Culver West Health Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide services to improve or maintain range of motion (ROM, full movement potential of a joint) for two of four sampled residents (Residents 9 and 10) with ROM and mobility (ability to move) concerns by failing to: Ensure Restorative Nursing Aide (RNA, nursing aide program that helps residents maintain any progress made after therapy intervention to maintain their function) provided passive ROM (PROM, movement at a given joint with full assistance from another person) exercises to Resident 9's left elbow and left knee in accordance with physician's orders, dated 2/19/2027.Objectively (unbiased, based on facts) measure Resident 10's ROM impairments of both shoulders during the Occupational Therapy (OT, profession that provides services to increase and/or maintain a person's capability to participate in everyday activities) evaluation, dated 4/2/2026.These deficient practices had the potential to cause ROM decline leading to contractures…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to:A. Ensure the facility staff are provided with one clear policy and procedures regarding whether or not, residents who independently smoked cigarettes, could keep smoking materials, lighters, matches or any other smoking related items as evidenced by the following two conflicting and confusing facility policies and procedures titled:1. Smoking Policy dated 1/12/2026 indicated, Residents are not permitted to keep smoking materials, lighters, matches or any other related items in their possession. Cigarettes, matches, lighters, and other materials will be kept by the designated staff of the facility .2. Smoking Policy-Residents dated 1/12/2026 indicated, Residents who have independent smoking privileges are permitted to keep cigarettes, pipes, tobacco, and other smoking articles in their possession. This deficient practice had the potential to cause confusion among staff and residents placing the residents, staff and guests at increased…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 and equipment to improve toileting and toilet transfer abilities for one of four sampled residents (Resident 5) who was continent (having voluntary control of urination and bowel movements) and able to walk and transfer (move from one surface to another) with assistance. This deficient practice resulted in Resident 5 wearing adult briefs (absorbent, disposable garments worn to manage bowel and bladder loss) and toileting in bed instead of walking to the bathroom or using a commode (portable toilet) due to lack of available toileting equipment for safe transfers, feelings of humiliation and low self-worth, and placed Resident 5 at risk for functional decline, skin breakdown (tissue damage caused by friction, shear, moisture, or pressure), and incontinence (having no or insufficient voluntary control over urination or bowel movements). Cross Reference F557 and F676Findings: During a review of Resident 5's admission Record…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation interview and record review, the facility failed to:1. Provide appropriate monitoring of insulin for one of five sampled residents (Resident 5).2. Initiate a comprehensive care plan that addressed Resident 5's diagnosis of diabetes or the administration of insulin.These deficient practices had the potential to result in complications from the use of insulin such as hypoglycemia and lethargy.Findings: A review of Resident 5's admission Record indicated the facility admitted the resident on 5/26/2023 and readmitted on [DATE] with diagnoses including but not limited to diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), morbid obesity and ESRD (End Stage Renal Disease-irreversible kidney failure). A review of Resident 5's Minimum Data Set (MDS - a resident assessment tool) dated 6/1/2026, indicated Resident 5 has intact cognition (ability to think and reason), required partial/moderate assistance (helper does less than half the effort)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, for one of one sampled residents (Resident 99), the facility failed to ensure Certified Nursing Assistant (CNA) 1 followed/verified a physician's order for minced and moist diet (therapeutic diet-a personalized meal plan prescribed by a doctor or registered dietitian to treat a medical condition or manage symptoms) dated 4/8/2026. CNA 1 brought and gave Resident 99 protein bars (a convenient, ready-to-eat snack designed to deliver a concentrated dose of protein) to eat. Resident 99 has a diagnosis of dysphagia (difficulty swallowing). This failure resulted in Resident 99 eating the protein bar/s placing Resident 99 at increased risk for choking, hospitalization, and death. Findings: Cross Reference F689 and F835 During a review of Resident 99's admission record, dated 6/14/2025, indicated Resident 99 was admitted to the facility on 6/14/2025 with diagnoses but not limited to transient ischemic attack (TIA- a temporary blockage of blood flow to the brain causing stroke symptoms), end stage renal disease (kidneys have permanently stopped working),…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 garbage dumpster lid completely closed and covered for one of two garbage dumpsters. This failure had the potential to attract pests (any living thing that can spread disease) and spread infection (when harmful germs like bacteria or viruses can enter your body and make you sick) to facility residents. Findings: During a concurrent observation and interview on 7/6/2026 at 9:10 A.M. with Dietary Aid (DA) 1 in the outdoor garbage area, a garbage dumpster was filled with trash bags to the point that the lid could not fully close. DA 1 stated the garbage dumpster lid should be fully closed to prevent pests and vermin (a small animal, bug, or parasite that can spread disease or destroy property) which can potentially make the residents sick. During an interview on 7/7/2026 at 2:10 P.M. with the Dietary Supervisor (DS), the DS stated insects or animals could travel inside the garbage dumpster if the lid is not fully closed and this can result in the residents becoming sick. During a record review of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure Certified Nursing Assistant (CNA) 1 adhered to the facility's professional code of conduct (rules for how employees should behave at work) by not engaging in an inappropriate romantic relationship with one of one resident (Resident 99) according to the facility's Employee Handbook, dated 3/2025 and evidenced by:1. CNA 1 making arrangements with a private transportation company (PTC) to pick up Resident 99 from the facility, transported Resident 99 to a bank in Pasadena 20 miles away from the facility, and transported Resident 99 back to the facility unaccompanied and without supervised, and without the knowledge of Resident 99's family members, and facility staff. 