Crenshaw Nursing Home

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure one out of three sampled residents (Resident 1) was treated with dignity when requesting to be cleaned by the Certified Nursing Assistant (CNA) 1.This deficient practice of not cleaning Resident upon request left Resident 1 to feel frustrated and upset. Findings:a. During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses hemiplegia (a condition characterized by loss of muscle strength), hemiparesis (weakness on one side of the body), osteoarthritis (a condition that causes pain, stiffness, and impaired mobility. During a review of Resident 1's History and Physical (H&P), dated 3/26/2025, the H&P indicated Resident 1 had the ability to make decisions for activities of daily living. During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool), dated 5/9/2025, the MDS indicated Resident 1…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to implement policies and procedures for one out of three sampled residents (Resident 1) that an abuse allegation was reported within two hours to the California Department of public Health (CDPH) and other agencies. This deficient practice of not reporting an abuse allegation within two hours caused a delay in investigating by the CDPH.Findings:a. During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses hemiplegia (a condition characterized by loss of muscle strength), hemiparesis (weakness on one side of the body), osteoarthritis (a condition that causes pain, stiffness, and impaired mobility. During a review of Resident 1's History and Physical (H&P), dated 3/26/2025, the H&P indicated Resident 1 had the ability to make decisions for activities of daily living. During a review of Resident 1's Minimum Data Set…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to obtain informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered) prior to administering a psychotropic medication (any drug that affects brain activities associated with mental process and behavior) for two of four sampled residents (Residents 16 and 41). This deficient practice violated the resident's right to make an informed decision regarding the use of psychotropic medication. Findings: 1. During a review of Resident 16's admission Record, the admission Record indicated Resident 16 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 16's diagnoses included anxiety disorder (a mental health condition characterized by excessive, persistent, and irrational worry or fear that interferes with daily life), chronic obstructive pulmonary disease ([COPD] a chronic lung disease causing difficulty of breathing) and dementia (a…

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

Based on observation, interview and record review, the facility failed to ensure the results of the most recent survey of the facility was posted in a place readily accessible to residents. This deficient practice had the potential to violate the rights of residents to examine the survey results of the facility and could lead to residents not being fully informed of the facility's deficient practices and how they were corrected. Findings: During an observation, on 3/20/2025 at 9:00 a.m., at the Annex Station, a signage was observed posted on the wall, inside of the nursing station indicating, CDPH survey information available upon request. During a concurrent observation and interview on 3/20/2025 at 9:47 a.m., with the Director of Nursing (DON), the DON stated all recertification survey results should have been in a folder at the nursing station, freely accessible to all residents. The DON stated the survey binder was not placed near the signage or around the nurse's station. The DON stated the risk of not providing free access to the facility's survey binder could result in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to: 1. Ensure the low air loss mattress ([LALM] a mattress designed to prevent and treat pressure ulcer (localized damage to the skin and/or underlying tissue usually over a bony prominence) was set and maintained at the correct setting according to the manufacturer's setting for two of three sampled residents (Residents 16 and 41). 2. Ensure one out of six sampled residents (Resident 105) had a LALM to prevent pressure ulcer. These deficient practices placed Residents 16 and 41 at risk for discomfort and skin breakdown. and had the potential to result in the worsening of Resident 105 pressure ulcer. Findings: 1. During a review of Resident 16's admission Record, the admission Record indicated Resident 16 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 16's diagnoses included anxiety disorder (a mental health condition characterized by excessive, persistent, and irrational worry or fear that interferes…

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

