During a review of Resident 87's admission Record, the admission Record indicated Resident 87 was admitted to the facility on [DATE] with diagnoses of end stage of renal disease (ESRD, a 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…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 informed consent for psychotropic medication (any drug that affects brain activities associated with mental processes and behavior) was obtained in accordance with the facility's policy and procedures for one of five sampled residents (Resident 6). This deficient practice placed Resident 6 at risk for experiencing unexpected and/or unwanted adverse effects or complications of the medications, including increased cognitive impairment (problems with a person's ability to think, learn, remember, use judgment, and make decisions), over sedation (excessive drowsiness, loss of response to verbal command, inappropriate movement, hearing abnormalities, visual disturbances, sweating, or nausea), and tardive dyskinesia (a chronic movement disorder that causes involuntary, repetitive movements in the body). Findings: During a review of Resident 6's admission Record, the admission Record indicated Resident 6 was admitted to the facility on [DATE]. 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 the needs and preference of two of 22 sampled residents (Resident 66 and Resident 50) were accommodated by failing to: 1. Ensure Resident 66's call light was kept within his reach. 2. Ensure Facility staff used a language interpreter when communicating with Resident 50. This deficient practice removed Resident 66's ability to exercise his right to request assistance from staff and removed Resident 50's ability to understand the care being provided to him. Findings: 1. During a review of Resident 66's admission Record, the admission Record indicated Resident 66 was originally admitted on [DATE] and was most recently readmitted on [DATE]. Resident 66's admitting diagnoses included dementia (a progressive state of decline in mental abilities), anxiety disorder (mental health conditions characterized by excessive fear and worry that can significantly impact daily life), and history of falling. During a review of Resident 66'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, Licensed Vocational Nurse (LVN) 3 failed to notify the physician when one of 22 sampled residents (Resident 74) experienced seizures (sudden, uncontrolled electrical disturbances in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness) on 2/13/2025, 2/16/2025, 2/20/2025, 2/28/2025, 3/1/2025, and 3/14/2025. This deficient practice prevented Resident 74's physician from being able to make adjustments to Resident 74's plan of care to prevent recurring seizure activity. Findings: During a review of Resident 74's admission Record, the admission Record indicated Resident 74 was originally admitted on [DATE] and was most recently readmitted on [DATE]. Resident 74's admitting diagnoses included seizures (sudden, uncontrolled electrical disturbances in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness). During a review of Resident 74's MDS, dated [DATE], the MDS indicated Resident 74 had severe cognitive…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 following were indicated for two of five sampled residents (Resident 6 and Resident 73): 1. Non-pharmacological interventions were attempted, and behavioral indications were present and documented prior to administering psychotropic medications (any drug that affects brain activities associated with mental processes and behavior) for Resident 6. 2. Specific behavioral indications were documented and monitored from 3/1/2025 to 5/7/2025 for Resident 73 before the administration of clonazepam (a medication used to treat anxiety disorder [a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities]) three times a day. These deficient practices placed Resident 6 and Resident 73 at risk for experiencing unwanted adverse effects or complications from the psychotropic medications, including increased cognitive impairment (problems with a person's ability…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 Sets (MDS, a resident assessment tool) for two of 22 sampled residents (Resident 38 and 74) accurately reflected the care and services they received. This deficient practice resulted in the transmission of inaccurate data to the Centers for Medicare and Medicaid Services (CMS) regarding the above residents' health status and unique healthcare needs. This deficient practice also created the potential for Residents 38 and 74 to not receive the interventions needed to monitor the effectiveness of the care received. Findings: 1. During a review of Resident 38's admission Record, the admission Record indicated Resident 38 was originally admitted on [DATE] and most recently readmitted on [DATE]. Resident 38's admitting diagnoses included congestive heart failure (CHF, a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling). During a review of Resident 38's physician order, dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of four sampled residents (Resident 74) had orders to monitor for seizures (sudden, uncontrolled electrical disturbances in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness) following his first seizure on 2/12/2025. This deficient practice placed Resident 74 at risk of experiencing injuries related to unwitnessed and/or undocumented seizures (e.g., falls, choking, low oxygen levels). Findings: During a review of Resident 74's admission Record, the admission Record indicated Resident 74 was originally admitted on [DATE] and was most recently readmitted on [DATE]. Resident 74's admitting diagnoses included seizures. During a review of Resident 74's Minimum Data Set (MDS), dated [DATE], the MDS indicated Resident 74 had severe cognitive impairment (a significant decline in thinking, learning, remembering, and other mental functions, to the point where individuals struggle with daily activities and may…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 their Policy and Procedure (P&P) for Intravenous line ([IV] a thin, flexible tube placed inside a vein, usually in the arm or hand, to deliver fluids, medications, or nutrients directly into the bloodstream) care for one Of eight sampled residents (Resident 87) by failing to: 1. Ensure Resident 87's left arm IV and IV dressing was changed per the physician's order. 2. Ensure Resident 87's right arm IV was assessed. These deficient practices increased Resident 87's risk of developing an infection (the invasion and growth of germs in the body), and caused pain and discomfort to Resident 87. Findings: During an observation on 5/5/2025 at 9:50 a.m., Resident 87's left arm IV was dated 4/28/2025. Resident 87's right arm IV's dressing was dislodged from the skin and the IV had blood on the tubing. The dressing was not dated. During an observation on 5/6/2025 at 1:06 p.m., Resident 87's left arm IV was dated 4/28/2025. Resident 87's right…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 the State Survey Agency (Bureau of Health Facility Licensing, Certification and Resident Assessment, within the Department of Public Health), a written report of the findings of the investigation of an allegation of abuse within five (5) working days of the occurrence of an incident of physical abuse for two of four sampled residents (Residents 1 and 2). This deficient practice had the potential to result in a delay in the State Survey Agency's investigation, unidentified abuse in the facility, and placed Residents 1 and 2 at risk for elder abuse. Findings: a. During a review of Resident 1 ' s Face Sheet (front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses including dementia (a progressive state of decline in mental abilities), anxiety (feeling of fear), dysphagia (difficulty…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of three sampled residents ' (Resident 1) muscle relaxant medication was readily available for use when needed and the injection medication for physician ' s administration to manage resident ' s pain was available. This failure placed the resident at risk for discomfort and severe pain, which can affect in maintaining the resident ' s highest practicable physical, mental, and psychosocial well-being. Findings: During a review of Resident 1 ' s admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE], with diagnoses including osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage), hereditary and idiopathic neuropathy (nerve damage), and chronic pain syndrome (pain that lasts longer than three months). During a review of Resident 1 ' s History and Physical (H&P) dated 11/23/2024, the H&P indicated Resident 1 had the mental capacity to understand and make 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 report unusual occurrence from one of four sampled residents (Resident 1) to the state agency California Department of Public Health (CDPH), when Resident 1 was noticed with a large bruise on her left side of the breast and left rib cage on 9/5/2024. This deficient practice resulted in a delay of an onsite inspection by CDPH to investigate Resident 1 ' s injury in a timely manner, a delay in prevention of further injuries and possible abuse. Findings: During a review of Resident 1 ' s admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with a diagnosis that included adult failure to thrive (a decline caused by chronic diseases and functional impairments which can cause weight loss, decreased appetite, poor nutrition, and inactivity), unspecified protein-calorie malnutrition (The lack of sufficient energy or protein to meet the body's metabolic demands), and type 2 diabetes (DM-a disorder 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 observation, interview and record review, the facility failed to ensure three of eight sampled residents (Resident 2, Resident 5 and Resident 6) call lights were placed within residents' reach. This deficient practice could result in residents ' needs not met and residents ' highest practicable physical, mental, and psychosocial wellbeing will not be maintained. Findings: a). During an observation on 8/23/2024 at 3:10 p.m., in Resident 2 ' s room, Resident 2 ' s call light was observed hanging on the left side of Resident 2 ' s bedside wall. Certified Nursing Assistant (CNA) 1 came and took the call light from the wall and gave it to Resident 2. During a review of Resident 2 ' s admission Record, the admission Record indicated Resident 2 was admitted to the facility on [DATE] with diagnoses of muscle weakness (loss of muscle strength), lack of coordination (problem with balance, movement, or coordination), and other abnormalities of gait and mobility (abnormal walking pattern). 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 ensure two of eight sampled residents (Resident 3 and Resident 4) who were on gastrostomy tube ([GT] a tube surgically inserted into the abdomen to administer medications and nutrition) feedings, received tube feedings (nutrition administered via GT) timely according to the physician ' s orders. This deficient practice had the potential to result in Resident 3 and Resident 4 ' s nutritional needs not met leading to weight loss and malnutrition (lack of proper nutrition). Findings: a) During an observation on 8/23/2024 at 3:25 p.m., in Resident 3 ' s room, Resident 3 was observed with GT feeding of Glucerna 1.2 calories (name of tube feeding formula) and a water bag with label, dated 8/23/2024 at 1:00 p.m., that was turned off. During a concurrent observation and interview on 8/23/2024 at 4:12 p.m., with Licensed Vocational Nurse 1 (LVN) in Resident 3 ' s room, Resident 3 ' s GT pump (machine used to deliver tube feeding) was turned off.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 effective infection control measures were practiced, by failing to ensure: 1. Cleaned and uncleaned oxygen concentrators (a medical device that takes air from the environment and filters it into purified oxygen) were not stored in the same storage room (Storage 1). 2. The oxygen concentrators were labeled to distinguish the cleaned oxygen concentrators from the uncleaned oxygen concentrators. These deficient practices had the potential to result in cross contamination and increase the risk of infection to residents receiving supplemental oxygen. Findings: During a concurrent observation and interview on 8/12/2024 at 4 p.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 pointed out the storage room used to store oxygen concentrators in the facility. LVN 1 stated all cleaned, used, and broken oxygen concentrators were placed in one storage room. The storage room held six oxygen concentrators, with one concentrator covered in plastic. The concentrators were unlabeled and facing in different directions,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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. Correctly use a Valve-bag-mask ([Ambu-bag] hand-held device commonly used to provide positive pressure ventilation [exchange of air between the lungs and the outside air] to residents who are not breathing or breathing inadequately) when one of one sampled resident (Resident 1) was in respiratory distress. 2. Ensure staff checked the Emergency Cart daily (cart with supplies used during emergencies) and ensure non-rebreather masks (device used to assist in the delivery of oxygen [O2] therapy) were stocked as per facility ' s policies and procedure (P&P). These deficient practices had the potential to result in residents not receiving emergency treatment and care needed in accordance with professional standards of practice. Findings: A review of Resident 1 ' s admission record indicated Resident 1 was originally admitted to the facility on [DATE] with diagnoses including respiratory failure (condition where there's not enough O2 or too…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide sufficient nursing staff to: 1. Provide range of motion ([ROM] full movement potential of a joint [where two bones meet]) exercises, apply splints (material used to restrict, protect, or immobilize a part of the body to support function, assist and/or increase range of motion), and perform ambulation (the act of walking) to 43 residents requiring a Restorative Nursing Assistant (RNA, nursing aide program that helps residents to maintain their function and joint mobility) program, including five of seven sampled residents (Resident 8, 27, 49, 61, and 63) with limited mobility (ability to move). This deficient practice had the potential for the 43 residents on RNA services, including Resident 8, 27, 49, 61, and 63, to experience a decline in range of motion and mobility, which could affect the residents' overall function. Cross reference F688. 2. Provide assistance to one of two sampled residents (Resident 61), to accommodate his…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 accurately assess functional limitation (limited ability to move a joint that interferes with daily functioning) in range of motion ([ROM] full movement potential of a joint [where two bones meet]) for five of seven sampled residents (Resident 8, 27, 49, 61, and 63) with limited mobility (ability to move) and ROM limitations. This deficient practice had the potential to affect the provision of care. Findings: a. A review of Resident 8's admission Record, indicated Resident 8 was admitted to the facility on [DATE] with diagnoses including hemiplegia or hemiparesis (weakness or inability to move one side of the body) affecting the left non-dominant (used less often) side, dementia (decline in mental ability severe enough to interfere with daily life), contractures (condition of shortening and hardening of muscles, tendons, or other tissue, often leading to joint stiffness) to both knees, and muscle weakness. A review of Resident 8's Rehab -…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 five of seven sampled residents (Resident 8, 27, 49, 61, and 65) with limited mobility (ability to move) and range of motion ([ROM] full movement potential of a joint [where two bones meet]) received services to maintain mobility and ROM by failing to: a. Apply Resident 8's left elbow extension splint (material used to restrict, protect, or immobilize a part of the body to support function, assist and/or increase range of motion) five times per week during 5/2024 in accordance with the physician orders and care plan. b. Provide Resident 61 with PROM to the right leg and active assistive range of motion (AAROM, use of muscles surrounding the joint to perform the exercise but required some help from a person or equipment) exercises to both arms and the left leg during 5/2024 in accordance with the physician orders and care plan. c. Provide Resident 27, 49, and 65 with passive range of motion (PROM, movement of joint through the ROM…

