East Terrace Rehabilitation & Wellness Centre, LP

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure oxygen was administered as prescribed for one of 8 sampled residents (Resident 53).This deficient practice had the potential to result in oxygen desaturation for Resident 53.Findings:During a review of Resident 53's admission Record, the admission Record indicated Resident 53 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD- a chronic lung disease causing difficulty in breathing), acute respiratory failure (a life-threatening condition where the lungs suddenly can't get enough oxygen into the blood or remove enough carbon dioxide), dementia (a progressive state of decline in mental abilities) and psychosis.During a review of Resident 53's history and physical (H&P), dated 10/4/2025, the H&P indicated Resident 53 was able to make needs known but could not make medical decisions.During a review of Resident 53's physician orders, dated…

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

Based on interview and record review, the facility failed to ensure competency assessment skill (a measurable pattern of knowledge, skills, abilities, behaviors, and other characteristics in performing that an individual needs to perform work roles or occupational functions successfully) checks were performed annually for two out of five randomly selected staff.This deficient practice had the potential for the facility not to be able to assess the skills necessary to provide nursing services to assure resident safety and to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident will not be performed within the acceptable standards of practice.Findings:During a concurrent interview and record review on 12/17/2025 at 3:21 p.m., with the Director of Staff Development (DSD), five random employees file were checked. The DSD stated Certified Nurse Assistant 1 (CNA 1) was hired on 7/27/2002 and did not have yearly competency assessment skills check on file. The DSD stated Certified Nurse Assistant 2 (CNA 2) was hired on 12/11/2023 and did…