2. CNA 1 visiting Resident 99 at a general acute care hospital (GACH) 1 on multiple occasions in the months of 5/2026 and 6/2026 when Resident 99 was admitted at GACH 1.3. CNA 1 bringing and giving protein bars (a convenient, ready-to-eat snack designed to deliver a concentrated dose…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 to ensure the medical record contained sufficient information for one of four sampled residents (Resident 10) was complete by failing to indicate the recommendations and plan of care on the Joint Mobility Assessment (JMA, a brief assessment of a resident's range of motion [ROM, full movement potential of a joint] in both arms and both legs), dated 4/2/2026, for Resident 10, who was identified as having a decline in ROM of both shoulders compared to the previous JMA, dated 9/9/2025. This deficient practice had the potential to delay and negatively affect the delivery of necessary care and services and result in ROM decline leading to contracture (loss of motion of a joint associated with stiffness and joint deformity) development and functional decline for Resident 10. Findings: During a review of Resident 10's admission Record (AR), the AR indicated Resident 10 initially admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 certified nursing assistant (CNA) 3 failed to put on personal protective equipment (PPE - clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments) before entering a room identified with signage as enhanced barrier precautions() to transfer Resident 3 from bed to chair for one of three sampled residents, Resident 3.This deficient practice placed other residents at risk of transmission of possible bacteria.A review of Resident 3's admission Record indicated the facility admitted this [AGE] year-old male on 12/17/2025 most recently with diagnoses including Chronic Obstructive Pulmonary Disorder (COPD-a chronic lung disease causing difficulty in breathing) dysphagia (difficulty swallowing), Congestive Heart Failure (CHF-a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), Hypertension (HTN-high blood pressure), glaucoma, atrial fibrillation…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interview and record review the facility failed to ensure the call light was accessible for one of three sampled residents, (Resident 1).This deficient practice caused Resident 1 to sit in wet diaper from 12:30 am to 6:30 am and further cause burning sensation to buttocks.A review of Resident 1's admission Record indicated the facility originally admitted this [AGE] year old male on 6/14/2025 and most recently on 9/21/2025 with diagnoses including Hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (total weakness of the arm, leg, and trunk on the same side of the body) of the right side, end stage renal disease(ESRD-End Stage Renal Disease-irreversible kidney failure), dependence on renal dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed), essential hypertension (HTN-high blood pressure), hyperlipidemia (fat in the blood), cerebral infarction(CI-stroke, loss…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 Vocational Nurse (LVN) failed to notify supervision of request for room change for one of four sampled residents, (Resident 2).This deficient practice left Resident 2 in a room across from Resident 4 while Resident 4 constantly yells and screams making it difficult for Resident 2 to sleep.A review of Resident 2's admission Record indicated the facility admitted this [AGE] year-old male on 11/18/2025 with diagnoses including gastroenteritis and colitis (infection in the colon), ulcerative chronic proctitis (long term inflammation of rectum), pleural effusion (fluid in the space between the lungs and chest wall), atherosclerosis (hardening of arteries), angina (chest pain), left ventricular heart failure (left side of heart does not pump properly), atrial fibrillation, diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), prosthetic heart valve, Anemia (a condition where the body does not have…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 document call system inspection monthly per the facility policy.This deficient practice placed the facility at risk for non-functioning call system.On 12/29/2025 The California Department of Public Health (CDPH) received a complaint alleging the call light was not working for 4 weeks.A review of the maintenance log for July, August and September 2025 indicated all the call lights were working.During an interview on 1/8/2025 at 2:00pm with the Maintenance Manager (MM). The MM stated the call lights and call system are checked monthly and should be documented. The MM stated there was no documentation for the months of November and December 2025.A review of the facility's policy and procedures titled, Building Systems Nurse's Call System reviewed 1/2025, the P&P indicated: Nurse's Call System Testing Procedure 1. Check weekly. A proportionate number of nurses call buttons. buzzers. cords. and lights so that each part of the system is checked at least monthly. Press the call button. Check to see that signal lights up over…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review for one of three sampled residents, Resident 1. The registered nurse (RN) 1 failed to review the new dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) transportation method prior to picking up Resident 2 for dialysis on 5/10/2025. This deficient practice caused Resident 1 to miss scheduled dialysis treatment on 5/10/2025 and be sent to the general acute care hospital (GACH) where Resident 1 did not receive dialysis because Resident 1 received it the day before at the GACH. Findings: A review of Resident 1 ' s admission record indicated the facility originally admitted this [AGE] year old female on 6/11/2021 and most recently on 5/9/2025 with diagnoses including, osteomyelitis (inflammation of bone or bone marrow, usually due to infection) of left shoulder, end stage renal disease (End Stage Renal Disease-irreversible kidney failure), non ST elevation (STEMI) myocardial infarction (heart…