Based on observation and interview, the facility failed to ensure the medication room storage refrigerator was maintained below 46 degrees as indicated in the facility's policy and procedure (P&P) titled, Medication Storage in the Facility. This deficient practice had the potential for medications be stored in improper temperature, or humidity and can alter the effectiveness of the medication. Findings: During an observation, on 3/19/2025, at 12:20 p.m., at the medication room storage refrigerator, the refrigerator had unopened insulin (a hormone that lowers the level of blood sugar in the blood) vials, insulin pens, and unopened multidose tuberculin (a substance used in a skin test to help diagnose tuberculosis [TB] infection) injection vials. The medication storage refrigerator temperature was observed at 48 degrees Fahrenheit. During a concurrent observation and interview, on 3/19/2025, at 12:22 p.m., with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated per policy, the temperature for the refrigerator should be maintained between 36-46 degrees. LVN 1 stated the refrigerator…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide a privacy bag (a cover placed over the urine collection bag, so it was not visible) for one out of six sampled residents (Resident 101) who had a urinary catheter (a hollow tube inserted into the bladder to drain or collect urine). This deficient practice had the potential for Resident 101 to feel uncomfortable while around other residents and negatively affect the resident's psychosocial well-being. Findings: During a review of Resident 101 's admission Record, the admission Record indicated Resident 101 was admitted to the facility on [DATE] with diagnoses including anxiety disorder (a mental health condition characterized by persistent and excessive fear that interferes with daily life and functioning), calculus of kidney (hard deposits of minerals and salts that form inside the kidneys), and the cerebral infraction (the death of brain tissue due to a lack of blood flow). During a review of Resident 101's History and Physical…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure one out of six sampled resident's (Resident 44) call light was within reach. This deficient practice had the potential for Resident 44 not to be able to call for assistance to obtain necessary care and services. Findings: During a review of Resident 44's admission Record, the admission Record indicated Resident 44 was initially admitted to the facility on [DATE] and was readmitted on [DATE]. Resident 44's diagnoses included chronic obstructive pulmonary disease ([COPD] a chronic lung disease causing difficulty in breathing), epilepsy (a chronic brain disorder that sends the wrong signals in the brain and cause seizures), and diabetes mellitus ([DM] a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 44's Minimum Data Set ([MDS] a resident assessment tool), dated 1/3/2025, the MDS indicated Resident 44 was usually able to understand. The MDS indicated Resident 44' had no…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop a baseline care plan for one of one sampled resident (Resident 202) who was on dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed). This deficient practice had the potential for Resident 202 to not receive appropriate care and treatments specific to the resident's dialysis need. Findings: During a review of Resident 202's admission Record, the admission Record indicated Resident 202 was admitted to the facility on [DATE] with diagnoses including End Stage Renal Disease ([ESRD] irreversible kidney failure), hypertension ([HTN] high blood pressure) and anemia (a condition where the body does not have enough healthy red blood cells). During a review of Resident 202's History and Physical (H&P) dated 3/9/2025, the H&P indicated Resident 202 had the mental capacity to understand and make medical decisions. During a review of Resident 202's Minimum Data Set ([MDS] a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to develop a care plan for one of six sampled residents (Resident 105) who was receiving oxygen (O2). This deficient practice had the potential for unidentified goals and interventions for Resident 105. Findings: During a review of Resident 105's admission Record, the admission Record indicated Resident 105 was initially admitted to the facility on [DATE] and was readmitted on [DATE]. Resident 105's diagnoses included end stage renal disease ([ESRD] irreversible kidney failure, diabetes mellitus ([DM] a disorder characterized by difficulty in blood sugar control and poor wound healing), and dementia (a progressive state of decline in mental abilities). During a review of Resident 105's Minimum Data Set ([MDS] a resident assessment tool), dated 3/18/2025, the MDS indicated Resident 105's cognition (ability to learn, reason, remember, understand, and make decisions) was moderately impaired. The MDS indicated Resident 105 was dependent on staff…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to monitor and record the blood pressure (BP) for one of one sampled resident (Resident 202) who had a physician's order for Midodrine (a medication to treat low blood pressure) every 8 hours as needed for systolic blood pressure ([SBP] the first number in a blood pressure reading) of less than 120. This deficient practice had the potential to result in Resident 1 not receiving the medication as needed and hypotension (low blood pressure) which could