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

Based on observation, interview, and record review, the facility failed to ensure a safe and hazard free environment was maintained for one of three sampled residents (Resident 75) when a pool of enteral nutrition (form of nutrition that is delivered as a liquid) was observed on the floor in Resident 75's room. This deficient practice had the potential to cause avoidable harm to Resident 75 related to slips, falls, and possible subsequent injury associated with a fall. Findings: A review of Resident 75's admission Record indicated the facility admitted Resident 75 on 1/15/2024. Resident 75's admitting diagnoses included abnormalities of gait (manner of walking) and mobility and generalized muscle weakness. A review of Resident 75's Minimum Data Set (MDS, a comprehensive care-screening and care-planning tool), dated 4/22/2024, indicated Resident 75 had intact cognitive skills for daily decision making (normal ability to think, learn, remember, use judgement, and make decisions). The MDS indicated Resident 75 required set-up or clean-up assistance with ambulation (walking), meaning…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 respiratory services for three of four sampled residents (Resident 13, 57, and 69) by failing to: a. Ensure Resident 13 was provided a nebulizer machine (a device used to administer medication in the form of a mist inhaled into the lungs), incentive spirometer (device that measures the volume of the air inhaled into the lungs during inspiration), oxygen cylinder (medical device to provide supplemental oxygen to resident), nasal cannula (a device used to deliver supplemental oxygen placed directly on the resident's nostrils), respiratory treatment via nebulizer every four hours, and incentive spirometer treatment twice per day. This deficient practice had the potential to cause shortness of breath, avoidable harm, respiratory distress, and chronic obstructive pulmonary disease ([COPD]- a lung disease causing restricted airflow and breathing problems) exacerbation (worsening symptoms). b. Ensure Resident 57 was provided a humidifier…

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

Based on observation, interview and record review, the facility failed to ensure safe and sanitary food storage and preparation practices when: 1. Nutritional supplements labeled store Frozen with manufactures instruction to use within 14 days of thawing, were not monitored for the date they were thawed to ensure expired shakes were discarded within the appropriate time frame. Four boxes containing 50 individual cartons of strawberry flavored nutrition supplements were stored in the walk-in refrigerator with no thaw date. This deficient practice had the potential to result in food borne illness in 24 residents who were on nutrition supplements at the facility. 2. One plastic bag of breaded cylinder-shaped food item was stored in the walk-in freezer with no label and date. One plastic bag of previously open ham with date 12/28/2023 and use by date of 3/28/2024 exceeding storage period for ham stored in the reach in freezer. The ham was covered in ice crystals. One plastic bag with previously open diced stew meat with date 10/25/2023 exceeding storage period for meat stored 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility did not provide accurate documentation for two of seven sampled residents (Resident 8 and 63) with limited mobility (ability to move) and range of motion ([ROM] full movement potential of a joint [where two bones meet]). a. Resident 8's clinical record for Restorative Nursing Aide (RNA, certified nursing aide program that helps residents to maintain their function and joint mobility) tasks did not indicate both knee splints (material used to restrict, protect, or immobilize a part of the body to support function, assist and/or increase range of motion) were applied from 11/2023 to 2/2024. b. Resident 63's clinical record for RNA tasks did not include passive range of motion (PROM, movement of joint through the ROM with no effort from the person) exercises to both legs from 12/16/2023 to 2/13/2024. These deficient practices provided inaccurate records of the RNA services provided to Resident 8 and 63. Findings: a. A review of Resident 8's admission…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility did not maintain infection control measures when: 1. Staff did not ensure enhanced barrier precautions (EBPs, an infection control intervention used to reduce transmission of multidrug-resistant organisms [MDROs, organisms resistant to at least one or more classes of antimicrobial agents]) were implemented for one of 18 sampled residents (Resident 27). This deficient practice increased the risk for spread of MDROs to vulnerable facility residents, and the potential incidence of preventable infection. 2. Clean one of one vinyl (type of plastic material) gait belt (assistive device used for lifting, transferring, and walking patients who have limited mobility issues) and front-wheeled walker (FWW, an assistive device with two front wheels used for stability when walking) after ambulation (the act of walking) with Resident 69. 3. Clean cloth gait belts in accordance with the manufacturer's recommendations for bleach sanitizing wipes (pre-moistened…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 did not ensure staff provided assistance to one of two sampled residents (Resident 61), to accommodate the resident's preference for getting out of bed at least once a day to sit in his wheelchair. This deficient practice had the potential to cause avoidable psychosocial distress and frustration for Resident 61 from an inability to participate in his preferred activity. Findings: A review of Resident 61's admission Record indicated the facility originally admitted Resident 61 on 12/13/2022. Resident 61's admitting diagnoses included symptoms and signs involving the musculoskeletal system, reduced mobility, and difficulty or inability to move his right side following a stroke (interruption of blood flow to the brain). A review of Resident 61's H&P, dated 2/8/2024, indicated Resident 61 had the capacity to understand and make decisions. A review of Resident 61's MDS, dated [DATE], indicated Resident 61 had mild cognitive impairment (problems with a person's…