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

Based on interview and record review, the facility failed to ensure staff consulted with a physician, the Interdisciplinary team (IDT - a group of professionals from different specialties working together to provide care) or the faciity Bioethics committee (a group of individuals, often including doctors, nurses, ethicists, and community members, who help navigate complex moral and ethical questions in healthcare and research) regarding vaccinations for one of five sampled residents (Resident 33) who did not have a resident presentative and did not have the mental ability to make decisions. This deficient practice violated Resident 33's right to be supported and represented supported in making decisions regarding vaccinations. Cross reference F883 Findings: During a record review of Resident 33's admission Record indicated the facility initially admitted Resident 33 on 3/10/2021 and readmitted Resident 33 on 7/30/2023 with diagnoses including adult failure to thrive (a state of decline in older adults characterized by a decline in physical, mental, and social functioning), anemia…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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's interdisciplinary team (IDT- a group of health care professionals with various areas of expertise who work together toward the goals of their clients) failed to ensure one out of four sampled residents (Resident 42) had a physician's order for self-administrations, was assessed determined capable to self-administer medications left at the bedside. This deficient practice had the potential for unintended for and unauthorized access to the medications which could result in adverse reactions (any unwanted, unpleasant, noxious, or potentially harmful effect of a drug or medication), unnecessary hospitalization and possible poor outcomes. Findings: During a record review, Resident 42's admission record indicated Resident 42 was admitted to the facility on [DATE], with diagnoses that include atrial fibrillation (an irregular and often very rapid heart rhythm), hypertension (a medical condition characterized by persistently elevated blood pressure),…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 an observation, interview and record review, the facility failed to ensure one out of 25 sampled Residents (Resident 16) was cared for in a manner that promotes, maintains and/or enhances his (Resident 16s) quality of life and individuality by failing to ensure Resident 16 by received routine personal hygiene (nail hygiene) services that meet the needs of residents. This deficient practice and the potential to result in Resident 16's loss of dignity, selfrespect, and identity that allows the resident to attain or maintain the highest practicable physical, mental, and psychosocial well-being. Findings: During a record review, Resident 16's admission record indicated Resident 16 was originally admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that include hyperlipidemia (abnormally high of fats in the blood), anemia, history of falling, fracture (break in a bone) of humerus (left arm) and pneumonia. During a record review, Resident 16's history and physical (H&P) dated 10/4/2024…

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 observation, interview, and record review, for two of five residents (Resident 29 and Resident 71), the facility failed to: 1. Label the indwelling catheter (a flexible tube that is used to drain urine in the bladder) bag (a device forcollecting urine) labeled with date and time the facility changed the indwelling catheter bag for Resident 71. 2. Immediately notify a physician of the abnormal lab values for urinalysis (a laboratory test that examines a person's urine to detect any abnormalities or health conditions) and record in the resident's medical record regarding the change in condition evaluation (COC -a noticeable alteration in someone's health or circumstances that could have a significant impact on their well-being or the situation they're in) on 4/21/2025 for Resident 29. 3. Timely administer Ertapenem (an antibiotic - medication used to treat severe infections) 1 gram (GM -unit of measure in weight) intramuscularly (IM - inject medication into a muscle) antibiotics (medicines that fight…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 timely administer Ertapenem (an antibiotic - medication used to treat severe infections) 1 gram (GM -unit of measure in weight) intramuscularly (IM - inject medication into a muscle) antibiotics (medicines that fight bacterial infections) leading to a nine-day delay of medication administration for Resident according to physician's order for urinary tract infection (UTI - an infection in the bladder/urinary tract) dated 4/24/2025. This deficient practice had the potential to result in hospitalization and/or death for Resident 29. Cross Reference F690 Findings: During a record review, Resident 29's admission Record indicated the facility initially admitted Resident 29 on 9/26/2023 and readmitted Resident 29 on 2/22/2025 with diagnoses including dependence on renal dialysis (a treatment to clean the blood to stay alive because the kidneys are no longer functioning properly), urinary tract infection (UTI - an infection in the bladder/urinary tract) and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, for two of five sampled residents (Resident 26 and Resident 33), the facility failed to assess the individual needs and food preferences to ensure the menus and/or the resident's food plan met the nutritional needs and preferences for Resident 26. This deficient practice had the potential for insufficient food intake and weight loss for Resident 26. Findings: During a record review, Resident 26's admission Record indicated Resident 26 was originally admitted to the facility on [DATE] and was re-admitted on [DATE] with diagnoses that included congestive heart failure (CHF- a weakened heart condition that causes fluid buildup in the feet, arms, lungs, and other body organs), chronic obstructive pulmonary disease (COPD-), atrial fibrillation (Afib-irregular heart beat), peripheral neuropathy (any nerve