lead to dizziness, falls and stroke (loss of blood flow to a part of the brain). Findings: During a review of Resident 202's admission Record, the admission Record indicated, Resident 202 was admitted to the facility on [DATE] with diagnoses including End Stage Renal Disease ([ESRD] irreversible kidney failure), hypertension ([HTN] high blood pressure), and anemia (a condition where the body does not have enough healthy red blood cells). During a review of Resident 202's History and Physical (H&P) dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure respiratory care (interventions and therapies aimed at improving or restoring lung function and addressing breathing difficulties) were provided to two of three sampled residents (Residents 12 and 16), in accordance with standards of practice, by failing to ensure: 1. Resident 12's tracheostomy (a surgical opening in the neck for an airway) site and tube were free of dried secretions (substance such as saliva or mucus). 2. Resident 16's face mask nebulizer (a medical device that uses a small machine to turn liquid medication into a mist that can be inhaled through a face mask, allowing medication to be delivered directly to the lungs) tubing was labeled with date when changed. These failures had the potential to cause respiratory infection for Resident 12 and 16. Findings: 1. During a review of Resident 12's admission Record, the admission Record indicated, Resident 12 was admitted to the facility on [DATE]. Resident 12's diagnoses included…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a resident who received hemodialysis ([HD] - a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) treatment received care in accordance with standards of practice for one of one sampled resident (Resident 202) by failing to: 1. Monitor and record resident's blood pressure every 8 hours who was receiving Midodrine (a medication to treat low blood pressure) as needed following parameters set by physician. This deficient practice had the potential to result in unintended consequences of Resident 202's management of low blood pressure. Findings: During a review of Resident 202's admission Record, the admission Record indicated, Resident 202 was admitted to the facility on [DATE]. Resident 202's diagnoses included End Stage Renal Disease ([ESRD]- irreversible kidney failure), hypertension ([HTN] - high blood pressure), and anemia (a condition where the body does not have enough…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 act on the pharmacist consultant's (a professional responsible for reviewing each resident's medication profile monthly to identify and report changes) recommendations timely, for two of four sampled residents (Residents 16 and 41). Cross Reference to F758. This deficient practice placed Residents 16 and 41 at risk for unnecessary medication administration. Findings: 1.During a review of Resident 16's admission Record, the admission Record indicated, Resident 16 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 16's diagnoses included anxiety disorder (a mental health condition characterized by excessive, persistent, and irrational worry or fear that interferes with daily life), chronic obstructive pulmonary disease ([COPD] - a chronic lung disease causing difficulty of breathing) and dementia (a progressive state of decline in mental abilities). During a review of Resident 16's Minimum Data Set ([MDS] - a resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure two of four sampled residents (Resident 16 and 41), who received as needed (PRN) psychotropic medication (any drug that affects brain activities associated with mental process and behavior), were reevaluated after 14 days. Cross Refer to F756. This deficient practice placed Residents 16 and 41 at risk for avoidable harm from unwanted adverse effects (a harmful and undesired effect resulting from a medication or intervention) related to psychotropic medication use. Findings: 1. During a review of Resident 16's admission Record, the admission Record indicated, Resident 16 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 16's diagnoses included anxiety disorder (a mental health condition characterized by excessive, persistent, and irrational worry or fear that interferes with daily life), chronic obstructive pulmonary disease ([COPD] - a chronic lung disease causing difficulty of breathing) and dementia (a…

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