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

Based on interview and record review, the facility did not ensure the Preadmission Screening and Resident Review (PASRR, a federal requirement to help ensure that individuals with a mental disorder or intellectual disabilities are not inappropriately placed in nursing homes for long term care) screening was accurate, and determination for necessity of potential necessary services was completed for one of two sampled residents (Resident 10). This deficient practice had the potential for Resident 10 to not receive required services and care for her diagnosed mental disorders. Findings: A review of Resident 10's admission Record indicated the facility admitted Resident 10 on 3/15/2024. Resident 10's admitting diagnoses included anxiety disorder (intense, excessive, and persistent worry and fear about everyday situations), unspecified, schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly), and depression (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in 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 observation, interview, and record review, the licensed nursing staff failed to follow professional standards of practice and implement the physician's written order for the administration of routine medications to one of three sampled residents (Resident 13). This deficient practice had the potential to place Resident 13 at risk to have complications of high blood pressure, avoidable harm, heart attack (heart muscle begins to die because not getting enough blood flow), respiratory distress, and chronic obstructive pulmonary disease (COPD, a lung disease causing restricted airflow and breathing problem) exacerbation (worsening of symptoms). Findings: A review of Resident 13's admission Record (Face Sheet), indicated Resident 13 was admitted to the facility on [DATE]. Resident 13's diagnoses included COPD, hypertension (high blood pressure), dementia (a loss of brain function such as memory, language, thinking), and depression (feeling of sadness and loss of interest). A review of Resident 13's History…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 fingernail care was provided, and grooming and personal hygiene was maintained for two of eight sampled residents (Resident 52 and 77), who were unable to carry out activities of daily living (ADLs, self-care activities performed daily). This deficient practice had the potential for a negative impact on Resident 52's and Resident 77's quality of life and self-esteem. Findings: 1. A review of Resident 52's admission Record (Face Sheet), indicated Resident 52 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 52's diagnoses included diabetes (high blood sugar), hypertension (high blood pressure), dementia (a loss of brain function such as memory, language, thinking), and dysphagia (difficulty swallowing). A review of Resident 52's Minimum Data Set ([MDS] a comprehensive standardized assessment and care-screening tool) dated 2/13/2024, indicated Resident 52 had the capacity to understand and make…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure fingernail care was provided, and grooming and personal hygiene was maintained for two of eight sampled residents (Resident 52 and 77), who were unable to carry out activities of daily living (ADLs, self-care activities performed daily). This deficient practice had the potential for a negative impact on Resident 52's and Resident 77's quality of life and self-esteem. Findings: 1. A review of Resident 52's admission Record (Face Sheet), indicated Resident 52 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 52's diagnoses included diabetes (high blood sugar), hypertension (high blood pressure), dementia (a loss of brain function such as memory, language, thinking), and dysphagia (difficulty swallowing). A review of Resident 52's Minimum Data Set ([MDS] a comprehensive standardized assessment and care-screening tool) dated 2/13/2024, indicated Resident 52 had the capacity to understand and 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.

Based on observation, interview, and record review, facility staff failed to administer enteral nutrition (the delivery of nutrients through a gastrostomy tube [a flexible plastic tube placed into the stomach wall]) as ordered for one of two sampled residents (Resident 27). This deficient practice had the potential to cause avoidable complications, such as malnutrition and/or delays in health promotion and maintenance for Resident 27. Findings: A review of Resident 27's admission Record indicated the facility originally admitted Resident 27 on 8/5/2021, and most recently readmitted Resident 27 on 3/30/2023. Resident 27's admitting diagnoses included gastrostomy status (the creation of an artificial external opening into the stomach for nutritional support), protein-calorie malnutrition (the state of inadequate intake of food [as a source of protein, calories, and other essential nutrients]), muscle wasting and atrophy (decrease in size of muscle tissue), dysphagia (difficulty or discomfort in swallowing). A review of Resident 27's active physician orders, dated 5/13/24, indicated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the licensed nurses failed to follow the facility policy and procedure (P&P) for initiation and maintenance of intravenous therapy ([IV] a way to give fluids, medicine, nutrition, or blood directly into the blood stream through a vein) for one of two residents (Resident 243) by: 1. Failing to label and date a peripheral intravenous catheter ([PIV] a short catheter inserted through a peripheral vein for the administration of solution or medication) site. 2. Failing to change the PIV site and dressing when the site appeared compromised. 3. Failing to remove the PIV after IV treatment was complete. This deficient practice had the potential to result in harm and lead to development of infection, infiltration (accidental leakage of non-vesicant solutions out of the vein into the surrounding tissue) and phlebitis (inflammation of a vein) for Resident 243. Findings: A review of Resident 243's admission Record (Face Sheet), indicated Resident 243 was admitted to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide timely pain management to two of two sampled residents (Resident 47 and 61). This deficient practice had the potential to cause avoidable discomfort and distress related to uncontrolled pain for Resident 47 and Resident 61. Findings: 1. A review of Resident 47's admission Record indicated the facility originally admitting Resident 47 on 7/22/2023. Resident 47's admitting diagnoses included lumbar spinal fusion (surgery to permanently join together two or more bones in the lower region of the spine), pain due to internal orthopedic prosthetic devices, implants, and grafts (a medical device manufactured to replace a missing joint or bone, or to support a damaged bone), and chronic pain. A review of Resident 47's History and Physical (H&P), dated 7/23/2023, indicated Resident 47 had the capacity to understand and make decisions. A review of Resident 47's Minimum Data Set (MDS, a comprehensive care planning and care screening tool), dated…