damage outside of the brain and spinal cord) and repeated falls. During a record review, Resident 26's Minimum Data Set (MDS - a resident assessment tool) dated 01/31/2025,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure one of two sampled residents (Resident 66) was served with the correct food portion per facility menu spreadsheet when serving meals to residents on 4/30/2025. This deficient practice had the potential for Resident 66 to suffer unintentional weight loss. Findings: During a record review of Resident 66's admission record (face sheet - a document containing demographic and diagnostic information) indicated, Resident 66 was admitted to the facility on [DATE] and was readmitted on [DATE] with the following diagnoses: hemiplegia (paralysis that affects one side of the body) and hemiparesis (weakness or the inability to move on one side of the body, making it hard to perform everyday activities like eating or dressing), essential primary hypertension (abnormally high blood pressure not caused by a medical condition), and muscle weakness (when muscles are weak causing difficulty performing normal activities that require strength). During a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, for two of two sampled residents (Resident 19 and Resident 71) the facility staff failed to: 1. Observe infection control measures by failing ensure Certified Nurse Assistant (CNA) 2 put on and use (don) personal protective equipment (PPE- not limited to gowns, and gloves) while providing Activities of daily leaving (ADL- self-care tasks necessary for daily functioning and maintaining independence) to Resident 19 who was on enhanced barrier precaution (EBP- infection control measures that expand the use of PPE, during high-contact resident care activities to reduce the spread of multidrug-resistant organisms (MDROs - These are microorganisms, typically bacteria, that have become resistant to multiple classes of antibiotics). 2. Ensure that an indwelling catheter (a flexible tube that is used to drain urine in the bladder) bag (a device forcollecting urine) was labeled with date and time to indicate the indwelling catheter bag was changed. These deficient…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 staff consulted with a physician, the Interdisciplinary team (IDT - a group of professionals from different specialties working together to provide care) or the faciity Bioethics committee (a group of individuals, often including doctors, nurses, ethicists, and community members, who help navigate complex moral and ethical questions in healthcare and research) regarding vaccinations for one of five sampled residents (Resident 33) who did not have a resident presentative and did not have the mental ability to make decisions. This deficient practice violated Resident 33's right to be supported and represented supported in making decisions regarding vaccinations and placed Resident 33 at increased risk for in infection and/or hospitalization. Cross reference F552 Findings: During a record review, Resident 33's admission Record indicated the facility initially admitted Resident 33 on 3/10/2021 and readmitted Resident 33 on 7/30/2023 with diagnoses including adult failure to thrive (a state of decline in older adults…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide reasonable accommodation for one out four sampled Resident (Resident 19) by failing to ensure the resident's call light was in working condition and within reach. This deficient practice had the potential to negatively impact on the psychosocial well-being of the residents or result in delayed provision of necessary and emergent services. Findings: During a record review, Resident 19's admission record indicated Resident 19 was admitted to the facility on [DATE] with diagnoses that included indwelling urethral catheter (flexible tube, that is inserted into the urethra (the tube carrying urine from the bladder) and into the bladder to drain urine or administer fluids) hematuria (blood in the urine), difficulty walking, type II diabetes mellitus (condition in which the body has trouble controlling blood sugar and using it for energy), obstructive and reflux uropathy (blockage in the urinary tract that prevents urine from flowing…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 essential lifesaving equipment, automated emergency defibrillator (AED, a portable device that can be used to treat a person whose heart has suddenly stopped working) machine at the designated nursing stations, Unit nursing stations and North and South Nursing stations. This deficient practice resulted in delayed life saving measures during Resident 1 ' s emergency resuscitation attempts by the facility staff on [DATE] at 7:34 PM. Findings: During a review of Resident 1's admission Record, dated [DATE], the admission Record indicated, Resident 1 was admitted to the facility on [DATE] with diagnoses including pneumonia (an infection that inflames the air sacs in one or both lungs), weakness, and paroxysmal atrial fibrillation (an irregular heartbeat that can lead to blood clots and increases the risk of stroke and other heart complications). During a review of Resident 1 ' s Physician Orders for Life-Sustaining Treatment (POLST-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, facility failed to ensure that the Licensed nurse (LVN) notified Resident 1 ' s family member (FM) about a change of condition (COC -a sudden or acute deviation from a patient ' s baseline that may lead to complications or death if left untreated) for one of three sampled residents (Resident 1) in accordance with the facility's policy and procedures (P&P) titled Change of condition management guideline revised 9/11/2023, by failing to notify Resident 1 ' s FM after a COC occurred on 8/6/2024. This deficient practice violated Resident 1 ' s FM ' s right to be notified of Resident 1 ' s care services provided and had the potential to result in lack of proper care and services. Findings: A review of Residents 1 ' s admission Record indicated the facility initially Resident 1 on 9/1/2011 and readmitted Resident 1 on 8/30/2024 with diagnoses including diabetes (a disease in which your body does not produce enough insulin needed to control sugar levels in the blood), hypertension (HTN - elevated blood pressure), and dementia (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.