Based on observation, interview and record review, the facility failed to ensure: 1. Kitchen refrigerator 1 had an external thermometer (an appliance to monitor the temperature of a refrigerator) in working condition. 2. The large clear egg noodle pasta bin in the dry storage area was labeled with name and date. 3. Kitchen refrigerator 2 had proper internal temperature (40 degrees Fahrenheit or lower) maintained for the refrigerated food items. This deficient practice had the potential to cause rapid growth of bacteria that can cause foodborne illness (food poisoning). Findings: 1). During the initial kitchen tour observation, on 3/18/2025, at 8:27 a.m., the external thermometer of refrigerator 1 was observed counting upwards in seconds and minutes starting from zero and the internal thermometer of refrigerator 2 was observed at 42 degrees Fahrenheit. During a concurrent observation and interview, on 3/18/2025, at 8:30 a.m., with the Dietary Aide 1 (DA 1), DA 1 stated he did not know why the external thermometer of refrigerator 1 was counting upwards or if it had malfunctioned. DA 1…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure the humidifier (a product that adds moisture to the air to help with breathing) for one of six sampled residents (Resident 105), was changed and labeled with date. This deficient practice placed Resident 105 at risk for respiratory infection (an infection affecting the nose, throat, sinuses, airways, and lungs). Findings: During a review of Resident 105's admission Record, the admission Record indicated Resident 105 was initially admitted to the facility on [DATE] and was readmitted on [DATE]. Resident 105's diagnoses included end stage renal disease ([ESRD] - irreversible kidney failure, diabetes mellitus ([DM]-a disorder characterized by difficulty in blood sugar control and poor wound healing), and dementia (a progressive state of decline in mental abilities). During a review of Resident 105's Minimum Data Set ([MDS] a resident assessment tool), dated 3/18/2025, the MDS indicated Resident 105's cognition (ability to learn,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 1. Report to the California Department of Public Health (CDPH- the state department responsible for public health in California) of a resident-to-resident physical altercation for two of four sampled residents (Resident 2 and Resident 3). This resulted in a delay in investigation by CDPH and placed Resident 3 at risk for further abuse. Findings: a. During a review of Resident 2 ' s face sheet, indicated Resident 2 was originally admitted on [DATE] and readmitted on [DATE] with diagnoses which included schizophrenia (a mental illness that is characterized by disturbances in thought), bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), epilepsy (a brain condition that causes seizures), and insomnia (trouble falling asleep or staying asleep). During a review of Resident 2 ' s Minimum Data Set (MDS- a federally mandated resident assessment tool), dated 1/3/2025, the MDS Section indicated Resident 2 ' s 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 interview and record review, the facility failed to report to the California Department of Public Health (CDPH), within 24 hours, for one of three sampled residents, Resident 3, who sustained a total of three bruises (result of a direct blow or an impact, such as a fall or after trauma, such as a blow to the body) of unknown source from 6/2024 to 12/2024. This deficient practice resulted in the delay of investigation by the CDPH. Findings: During a review of Resident 3 ' s admission Record, the admission Record indicated Resident 3 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including schizophrenia (serious mental illness that affects how a person thinks, feels, and behaves) and major depressive disorder (mood disorder that causes a persistent low mood and loss of interest in activities). During a review of Resident 3 ' s Minimum Data Set ([MDS], a standardized assessment and care screening tool), dated 2/2/2024, the MDS indicated Resident 3 had impaired…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 investigate swelling and bruises (an injury appearing as an area of discolored skin on the body, caused by a blow or impact rupturing underlying blood vessels) of unknown source, on 6/18/2024, 11/5/2024 and 12/24/2024, for one of three sampled residents, Resident 3. This failure resulted in Resident 3 ' s continued sustaining injuries requiring interventions. This failure placed the resident at risk for severe injuries, resulting in hospitalization and death. Findings: During a review of Resident 3 ' s admission Record, the admission Record indicated Resident 3 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including schizophrenia (serious mental illness that affects how a person thinks, feels, and behaves) and major depressive disorder (mood disorder that causes a persistent low mood and loss of interest in activities). During a review of Resident 3 ' s Minimum Data Set ([MDS], a standardized assessment and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to develop an individualized plan of care for the safety of a resident that required to be within sight at all times of day and night for one of three sampled resident (Residents 3). This deficient practice had the potential for recurrent injuries or falls for Resident 3. Findings: During a review of Resident 3 ' s admission Record, the admission Record indicated Resident 3 was admitted on [DATE] with diagnoses including schizophrenia (a mental illness that is characterized by disturbances in thought) and major depressive disorder (mood disorder that causes a persistent feeling of sadness and loss of interest). During a review of Resident 3 ' s care plan, titled At Risk for Falls/Injury, dated 2/14/2024, the goal of care plan was to keep Resident 3 free from falls and injury. Interventions indicated facility would visibly observe resident frequently. The care plan did not indicate what frequency Resident 1 should be monitored or observed. During a review…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to: 1). Provide an environment free of accident hazards as possible and provided one of three residents ' (Resident 3), adequate supervision and assistance to prevent accidents. 