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

Based on observation, interview, and record review, the facility failed to ensure the trash stored in the dumpster area was maintained in a sanitary manner when: One of three garbage dumpsters lid was open and overfilled with cardboard boxes. The ground around the trash dumpsters was not clean and had plastic utensils, gloves, and paper around and under the dumpsters. This deficient practice had the potential for harborage and feeding of pests. Findings: During a concurrent observation and interview with Maintenance Staff (MS 1) on 5/14/2024 at 9:00 a.m., there was one dumpster outside of the kitchen back exit that was not covered. The dumpster was overfilled with cardboard boxes and not covered. There was trash on the ground including plastic forks, gloves, and paper. MS 1 stated the cardboard boxes should be made flat so they could fit in the dumpster and the lids could close. MS 1 sated the trash on the floor was from the neighbor who lived next door to the facility who threw their trash into the facility's trash bins and on the ground. MS 1 stated the area should be clean and…

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

Based on interview and record review, the facility failed to follow their policy when discussing binding arbitration agreements (a form of alternative dispute resolution in which both parties agree to have their case heard by a neutral party instead of a judge and jury) with three of three sampled residents and/or their responsible parties (Resident 73, 80, and 241). This deficient practice increased the risk that Resident 73, Resident 80, and Resident 241 and/or their responsible parties unknowingly forfeited their right to resolve any disputes with the facility in court, alongside a judge and/or jury. Findings: 1. A review of Resident 73's admission Record indicated the facility originally admitted Resident 73 on 1/27/2024. Resident 73's admission record indicated the resident had a responsible party (RP) making decisions on her behalf. A review of the facility document titled Arbitration Agreement, dated 1/20/2022, indicated Resident 73's RP (RP 1) signed the binding arbitration agreement on 3/5/2024, indicating Resident 73 no longer had the right to a jury or court trial 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to document information related to the resident ' s mental status or orientation when there was a significant change of condition in one of three residents (Resident 1). This deficient practice resulted in Resident 1 not having sufficient documentation regarding her mental status and orientation during a change in condition and before transferring to a higher level of care. This deficient practice had the potential to cause harm to Resident 1 due to poor communication of resident ' s health status which could cause inaccurate and delayed treatment to the resident. Findings: During a review of Resident 1 ' s admission Record, dated 1/4/2023, the admission record indicated Resident 1 was initially admitted to the facility on [DATE]. Resident 1's diagnoses included type 2 diabetes mellitus (condition that results in too much sugar circulating in the blood), chronic obstructive pulmonary disease (COPD - a lung disease characterized by long-term poor airflow),…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the licensed nurse failed to do the following for one of three sampled residents (Resident 1): 1. Follow facility established process when attempting to communicate with Resident 1 ' s medical doctor (MD). 2. Initiate an situation, background, assessment, and recommendation (SBAR- form of communication between staff) form during a sudden acute change in Resident 1 ' s health. These deficient practices had the potential for Resident 1 to have suffered life threatening complications and requiring a longer stay at a general acute care hospital (GACH). Findings: During a review of Resident 1 ' s admission Record, the admission record indicated Resident 1 was admitted to the facility on [DATE], and re-admitted on [DATE], with diagnoses that included end stage renal disease (ESRD- kidney failure), diabetes (high blood sugar), and hypertension (high blood pressure). During a review of Resident 1 ' s History and Physical (H&P) dated 11/11/2023, the H&P indicated Resident 1 had 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 isolate (separation of a sick resident with a contagious disease from a resident who was not sick) one of six sampled residents (Resident 2) who tested positive for Coronavirus disease ([Covid-19], an infectious disease caused by the SARS-CoV-2 virus that affects the respiratory system) in a timely manner. This deficient practice had the potential to spread Covid-19 to other residents and staff throughout the facility. Findings: During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was admitted to the facility on [DATE] with diagnoses including hypothyroidism (defiency in thyroid hormones), hyperlipidemia (high cholesterol) and dementia (a decline in cognitive abilities such as memory and thinking). During a review of Resident 2's MDS dated [DATE], the MDS indicated Resident 2 did not have the capacity to understand and make decisions. The MDS indicated Resident 2 required limited assistance with ADL's including…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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's Quality Assessment and Assurance (QAA) Committee failed to implement corrective actions to the systemic problems identified: a. Ensure the medication administration error rate was below five (5) percent; b. Ensure consistent implementation of the facility's antibiotic stewardship program (effort to measure and improve how antibiotics [medications that fight infections-- germs invade body and makes the body sick]were prescribed by clinicians and used by residents in the facility) c. Ensure the competency of kitchen staff when following a pureed diet [food that doe not need to be chewed] recipe and serving the correct amount of food to residents as specified in the menus; d. Ensure competency of nursing staff when providing residents with an indwelling catheter (flexible tube inserted to bladder to drain urine) care; and e. Ensure sufficient nursing staff in the day-to-day operations. As a result, the facility's deficient practices placed 76 out of 76 residents at risk for not receiving the quality treatment necessary to adequately…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 staff failed to ensure resident call lights were within reach for three of three sampled residents (Residents 27, 35 and 43), and failed to ensure one of 20 random selected residents (Resident 37) was provided with a communication board. This deficient practice had the potential for Residents 27, 35, and 43's needs to not be met timely, and Resident 37 not receiving a functional communication system to facilitate communication with staff. Findings: a. A review of Resident 27's admission Record (Face Sheet) indicated Resident 27 was admitted to the facility on [DATE]. Resident 27's diagnoses included bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs), dementia (a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning), history of falling, and dysphagia (difficulty swallowing). 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 maintain an uncluttered physical environment, and a safe, clean, comfortable and home-like environment for four of four sampled residents (Resident 3, 30, 38 and 42). This deficient practice created an unsafe environment for Resident 38 whose wheelchair was bumped by Resident 3 at the entrance door of the patio while being wheeled by Resident 30, and Resident 42 was using disposable bed pads as a floor mat. These failures had the potential for other residents, staff, and visitors to have an accident and get hurt. Findings: a. During a review of Resident 3's admission Record, the admission Record indicated Resident 3 was admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses not limited to history of fall, muscle weakness, abnormalities of gait and mobility, paranoid schizophrenia (altered perception of reality), blindness in one unspecified eye, and anxiety disorder (intense, excessive and persistent worry and fear…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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. Obtain an order to titrate the use of oxygen ([O2] the life supporting component of air), and date and label the oxygen nasal cannula tubing as ordered for Resident 49. 2. Obtain an order for the use of oxygen and perform a thorough assessment of Resident 261's lung sounds. These deficient practices had the potential for health complications associated with lack of guidance from the physician, delay in assessment, treatment plan and poor continuity of care and follow-up on the resident's status. Findings: a. During a review of Resident 49's admission Record, the admission Record indicated Resident 49 was admitted to the facility on [DATE]. Resident 49's diagnoses included heart failure (heart muscle doesn't pump blood as well as it should), acute kidney failure (when kidneys suddenly become unable to filter waste products from blood), muscle weakness, iron deficiency anemia (blood lacks adequate healthy red blood cells which carry O2…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure three of three staff (Certified Nurse Assistants [CNA 2], CNA 3, and CNA 4) had the necessary knowledge and skills to care for residents with an indwelling catheter (a urethral catheter designed to be held in place to drain urine from the bladder). The deficient practice had the potential to result in infection and hospitalization for the residents Findings: During a review of Resident 59's admission Record, indicated Resident 59 was admitted to the facility on [DATE]. Diagnosis included diabetes mellitus (abnormal sugar), hydronephrosis (excess urine accumulation in kidneys that causes swelling of kidneys) with renal and urethral calculous obstruction ( a blockage in one or both of the tubes that carry urine from the kidneys to the bladder), high blood pressure (the force of blood pushing against the walls of blood vessels, is consistently too high), history of urinary tract infections ([UTI] an infection in any part of urinary…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 (5) percent, due to improper medication administration for three (3) of four (4) randomly selected residents (Resident 56, 29, and 11) during the medication administration. The outcome was six (6) medication errors out of thirty (30) opportunities, which resulted in a medication administration error rate of 20 percent and exceeded the five (5) percent threshold. Findings: a). During a review of Resident 56's admission Record (face sheet), the admission Record indicated Resident 56 was admitted to the facility on [DATE]. Resident 56's diagnoses included hemiplegia (paralysis [inability to move] of one side of the body) following cerebral infarction (brain injury) affecting the right dominant side, arthritis (condition that causes swollen and painful joints), dementia (term for loss of memory, language, problem-solving and other thinking abilities severe enough to interfere with 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.