Based on observation, interview and record review, the facility failed to provide reasonable accommodation of needs for one of three sampled residents (Resident 1) by failing to ensure Resident 1 ' s call light (a device with a button or touchpad a resident uses to set off an alarm that flashes/rings to alert the facility staff the resident needs assistance) was within reach as indicated in the facility ' s Policy and Procedures (P&P) titled Call Light Answering revised on 9/11/23. This deficient practice had the potential for Resident 1 not to receive emergency care or have a delay in care and services that could result in a fall or accident. Findings: A review of Resident 1 ' s admission Record indicated the facility admitted the resident on 5/29/2024 with diagnoses that included chronic obstructive pulmonary disease (COPD-a common lung disease causing restricted airflow and breathing problems), acute and chronic respiratory failure (acute respiratory failure-occurs when there is a sudden decrease in the ability to exchange oxygen and carbon dioxide between the lungs and blood…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 and report allegations physical abuse (willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish) for one out of three sampled residents (Resident 1) to the Department of Public Health, Ombudsman (an official appointed to investigate individuals' complaints against maladministration), and to the local law enforcement in accordance with the facility's policy and procedures (P&P) titled Abuse and Crime Reporting effective 9/11/2023, by failing to report the unusual occurrence of a resident-to-resident altercation to the State Survey Agency (SSA) within 2 hours after the allegation occurred on 4/23/2024. This deficient practice had the potential to place Resident 1 at risk for elder abuse and delay onsite inspection by the Department of Public Health to ensure the residents' allegation of abuse was investigated. Findings: A review of Resident 1's admission Record…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to prepare and store food in safe and sanitary condition and/or manner to prevent growth of microorganisms when: 1. Hairnets were not worn in the kitchen according to the facility's policy and procedures. 2. Hand hygiene and apron change were not performed during dishwashing when transition from dirty dishes to clean dishes. 3. Drinks and other food items were left at bedside for Resident 33 without proper storage and/or refrigeration for over 14 hours. Those deficient practices had the potential to cause foodborne illness (infections or irritations of the gastrointestinal tract caused by food or beverages that contain harmful bacteria, parasites, viruses, or chemicals) among 75 of 85 residents, who received the food from kitchen. Findings: a. A review of the Facility Resident Census and Minimum Data Set (MDS - a standardized assessment and care screening tool and matrix (is used to identify pertinent care categories), indicated there were…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 storage and conduct inventory for personal belongings for homelike environment for one of six sampled residents (Resident 38). This deficient practice resulted in Resident 38 storing personal belongings in several boxes on the floor and the resident complaining of having lost some personal belongings. Cross Reference F584 Findings: A review of Resident 38's admission Record indicated Resident 38 was admitted to the facility on [DATE] with diagnoses that included type 2 diabetes (a disease in which your body does not produce enough insulin needed to control sugar levels in the blood) and morbid obesity (when a person's weight is more than 80 to 100 pounds above their ideal body weight). A review of Resident 38's History and Physical Examination dated 11/9/23 indicated, Resident 38 had the capacity to understand and make decisions. A review of Resident 38's Minimum Data Set (MDS - a standardized assessment and care…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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. Provide appropriate bed to accommodate one of six sampled residents (Resident 38). 2. Ensure call light was within reach for one of 28 sampled Residents (Resident 29). These deficient practices had the potential to result in Resident 38 developing new pressure injuries (Injury to skin and underlying tissue resulting from prolonged pressure on the skin), and for staff not to meet Resident 29's needs, which could place the resident at risk for incidents. Findings: a. A review of Resident 38's admission Record indicated Resident 38 was admitted to the facility on [DATE] with diagnoses that included type 2 diabetes (a disease in which your body does not produce enough insulin needed to control sugar levels in the blood) and morbid obesity (when a person's weight is more than 80 to 100 pounds above their ideal body weight). A review of Resident 38's History and Physical Examination dated 11/9/23 indicated, Resident 38 had the capacity 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 homelike environment for one of six sampled residents (Resident 38). This deficient practice resulted in Resident 38 storing personal belongings in boxes on the floor. Cross Reference F557 Findings: A review of Resident 38's admission Record indicated Resident 38 was admitted to the facility on [DATE] with diagnoses that included type 2 diabetes (a disease in which your body does not produce enough insulin needed to control sugar levels in the blood) and morbid obesity (when a person's weight is more than 80 to 100 pounds above their ideal body weight). A review of Resident 38's History and Physical Examination dated 11/9/23 indicated, Resident 38 had the capacity to understand