2). Conduct accurate fall risk assessment to one of 3 residents, Resident 3, who had history of fall. 3). Implement its policy and procedure (P&P) titled Safety and Supervision of Residents, which indicated safety risks and environmental hazards are identified on an ongoing basis and the Quality Assurance and Performance Improvement (QAPI) review safety and incident/accident data; and a facility-wide commitment to safety at all levels of the organization. These failures resulted in Resident 3 experienced multiple incidents of bruising (an injury appearing as an area of discolored skin on the body, caused by a blow or impact rupturing underlying blood vessels). Resident 3 sustained swollen tibia (shinbone), fibula (calf bone) on 6/18/2024. Resident 3 sustained swollen left wrist on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility's dietary staff failed to serve the correct consistency per physician's order on June 1, 2024. This deficient practice placed the resident at risk for potential aspiration (happens when food, liquid, or other material enters a person's airway and eventually the lungs.) Findings: A review of Resident 1's admission record, indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis of dysphagia, oropharyngeal phase (swallowing problems occurring in the mouth and/or the throat) and muscle weakness. A review of Resident 1's Minimum Data Set ([MDS], a standardized assessment and care screening tool), dated 6/8/2024, indicated Resident 1 had an intact cognition (mental capacity). Resident 1 required moderate assistance with eating and dressing and maximal assistance with oral hygiene and showers. Resident 1 was dependent for toileting hygiene, and dressing. A review of Resident 1's care plan, titled Mechanically…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to: 1. Ensure one of one sampled resident (Resident 1) with a pressure ulcer (injury to skin and underlying tissue resulting from prolonged pressure on the skin) was provided with low air loss mattress (small air holes in the mattress top surface continually blow out air causing the patient to float, which reduces skin interface pressure at the mattress surface and moisture is wicked away so the patient stays dry) to promote wound healing. This failure had the potential to cause residents to experience the development or deterioration of pressure ulcers. Findings: A review of Resident 1's admission Record, indicated Resident 1 was admitted to the facility on [DATE] with diagnoses of enterocolitis due to clostridium difficile (bacterial infection that causes diarrhea), unstageable pressure ulcer (full thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed us obscured 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 provide adequate supervision during the night shift for one of 4 sample residents (Resident 4). Resident 4 was observed, going to the bathroom unsupervised on 6/14/2024 and 6/20/2024, while Certified Nurses Assistance (CNA) 2, was asleep at the nurse's station. This failure had the potential to lead to accidents, falls and injuries for Resident 4. Findings: A review of Resident 4's admission Record indicated Resident 4 was admitted to the facility on [DATE], with diagnoses including anxiety (causes feelings of worry and nervousness,), Major Depressive Disorder (mental illness that could affect a person's mood and thoughts characterized by a persistent feeling of sadness and loss of interest and can interfere with your daily life), and dementia (loss of memory, language, problem-solving and other thinking abilities). A review of Resident 4's Fall Risk care plan dated 4/13/2022, indicated Resident 4 was at risk for falls/injury related to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide a sanitary environment for residents by failing to maintain residents room walls, floors, shower rooms, and laundry area clean. These deficient practices had the potential to result in cross contamination (transfer of harmful bacteria from one person, object, or place to another), pest activity and negatively affect resident's wellbeing. Findings: During an observation on 6/21/2024, at 5:05 a.m., in residents' room [ROOM NUMBER], the walls next to bed A and bed B were observed with brown, dry, dirty stains. During an observation on 6/21/2024, at 5:10 a.m., in residents' room [ROOM NUMBER], the floor behind bed A's headboard was observed with dry, old mouse dropping. During an observation on 6/21/2024, at 5:20 a.m., in residents' room [ROOM NUMBER], the wall, close to the bathroom, was observed with brown spots. During an observation on 6/21/2024, at 5:30 a.m., outside the laundry area, dirty plastic bags was observed placed