Based on observation, interview, and record review, the facility failed to remove and replace expired medical supplies and tube feeding formula in one of two Storage Rooms. This deficient practice had the potential to result in the use of ineffective or spoiled equipment and formula for the residents. Findings: During a concurrent observation and interview on 3/22/2022 at 11:40 a.m., with Licensed Vocational Nurse (LVN) 4, during an inspection of the Storage Room located at Nursing Station 1 there were expired medical supplies and tube feeding formula. LVN 4 stated, Anything expired should be disposed of. Every shift should be checking for expiration. The following medical equipment and tube feeding formula supplies were found: 1. Four Irrigation Trays (used in wound irrigation and bladder irrigation), REF DYND20300 with expired date of 12/2021. 2. One IsoSource HN Complete Nutrition 1.2 kcal/ml unflavored (liquid food mixture containing protein, carbohydrates [sugar], fats, vitamins, and minerals, given through a tube into the stomach or small intestine) with expired date 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 ensure dietary staff (Cook 1 and [NAME] 2) had appropriate skills set to carry out the duties of a cook. This deficient practice resulted in 69 residents, who were receiving regular, pureed, or mechanical diets, receiving an incorrect portion size for pureed carrots, mechanical soft chicken, and potato salad, and 13 residents who were on a pureed diet received pureed carrots and pureed bread made with water instead of broth and milk. Findings During an observation on 3/22/22 at 12:15 p.m. of the tray line, [NAME] 1 was observed using the following scoop colors: 1. [NAME] scoop for potato salad for Pureed, Regular and Mechanical Soft diets. 2. [NAME] scoop for BBQ chicken, and a gray ladle (4 oz) for carrots for Mechanical Soft and Regular diets. 3. Gray scoop for BBQ chicken and gray scoop for carrots for Pureed diets. During a concurrent observation and interview with [NAME] 1 on 3/22/22 at 12: 15 p.m., scoop numbers were reviewed and compared against the facility's menu spreadsheet. The following scoop…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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: a. Follow its menu as written for residents on regular, pureed, and mechanical soft diets. 69 residents who were receiving regular, pureed, or mechanical diets received an incorrect portion size for puree carrots, mechanical soft chicken and potato salad. This deficient practice had the potential to affect the residents' weight resulting in weight loss when the menu was not followed for residents on regular, pureed, and mechanical soft diet. b. Follow the pureed recipe for making pureed carrots and pureed bread. 13 residents who were receiving a pureed diet received pureed carrots and pureed bread made with water instead of broth and milk. These deficient practices had the potential to affect the nutritive value of the pureed carrots and bread served to the residents. Findings a. During an observation on 3/22/22 at 12:15 p.m. of the tray line, [NAME] 1 was observed using the following scoop colors: 1. [NAME] scoop for potato salad for Pureed, Regular and Mechanical Soft diets. 2. [NAME] scoop for BBQ…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 for food service safety when: 1. Several food items were not dated and labeled after being placed in the reach-in freezer and walk-in refrigerator. 2. Vegetables were stored in open bags in the walk-in refrigerator. 3. The ice machine was not cleaned properly and there was pink residue inside the ice machine. This failure had the potential to result in germ exposure to residents and placed residents at risk for developing foodborne illness (food poisoning: any illness resulting from the food spoilage of contaminated food, pathogenic bacteria, viruses, or parasites that contaminate food, as well as toxins) which can lead to other serious medical complications and hospitalization for 69 out of the 76 residents who received food from the kitchen. Findings During a concurrent interview and observation on 3/22/2022 at 8:15 a.m. with the Dietary Manager (DM), multiple items in the reach-in freezer (6 bags of yellow corn, 7 bags of sugar snap peas, and 4 bags of…