and make decisions. A review of Resident 38's Minimum Data Set (MDS - a standardized assessment and care screening tool) dated 3/1/24, indicated the resident had intact cognition (capable of remembering, learning new things, concentrating, or making…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 assess and identify environmental hazards and risk factors for accidents for one of twenty-eight sampled Residents (Resident 35). This deficient practice had the potential to result in, harm through ingestion of hazardous liquid leading to poisoning and/or allergic reactions (A condition in which the immune system reacts abnormally to a foreign substance), unnecessary hospitalizations, and even death. Findings: A review of Resident 35's admission record indicated Resident 35 was initially admitted to the facility on [DATE], with diagnoses that included diabetes mellitus (high sugar in the blood), chronic obstruction pulmonary disease (COPD- is a common lung disease causing restricted airflow and breathing problems), pneumonia (an infection that inflames the air sacs in one or both lungs) and congestive heart failure (CHF- a condition that develops when your heart doesn't pump enough blood for your body's needs.) A review of Resident 35'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 observation, interview, and record review, the facility failed to ensure one of four sampled residents (Resident 65) received continuous feeding of isosource 1.5 (Nutritional formula) as per physician's order, This deficient practice had the potential to cause inadequate nutrition for Resident 65. Findings: A review of Resident 65's admission Record indicated Resident 65 was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses including moderate protein-calorie malnutrition (poor nutrition), dysphagia (swallowing difficulties), and gastro-esophageal reflux disease (a common condition in which the stomach content move up into the esophagus). A review of Resident 65's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 3/1/24, indicated Resident 65's cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision-making were impaired. The MDS indicated Resident65 was dependent to substantial/maximal…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to ensure that pain was managed in a timely manner for one of four sampled residents (Resident 33). This deficient practice resulted in Resident 33 experiencing unnecessary pain. Findings: A review of Resident 33's admission Record indicated the resident was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses including atherosclerotic heart disease (hardening of the arteries [blood vessels that distribute oxygen -rich blood to the entire body] cause by buildup of plaque [small, abnormal patch of tissue on a body part or an organ] in the inner lining of an artery of native coronary [relating to heart] artery with unspecified angina), autonomic neuropathy (damage to the nerves that control automatic body function), and heart failure (when heart muscle does not pump blood as well as it should). A review of Resident 33's History and Physical (H&P - physicians' examination of patient), dated 7/26/23, indicated Resident 33…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, interviews, and record review, the facility failed to: 1. Provide functioning call light to one of six sampled residents (Resident 37). 2. Ensure call light was within reach for one of 28 sampled Residents (Resident 29). This deficient practice had the potential for staff not to the needs for Residents 37 and 29, which could result in physical and emotional harm to the residents. Findings: a. A review of Resident 37's admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses that included Type 2 Diabetes (a disease that results in blood sugar being too high), lung transplant, heart failure and major depressive disorder (decreased interest in pleasurable activities, feelings of guilt or worthlessness, lack of energy, poor concentration, appetite changes, psychomotor retardation or agitation, sleep disturbances, or suicidal thoughts). A review of Resident 38's History and Physical Examination dated 4/3/24 indicated, Resident 37 had the capacity 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 functioning call light (the primary method of patient-nurse communication in a hospital setting, often used as a measure of nurse responsiveness) for two of five selected residents (Residents 1 and 3). This deficient practice had the potential to result in staff delay in meeting resident's needs for hydration, toileting, and activities of daily living as well as a delay in provision of assistance which may lead to falls and accidents. Findings: A review of Resident 1's admission record indicated Resident 1 was admitted to the facility on [DATE], with diagnoses which included, legal blindness (some vision, but the field of vision may be very narrow or blurry. Or may have blind spots that glasses cannot correct), generalized anxiety (usually involves a persistent feeling of anxiety or dread that interferes with how you live your life), and major depressive disorder (a common and serious medical illness that negatively affects how…

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