next…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 ensure one out of three Resident (Resident 1) had a documented assessment for an injured right index finger after a notification of change of condition. This deficient practice of not having documented assessment placed Resident 1 at risk for worsening of injury of the right index finger. Findings: During a review of Residents 1's admission Record (Face Sheet), the face sheet indicated Resident 1 was admitted to the facility on [DATE] and readmitted on [DATE]. Resident 1 diagnoses not limited to schizoaffective disorder (combination of psychosis and mood symptoms), bipolar disorder (a mental illness that causes dramatic shifts in a person's mood, energy, and ability to think clearly), and metabolic encephalopathy (a problem with the brain caused by a chemical imbalance in the blood). During a review of Residents 1's History and Physical (H&P), dated 4/9/2024, the H&P indicated, Resident 1 is able to make decisions for activities of daily…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, for two of two sampled residents (Resident 1 and Resident 2), the facility failed to implement its policy and procedure titled, Abuse & Mistreatment of Residents, which indicated the following: 1. When incidents involving the health, welfare, or safety of residents are reported, the involved resident(s) shall be removed from the environment that threatened resident's health, welfare, or safety. 2. The Charge Nurse and/or nursing supervisor shall conduct an immediate resident assessment to identify any injuries or extent of injuries, if any, shall notify the attending physician of incident for necessary interventions and notify family members and or legal agents of incident. 3. The Charge Nurse and/or Nursing Supervisor shall initiate resident care plan to reflect current conditions and measures taken to prevent recurrence of event. All findings are to be documented and if the suspected perpetrator is another resident, the residents shall be separated to avoid any further…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 to the California Department of Public Health (CDPH) within two hours, the alleged abuse reported on 4/1/2024 and 4/23/2024 for two out of three sampled residents (Resident 1 and Resident 2). This violation delayed the investigation by the CDPH. Findings: a.) A review of Resident 1 ' s admission record, dated 4/23/2024, indicated Resident 1 was originally admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included essential primary hypertension (high blood pressure) type 2 diabetes mellitus (abnormal blood sugar) and muscle weakness. A review of Resident 1 ' s Minimum Data Set ([MDS], a standardized assessment and care screening tool), dated 4/5/24, indicated Resident 1 was cognitively intact (involving the processes of thinking and reasoning) in making decisions of activities of daily living (ADLs) and able to understand. The MDS indicated Resident 1 required set up for eating, oral hygiene, and personal hygiene…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to investigate a resident-to-resident altercation on 4/1/2024 between two of three sampled residents (Resident 1 and Resident 2). This deficient practice resulted in Resident 2 hitting Resident 1 in the face on 4/23/2024, that resulted in a red bruise and swelling on right eyelid. This also placed Resident 1 at risk for repeated physical abuse by Resident 2, which had the potential for more serious injuries requiring hospitalization, possible coma, or death. Findings: a). A review of Resident 1 ' s admission record, dated 4/23/2024, indicated Resident 1 was originally admitted to the facility on [DATE] and initial admission date was 4/10/2023 with diagnosis including essential primary hypertension (high blood pressure) type 2 diabetes mellitus (abnormal blood sugar) and muscle weakness. A review of Resident 1 ' s Minimum Data Set ([MDS], a standardized assessment and care screening tool), dated 4/5/24, indicated Resident 1 was cognitively intact…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to develop a comprehensive and resident-centered abuse care plan, on two alleged physical abuse incidents on 4/1/2024 and 4/23/2024, for two out of three sampled residents (Resident 1 and Resident 2). This deficient practice resulted in a repeated physical abuse to Resident 1 by Resident 2 on 4/23/2024, that resulted in a red bruise and swelling on right eyelid. This also placed Resident 1 at risk for repeated physical abuse by Resident 2, which had the potential for more serious injuries requiring hospitalization, possible coma, or death. Findings: a). A review of Resident 1 ' s admission record, dated 4/23/2024, indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis of essential primary hypertension (high blood pressure) type 2 diabetes mellitus (abnormal blood sugar) and muscle weakness. A review of Resident 1 ' s Minimum Data Set ([MDS], a standardized assessment and care screening…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to: 1. Ensure an oxygen sign was posted and extension cord was free from hazards for two out of two sampled residents (Resident 11 and 34). This deficient practice had the potential for an unsafe environment with a fire hazard risk and placing Resident 34 at risk for a fall and injury. Findings: a. During a review of Resident 34's admission Record, the admission Record indicated Resident 34 was initially admitted to the facility on [DATE] and last readmitted on [DATE]. Resident 34's diagnoses include hypertension (when the pressure in your blood vessels is too high), gastro-esophageal reflux disease (GERD - a digestive disease in which stomach acid or contents irritates the food pipe lining), and cerebral infarction (damage to tissues in the brain due to a loss of oxygen to the area). During a review of Resident 34's History and Physical (H&P), dated 2/18/2023, the H&P indicated Resident 34 is able to make decisions for activities of daily…

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

Based on observation, interview and record review, the facility failed to: 1. Ensure medications were properly labeled with open dates in medication cart 1 for five out of 23 residents (Resident 45, Resident 46, Resident 11, Resident 47, and Resident 29). This deficient practice had the potential to result in unintentional medication administration of possibly expired medications. Findings: During a medication cart inspection and observation of Cart 1 on 3/23/24 at 11:39 AM and a concurrent interview with Licensed Vocational Nurse 2 (LVN 2), Cart 1 was noted to have 7 opened medications: Humulin (a medication also known as regular insulin used to treat diabetes mellitus), Sucrafate (a medication used in the treatment of gastric ulcers), Pantoprazole (a medication used to treat gastroesophageal reflux disease), Lactulose (a medication used to treat constipation and can also treat liver disease), Levetiracetam (a medication used to treat seizures) and Geri-Tussin (Cough medicine and Cold medication) stored in the cart with no indication of any open dates. LVN 2 stated all opened…

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

The facility failed to: 1. Ensure refrigerator temperatures were at or below 40 F. 2. Ensure food items were labeled with open and used by dates in the reach-in refrigerators, reach-in freezers, seasoning rack and dry storage room of the kitchen. These deficient practices had the potential to cause food-borne illnesses. Findings: During a kitchen observation on 3/23/24 at 7:55 AM and a concurrent observation and interview with Dietary Aide 1 (DA 1), Refrigerator 2, Refrigerator 3 and Refrigerator 4 was noted to have a internal temperature of 43-45 degrees Fahrenheit. DA 1 stated the protocol for refrigerators temperatures should be at 40 degrees Fahrenheit or below. DA 1 stated the risk of having refrigerator temperatures at or above 40 can cause food to soil and cause residents to become sick. During a concurrent observation and interview on 3/23/24 at 8:00 AM with DA 1, Refrigerator 1, Refrigerator 3, Refrigerator 4, Freezer 1 was noted to have opened milk cartons, a clear plastic bin of tomatoes, glasses of juices and milk, opened boxes of meat, vegetables and bread in each…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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: 1. Have a written Quality Assurance and Performance Improvement (QAPI) program in place for a census of 42. This deficient practice had the potential to affect how the facility ensures care and services are delivered meet accepted standards of quality, identify problems and opportunities for improvement, and ensure progress toward correction or improvement is achieved and sustained. Findings: During an observation on 3/24/24 at 09:09 AM, Administrator (Admin) and Director of Nursing 2 (DON 2) was asked to produce the facility's QAPI program binder. During an interview on 3/24/24 at 12:04 PM with Director of Nursing 2, DON 2 stated he was attempting to find the facility's QAPI book. DON 2 stated QAPI meetings should be done every 3 months. [NAME] 2 stated he would speak to the Administrator regarding the program binder. During an interview on 3/24/24 at 12:40 PM with the Infection Preventionist Nurse (IP 1), IP 1 states the facility's QAPI meetings are every quarter due to being a small facility. IP Nurse stated she was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to: 1. Use a dignity bag (blue nonwoven material that conceals fluid in the drainage bag to improve resident dignity) for a foley catheter drainage bag (device that holds the urine that drains from the resident's body) for one of one sampled resident (Resident 40). This deficient practice had the potential to negatively affect Resident 40's self-esteem and self-worth and to cause psychosocial harm or decline to the resident and violates resident's right to be treated with dignity. Findings: During a review of Resident 40's admission Record, the admission Record indicated Resident 40 was initially admitted to the facility on [DATE] and last readmitted on [DATE]. Resident 40's diagnoses include intestinal obstruction (something is blocking your intestine. Food and stool may not be able to move freely), anxiety disorder (persistent