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

Based on interview and record review, the facility failed to ensure a facility-wide assessment was implemented when the facility failed to: a. Ensure the competency of kitchen staff when preparing meals for the pureed diet (food that does not need to be chewed) recipe and serving the correct amount of food to residents as specified in the menus. b. Ensure competency of nursing staff when providing residents with an indwelling catheter (flexible tube inserted to bladder to drain urine) care and when administering medications safely. c. Ensure sufficient nursing staff in the day-to-day operations. This deficiency had the potential to result in poor resident health outcomes and diminished quality of care for facility residents. Cross Reference F759, F725, F726, F801 Findings: During a concurrent interview with the Administrator (ADM) and record review of the facility's Facility Assessment Tool, dated 2/24/2022, on 3/25/2022 at 2:33 p.m., ADM confirmed ensuring staff competency was part of the facility assessment requirement and should have been implemented properly. The ADM 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, interview, and record review, the facility failed to maintain an effective infection control and prevention program to prevent the development and transmission of communicable diseases by not ensuring the use of personal protective equipment ([PPE] protective clothing, garments or equipment designed to protect the wearer or the resident from infections) prior to entering a yellow zone room (designated area for residents exposed to COVID-19). This deficient practice placed the residents, staff, and the community at higher risk for cross contamination, and increased spread of COVID-19 (a potentially severe respiratory illness caused by a coronavirus and characterized by fever, coughing, and shortness of breath) in the facility and the community. Findings: During an observation on 3/22/2022 at 10:24 a.m., Certified Nursing Assistant 5 (CNA 5) was observed exiting a shower room in the yellow zone without changing gowns and gloves. CNA 5 was observed wheeling a resident back to their room 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not ensure two of two residents (Resident 55 and Resident 51) were prescribed antibiotics appropriately by failing to develop a clear policy and implementing an antibiotic stewardship program. This deficient practice had the potential to increase antibiotic resistance and provide antibiotics without justification. Findings During a concurrent interview with the Infection Preventionist Nurse (IP) and record review of Resident 55's electronic health record (EHR) on 3/23/22 at 2:08 p.m., the IP stated that there was no completed McGeer's criteria (criteria used to determine appropriate use of antibiotics) in Resident 55's chart. During a concurrent interview with the IP and record review on 3/23/22 at 2:08 p.m. of Resident 51's EHR, the IP stated that there was no completed McGeer's criteria in Resident 51's chart. A review of Resident 55's admission Record indicated the resident was originally admitted to the facility on [DATE] and readmitted on [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: 1. Develop and implement residents' rights policies and procedures, in accordance to state laws and regulations, related to psychotherapeutic (used to treat psychosis, which refers to a group of mental disorders such as depression, schizophrenia, and manic-depressive disorders, that affect mood and behavior) informed consent for one of 20 residents (Resident 34). 2. Have a policy and procedure (P/P) in place for psychotherapeutic medication informed consent usage. This deficient practice potentially affected the resident or responsible party to make informed health care decisions based on the resident's medical condition, changes in medical condition, benefits and reasonable risks of medications or treatment, and reasonable available alternatives. Findings: a. During a review of Resident 34's admission Record, the admission Record indicated the resident was admitted to the facility on [DATE] and readmitted to the facility on [DATE]. Resident 34's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure residents' medical records were updated to show documentation that advance directives (written statement of a person's wishes regarding medical treatment made to ensure those wishes are carried out should the person be unable to communicate them to a doctor) were discussed and written information was provided to the residents and/or responsible parties for one of 20 residents (Resident 37). This deficient practice violated Resident 37's and/or the representatives' right to be fully informed of the option to formulate their advance directives and had the potential to cause conflict with the residents' wishes regarding health care. Findings: During a review of Resident 37's admission Record, the admission Record indicated Resident 37 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 37's diagnoses included dysphagia (language disorder marked by deficiency in the generation of speech, and sometimes also in its…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 interview, the facility failed to revise the care plan after one of two sampled residents sustained a fall (Resident 20). This failure had the potential to result in repeated falls, harm, and serious injury to Resident 20 due to a delay in developing cause-specific interventions to prevent further falls. Findings A review of Resident 20's facesheet indicated Resident 20 was originally admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included unspecified fall and unsteadiness on feet. A review of Resident 20's Minimum Data Set (MDS - a comprehensive assessment and screening tool) dated 1/18/2022, indicated Resident 20 was cognitively intact and independent in activities of daily living in the areas of transfers, dressing, eating, toilet use, personal hygiene, and bathing, and was continent (able to control) of bowel and bladder. During an interview