Based on interview and record review, the facility failed to implement its abuse prevention policy by failing to report an alleged abuse related missing funds to the state agency (Department of Public Health) within 2hrs after the allegation was reported by Resident 1. This deficient resulted in a delay of an onsite inspection by the Department of Public Health and had potential to place all 77 residents in the facility at risk of elder abuse through misappropriation of funds. Findings: On 1/23/2024 at 9:25am an unannounced visit was made to the facility to investigate an allegation regarding Physical abuse of Resident 1. A review of Resident 1 ' s admission record indicated; facility originally admitted the 72yr old female on 08/24/2018 with diagnoses which included chronic obstructive pulmonary disease (COPD- lung disease causing restricted airflow and breathing problems), morbid Obesity (weight is more than 80 to 100 pounds above their ideal body weight), abnormality of Gait and mobility (an unusual walking pattern that may be caused by underlying health conditions) and weakness.…

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

Based on interview, and record review the facility failed to provide the care, assistance, and supervision needed to ensure an environment free of risks and hazards for one out of one sampled resident (Resident 1), by failing to safely transfer Resident 1 from the wheelchair to the bed with an ordered Hoyer lift (a patient lift used by caregivers to safely transfer patient) on 1/4/2024. This deficient practice resulted in Resident 1 falling on 1/4/2024 during the transfer sustaining a laceration (deep cut) on the right lateral (outer part) leg with bleeding severe enough to require transport to the hospital. Findings: On 1/23/2024 at 9:25am an unannounced visit was made to the facility to investigate an allegation regarding Physical abuse of Resident 1. A review of Resident 1 ' s admission record indicated; facility originally admitted the 72yr old female on 08/24/2018 with diagnoses which included chronic obstructive pulmonary disease (COPD- lung disease causing restricted airflow and breathing problems), morbid Obesity (weight is more than 80 to 100 pounds above their ideal body…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide reasonable accommodations for resident needs and preferences for one of four sampled residents (Resident 1) by not providing showers as Resident 1 preferred. This deficient practice had the potential to negatively affect Resident 1 ' s wellbeing, level of satisfaction with life, self-worth, and self-esteem due to lack of and/or delay in receiving sufficient services to maintain good grooming and personal hygiene. Findings: A review of admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses including sepsis (a life-threatening condition that arises when the body ' s response to infection causes injury to its own tissues and organs), major depressive disorder (a mental disorder that have a persistent feeling of loss of pleasure or interest in life), and acute and chronic respiratory failure (condition in which your blood does not get enough oxygen or has too much carbon…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 and report allegations of either verbal abuse (mocking, insulting, ridiculing; yelling, with the intent to intimidate), neglect (failure to provide necessary care and services to avoid harm), or physical abuse (willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish) for one out of four sampled residents (Resident 1) to the Department of Public Health, Ombudsman (an official appointed to investigate individuals' complaints against maladministration), and to the local law enforcement in accordance with the facility's policy and procedure within five (5) working days of the allegation. This resulted in a delay of an onsite inspection by the Department of Public Health to ensure the residents' allegation of abuse was investigated which could also lead to a delay in prevention abuse for all 84 residents in the facility. Cross Reference: F610 Findings: A review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement its abuse prevention policy by failing to report an allegation of abuse within 24 hours or in accordance with state or federal law for one of four sampled residents (Resident 1). This deficient practice had the potential to result in unidentified abuse in the facility and failure to protect all 84 facility residents from abuse. Cross Reference F609. Findings: A review of admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses including sepsis (a life-threatening condition that arises when the body ' s response to infection causes injury to its own tissues and organs), major depressive disorder (a mental disorder that have a persistent feeling of loss of pleasure or interest in life), and acute and chronic respiratory failure (condition in which your blood does not get enough oxygen or has too much carbon dioxide). A review of Resident 1 ' s Minimum Data Set (MDS - a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to ensure a resident who is incontinent of bowel and bladder receives appropriate treatment and services to prevent reoccurrence of urinary tract infection (UTI - an infection that can occur in any area of the urinary tract, including the ureters, bladder, kidneys, or urethra) for one of four sampled residents (Resident 2) by failing to ensure Resident 2 ' s skin remained clean, dry and free of irritation. This deficient practice had the potential to negatively affect the resident's physical comfort and psychosocial well-being and had the potential for formation of pressure sores (injury to skin and underlying tissue resulting from prolonged pressure on the skin) and a buildup of bacteria and a reoccurrence of infection. Findings: A review of Resident 2's admission Record indicated Resident 2 was admitted to the facility on [DATE] with diagnoses including urinary tract infection (UTI- an infection in any part of the urinary system, including the kidney,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 monitor two of two sampled residents (Residents 1 and 2) for specific target behaviors for the use of Risperdal and Zyprexa (antipsychotic medications used to treat psychosis, a mental disorder characterized