and excessive worry that interferes with daily activities), and urinary retention (a condition in which you are…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to: 1. Ensure the overhead room light was in working condition for one of 12 sampled residents (Resident 21). This deficient practice had the potential for an unsafe environment with placing Resident 21 at risk for a fall and injury. Findings: During a review of Resident 21's admission Record, the admission Record indicated Resident 21 was initially admitted to the facility on [DATE] and last readmitted on [DATE]. Resident 21's diagnoses include type 2 diabetes mellitus (abnormal blood sugar), Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination), hypertension (when the pressure in your blood vessels is too high), and history of falling. During a review of Resident 21's History and Physical (H&P), dated 5/5/2022, the H&P indicated Resident 21 had the capacity to understand and make decisions. During a review of Resident 21's Minimum…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to: 1. Ensure one out of six Residents (Resident 35) had a change of condition (COC) assessment after an altercation. This failure had the potential to result in Residents 35 receiving inadequate and inappropriate care and services necessary to reach their highest practical physical, mental, and psychosocial well being. Findings: During a review of Residents 35's admission Record (Face Sheet), the admission Record indicated Resident 35 was initially admitted to the facility on [DATE] and readmitted to the facility 1/2/2024. Resident 35 diagnoses not limited to schizoaffective disorder (a combination of mood disorder conditions such as depression and [schizophrenia] delusions, hallucinations, unusual physical behavior, disorganized thinking and speech), malignant neoplasm (cancer that can spread and invade nearby tissues), and anxiety (a feeling of fear, dread, and uneasiness). During a review of Residents 35's History and Physical (H&P), dated 1/2/2024,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to: 1.Ensure one out of six sampled residents (Resident 11) had a physician order for the use of oxygen. This deficient practice of not having a physician order for oxygen usage placed Resident 11 at risk for incorrect oxygen usage. Findings: During a review of Residents 11's admission Record (Face Sheet), the admission Record indicated Resident 11 was initially admitted to the facility on [DATE] and readmitted to the facility 3/20/2024. Resident 11 diagnoses not limited to diabetes mellitus (a disorder known for disrupting the way your body uses sugar), dementia (the loss of cognitive functioning in thinking, remembering, and reasoning), and chronic kidney disease (a condition in which the kidneys are damaged). During a review of Resident 11's Minimum Data Set ([MDS] a standardized assessment and care screening tool), dated 3/8/2024, MDS indicated Resident 11 cognitive (the ability to understand or to be understood by others) was not able to recall…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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.Label and date the humidifiers (a device that adds moisture to a space) and nasal cannula (a device that gives you additional oxygen) for one out of six Residents (Resident 11). This deficient practice placed Resident 11 at risk for respiratory infection. Findings: During a review of Residents 11's admission Record (Face Sheet), the admission Record indicated Resident 11 was initially admitted to the facility on [DATE] and readmitted to the facility 3/20/2024. Resident 11 diagnoses not limited to diabetes mellitus (a disorder known for disrupting the way your body uses sugar), dementia (the loss of cognitive functioning in thinking, remembering, and reasoning), and chronic kidney disease (a condition in which the kidneys are damaged). During a review of Residents 11's History and Physical (H&P), dated 1/2/2024, the H&P indicated, Resident 35 had the capacity to make decisions for activities of daily living. During a review of Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure narcotic medications administered were documented accurately in the medication administration record (MAR) and the controlled drug record sheets (drugs or other substance tightly controlled by the government that may be abused or cause addiction) for one of four sampled residents (Resident 1). This deficient practice had the potential for medication errors and can result in overdosage of narcotic medication and/or hospitalization. Findings: During a review of Resident 1 ' s admission record, the admission record indicated Resident 1 was admitted on [DATE], with a diagnosis that included acute myeloblastic leukemia (type of cancer in which the bone marrow makes a large number of abnormal blood cells), major depressive disorder (mood disorder that causes a persistent feeling of sadness and loss of interest and can interfere with your daily), and anxiety disorder (persistent and excessive worry that interferes with daily activities). During a…

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