on 3/22/2022 at 9:31 a.m. with Resident 20, Resident 20 stated he fell yesterday in the dining room as he…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 services that meet professional standards of quality for three of three sampled residents (Residents 11, 52, and 18) by failing to ensure: a. Licensed Vocational Nurse 3 (LVN 3) did not administer Resident 11's medications via gravity through the resident's gastrostomy tube ([G-Tube] tube surgically inserted into the stomach for nutrition, hydration, and medication). This failure had the potential to cause clogging or damage to the G-Tube. b. The licensed nurse received an order to transfer Resident 52 to the hospital and provided adequate documentation upon the resident's transfer. This failure had the potential to cause miscommunication regarding Resident 52's change of condition. c. The facility failed to carry out the physician order to check Resident 18's oxygenation saturation and respirations every four hours for 14 days, and to ensure vital signs were taken every four hours in accordance with the facility's policy 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 accurately assess Resident 261's health status and initiate a change of condition (COC). This deficient practice had the potential to result in Residents 261 not receiving needed treatment and/or services. Findings: A review of Resident 261's admission Record (Face Sheet) indicated Resident 261 was admitted to the facility on [DATE]. Resident 261's diagnoses included iron deficiency anemia (a condition in which blood lacks adequate healthy red blood cells), congestive heart failure (occurs when the heart muscle doesn't pump blood as well as it should), pressure ulcer (an injury that affects areas of the skin and underlying tissue caused from prolonged pressure) of the right hip, muscle weakness, and cirrhosis of the liver (late-stage liver disease in which healthy liver tissue is replaced with scar tissue and the liver is permanently damaged). A review of Resident 261's Minimum Data Set (MDS), a comprehensive assessment and care screening…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure the facility was free from clutter and accidental hazards and provided adequate supervision to prevent accidents for four of four sampled residents (Resident 3, 30, 38 and Resident 42). This deficient practice had the potential to result in serious harm and injury to residents, staff, and visitors. Findings: a. During a review of Resident 3's admission Record, the admission Record indicated Resident 3 was admitted to the facility on [DATE] and was readmitted on [DATE]. Resident 3's diagnoses included a history of falls, muscle weakness, abnormalities of gait and mobility, paranoid schizophrenia (altered perception of reality), blindness in one unspecified eye, and anxiety disorder (intense, excessive and persistent worry and fear about everyday situations). During a review of Resident 3's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 3/9/2022, the MDS indicated Resident 29's cognitive (the ability…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 Nurse Assistants (CNA) 2 performed indwelling catheter (a urethral catheter designed to be held in place to drain urine from the bladder) care that meets professional standards of quality. CNA 2 did not maintain clean technique (reduce the risk of introducing potentially pathogenic micro-organisms into susceptible sites) and caused pain and discomfort while providing indwelling catheter care to one of three Residents (Resident 59). This deficient practice had a potential to result in Resident 59 being at higher risk for developing a urinary tract infection (is an infection in any part of the urinary system) as well as other complications. Findings: During a review of Resident 59's undated admission record, the admission record indicated Resident 59 was admitted to the facility on [DATE], with diagnoses that included diabetes mellitus (ability to produce or respond to the hormone insulin is impaired, resulting in abnormal…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 licensed nurse did not administer medications via gravity (holding up a syringe to allow nutrition formula, water, or medications to flow by gravity) through a gastronostomy tube ([G-tube] a flexible tube placed into the surgical opening in the stomach that allows for nutrition, fluids, and medications) for one of three sampled residents (Resident 11). This failure had the potential to cause clogging and/or damaging Resident 11's G-tube. Findings: During a review of Resident 11's admission Record, the admission Record indicated Resident 11 was admitted to the facility on [DATE] and was readmitted on [DATE]. Resident 11's diagnoses included dysphagia (difficulty swallowing), oropharyngeal phase (difficulty swallowing), gastroesophageal reflux disease (the stomach contents sometimes flow backward, up into the esophagus), attention to gastrostomy (surgical opening in the stomach), anxiety disorder (intense, excessive and persistent…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 the influenza (flu) vaccine (substance to protect against influenza viruses [germ that infects people and attacks the respiratory system--nose, throat, lungs]) to one of five sampled residents (Resident 20). This deficient practice placed Resident 20 at higher risk for acquiring and transmitting the flu to other residents in the facility. Findings: During a review of Resident 20's admission Record, the admission Record indicated Resident 20 was admitted to the facility on [DATE]. Resident 20's diagnoses included type 2 diabetes mellitus (impairment in the way body regulates and uses sugar[glucose] as fuel), hypertension (high blood pressure [force it takes for blood to pump in body]), dementia (term for loss of memory, language, problem-solving and other thinking abilities severe enough to interfere with daily life), heart failure (heart muscle doesn't pump as well as it should), failure to thrive (state of decline that is multifactorial…

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