by a disconnection from reality) respectively. This deficient practice had the potential to result in overuse of an antipsychotic medication, without adequate indication for use, nonpharmacological interventions, or monitoring for the effectiveness and/or ineffectiveness of the medication; and could increase Resident 1 and Resident 2 ' s risk of adverse drug reactions and potential to not recognize or address the residents ' underlying causes of behavior (e.g., pain, discomfort) or psychosocial stressors (e.g., loneliness). Findings: 1. A review of Resident 1 's admission Record indicated the facility admitted the resident on 5/25/2022 and readmitted on [DATE]. Resident 1 's diagnoses included Dementia (a progressive disease that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain the facility pest free (free of cockroaches and flies), maintain the facility clean, prevent pest harborage areas, and maintain an effective pest control program. As a result of the noncompliance, Resident 1 was transferred to the general acute care hospital 1 (GACH 1) on 8/23/2023, and reported maggots (small, wormlike fly larva [a worm-like creature, which emerges from an egg]) were found in Resident 1 ' s left heel wound upon admission in the Emergency Department (ED). Resident 1 needed intravenous (IV – administering fluid medication through a needle or tube inserted into a vein) antibiotics (medication that fight bacterial infection) and amputation (removal of the limb) below the knee (BKA) was performed. Findings: A. A review of Resident 1 ' s admission Record indicated that Resident 1 was originally admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses including type II DM, sepsis (a life-threatening…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement its incident reporting for residents and visitors ' policy for one of 10 sampled residents (Resident 1) by failing to report an unusual occurrence to the State Survey Agency and send a written report within 24 hours for Resident 1 after they were made aware by General Acute Care Hospital 1 (GACH 1) that maggots were found in Resident 1 ' s left heel wound. This deficient practice resulted in a delay of an onsite inspection by the Department of Public Health and had potential to place other residents at risk for neglect. Findings: During a review of Resident 1 ' s admission Record indicated that Resident 1 was originally admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses including type II diabetes mellitus (DM-a chronic condition that affects the way the body processes blood sugar [glucose]), sepsis (a life-threatening condition that arises when the body ' s response to infection causes injury to its own tissues 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 and implement a comprehensive person-centered care plan for one of 10 sampled residents by failing to implement a comprehensive and resident-centered care plan regarding Resident 1 diagnosis and left heel wound. This deficiency findings placed Resident 1at risk of further delay of wound healing and treatment of the disease. Findings: A review of Resident 1 ' s admission Record indicated that Resident 1 was originally admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses including type II diabetes mellitus ((DM-a chronic condition that affects the way the body processes blood sugar [glucose]), sepsis (a life-threatening condition that arises when the body ' s response to infection causes injury to its own tissues and organs) and chronic kidney disease (CKD-a longstanding disease of the kidneys leading to renal failure). A review of Resident 1's Minimum Data Set (MDS - a comprehensive standardized assessment and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure the appropriate setting of the low air loss mattress (LAL-a mattress designed to prevent and treat pressure wounds) was properly set up for three of 10 sampled residents (Resident 1) according to the residents' needs and professional standard of care. These deficient practices placed Resident 1 at risk to develop a pressure injury (bed sore-localized damage to the skin and or underlying soft tissue over bony prominence) or at risk of poor wound healing of the current pressure ulcer. Findings: A. A review of Resident 1 ' s admission Record indicated that Resident 1 was originally admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses including type II DM, sepsis (a life-threatening condition that arises when the body ' s response to infection causes injury to its own tissues and organs) and chronic kidney disease (CKD-a longstanding disease of the kidneys leading to renal failure). A review of Resident 1'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 observation, interview, and record review, the facility failed to ensure one of 10 sampled residents, Resident 1 received the nutritional management for patient with diabetes by administering the ordered enteral tube feeding (TF - a method of supplying nutrients directly into the stomach) formula of Diabetisource (a unique carbohydrate blend includes pureed fruits and vegetables to help with the nutritional management of patients with diabetes or stress-induced hyperglycemia (high blood sugar), instead Resident 1 was observed receiving Fibersource TF (formulated with fiber to meet the nutritional needs for tube feeding patients with normal or elevated calorie and/or protein requirements and has higher carbohydrate content). This deficient practice resulted in Resident 1 receiving the incorrect TF formula and not receiving the correct nutrition ordered by the physician and puts resident at risk of hyperglycemia (high blood glucose). Findings: A review of Resident 1 ' s admission Record indicated that…

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