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

Based on interview and record review, the facility failed to ensure Performance Evaluations (a process that organizations follow to assess an employee's work quality and skills over a specific period) were performed yearly for two out of five randomly selected staff.This deficient practice had the potential to compromise resident care and safety.Findings:During a concurrent interview and record review on 12/17/2025 at 3:26 p.m., with the Director of Staff Development (DSD), five random employees file were checked. The DSD stated Certified Nurse Assistant 1 (CNA 1) was hired on 7/27/2002 and did not have yearly Performance Evaluations on file. The DSD stated Certified Nurse Assistant 2 (CNA 2) was hired on 12/11/2023 and did not have yearly Performance Evaluations on file. The DSD stated she was responsible for validating CNA's Performance Evaluation once a year. The DSD stated she oversaw CNA in-service training. The DSD stated Performance Evaluations are tools to rate the staff's performance and to check their areas of improvement and weaknesses. The DSD stated it was important 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 interview and record review, the facility failed to ensure one of six sampled residents (Resident 8), who was receiving Quetiapine Fumarate (a psychotropic medication [any drug that affects brain activities associated with mental processes and behavior] to treat certain mental/mood disorder), was monitored for behavior and its side-effects (an effect of a drug that is in addition to or beyond its desired effect).This deficient practice had the potential for Resident 8 using an unnecessary psychotropic medication that could cause be harmful to the resident.Findings:During a review of Resident 8's admission Record, the admission Record indicated Resident 8 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 8's diagnoses included psychosis (a severe mental health condition in which thought, and emotions are so affected that contact is lost with reality), dementia (a progressive state of decline in mental abilities), and gastrostomy tube ([GT] - a surgical opening fitted…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 label a floor stock medication bottle with an opened date in Medication cart one.This deficient practice had the potential to result in administering an expired medication which could affect the health and condition of the residents.Findings:During a concurrent observation and interview on [DATE] at 7:42 a.m., with Registered Nurse 1 (RN 1) at the Medication Cart 1, RN 1 verified one bottle of Geri-Lanta (medication used to treat the symptoms of too much stomach acid such as stomach upset, heartburn, and acid indigestion) was unlabeled with opened date. RN 1 stated it was important to label the bottle with an opened date to know the validity of the medication. RN 1 stated that when medications are not labeled with an open date, there was a high risk that Geri-Lanta could be expired and the medication could be ineffective and placed the residents receiving Geri-Lanta at risk for possible harm. RN 1 stated she will dispose the one bottle 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 the physician's orders to draw monthly laboratory tests (a medical analysis of a body sample (blood, urine, tissue) to check health, diagnose diseases and monitor chronic conditions) for one of one sampled resident, (Resident 1). This deficient practice had the potential to result in the delay of identification of medical concerns, delaying the care and services necessary for the affected resident.Findings:During a review of Resident 1's admission Record, the admission Record indicated, Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 1's diagnoses included bipolar disorder (mood swings that range from the lows of depression to elevated periods of emotional highs), epilepsy (brain condition that causes recurring seizures), and congestive heart failure ([CHF] - a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling).During a review of Resident…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 perform hand hygiene (cleansing hands with soap or an alcohol-based rub) prior to putting on personal protective equipment ([PPE] protection equipment that includes face shields, gloves, goggles and glasses, gowns, head covers, masks, respirators, and shoe cover to protect against the transmission of germs through contact and droplet routes) and prior to caring for one of seven residents, Resident 96. This failure had the potential for cross contamination (process by which bacteria or other microorganisms are unintentionally transferred from one object or person to another, with harmful effect) and risk to expose Resident 96 to infectious organisms (germs).Findings:During a review of Resident 96's admission Record, dated 9/25/2025, the admission Record indicated Resident 96 had Metabolic Encephalopathy (a brain dysfunction due to chemical imbalance in the body), Acute Respiratory Failure ( a sudden condition when the lungs cannot get enough oxygen into the blood) with Hypoxia (lack of oxygen), and Severe…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure staff performed hand hygiene before entering one out of two sampled resident's (Resident 1) room, touching Resident 1's clothing, and exiting the room.This failure had the potential to result in Resident 1 being exposed to infectious organisms and getting sick.Findings:During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnosis including psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality), dementia (a progressive state of decline in mental abilities), and schizophrenia (a mental illness that is characterized by disturbances in thought).During a review of Resident 1's History & Physical (H&P), dated 10/23/2025, the H&P indicated Resident 1 had fluctuating capacity to understand and make decisions.During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool),…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 their Policy and Procedure (P&P) titled, Bed Hold which indicated the facility would hold the resident's bed for up to seven (7) days if the resident was transferred to a General Acute Care Hospital (GACH) for one of 7 sampled residents (Resident 7).This deficient practice violated Resident 7's right to a Bed Hold and had the potential for result in Resident 7 not being able to return to the facility. Findings:During a review of Resident 7 admission Record, the admission Record indicated Resident 7 was originally admitted to the facility on [DATE] and readmitted on [DATE]. The admission Record indicated Resident 7's diagnoses included Schizophrenia (a mental illness that affects thoughts, mood and behavior), Psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality), and dementia (a progressive state of decline in mental abilities).During a review of Resident's 7 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 ensure the facility's Notice of Proposed Transfer and Discharge form was signed by of 1 of 3 sampled residents (Resident 1), and / or its family representative, and provided to, prior to discharge to a lower level of care on 9/4/2025.This failure had the potential to result in the resident's discharge to a Residential Care Facility for the Elderly (RCFE- a licensed assisted living facility that provides non-medical care and supervision for adults aged 60 and over who need help with daily living but not 24-hour skilled nursing care) where the resident needs for activities of daily living will not be met and provided.Findings:During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including Parkinsonism (a syndrome marked by tremor, muscular rigidity, and slow and difficult movement, occurring as a result of disease of the nervous system or exposure to certain drugs…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 an unwitnessed fall with injury for one out of three sampled residents (Resident 7) to California Department of Public Health (CDPH).This deficient practice caused a delay in an investigation of a fall with injury by CDPH.Findings:During a review of Resident 7's admission Record, dated 9/3/2025, the admission Record indicated Resident 7 was initially admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses of polyarthritis (the inflammation or involvement of five or more joints as the same time), muscle weakness (a reduction in muscle strength, affecting patient's ability to maintain mobility), and difficulty in walking (a patient's has limitation/ability to move independently affecting their walking). During a review of Resident 7's History and Physical (H&P), dated 7/24/2025, the H&P indicated Resident 7 could make needs known but could not make medical decisions.During a review of Resident 7's Minimum Data Sheet ([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 ensure one out of three sampled residents (Resident 1) had a care plan after an injury to his right hand.This deficient practice had the potential to place Resident 1 at risk for infection and worsening of the injury to the right hand.Findings:During a review of Resident 1's admission Record, dated 9/3/2025, the admission Record indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), depression (a persistent mood disorder characterized by sadness and a loss of interest), and anxiety (a feeling of apprehension, fear, or dread in response to a real or perceived threat).During a review of Resident 1's History and Physical (H&P), dated 7/31/2025, the H&P indicated Resident 1 could make needs known but could not make medical decisions.During a review of Resident 1's Minimum Data Sheet ([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 three of the five sampled residents (Resident 3, Resident 4, and Resident 5) had an individualized resident care plan developed for Coronavirus ([COVID-19]- highly contagious viral infection) infection. This deficient practice had the potential to place the residents at risk for complications of COVID-19 infection and had the potential for the COVID-19 virus to spread, placing other residents and staff at risk of infection. Findings:a. During a review of Resident 3's admission Record, the admission Record indicated Resident 3 was originally admitted to the facility on [DATE] with diagnoses including hypertension (HTN-high blood pressure,) hyperlipidemia (high levels of fat particles (lipids) in the blood) and unspecified polyarthritis (four or more joints in the body are painful and inflamed.)During a review of Resident 3's History and Physical (H&P) dated 6/23/2025, the H&P indicated Resident 3 had the mental capacity to make needs known but…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 report facility's two coronavirus ([COVID-19]- a highly contagious viral infection) confirmed cases to the California Department of Public Health (CDPH), for two of 3 residents (Residents 2 and 3), as indicated in the facility's policy and procedures (P&P) titled Unusual Occurrence Reporting, reportable disease outbreak (are those that, by law or regulation, must be reported to public health agencies when diagnosed by healthcare providers or laboratories) This failure delayed the investigation by the CDPH and had the potential for the COVID-19 virus to spread in the facility, potentially infecting other residents, visitors and staff.Findings:a). During a concurrent observation and interview on 8/12/2025 at 10:30 a.m. in Resident 2's room, Resident 2's door was closed and had a Novel Respiratory precaution (used for patients known or suspected of being infected with novel respiratory pathogens such as, COVID-19) sign. Resident 2 was in his…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to protect one of four residents (Resident 1), from sexual abuse (a non-consensual sexual contact of any type with a resident). The facility failed to: 1). Ensure Resident 2 ' s (perpetrator) whereabouts (location) was monitored onb 6/10/2025. 2). Ensure Resident 2 who was alert and can make self-understood, did not went into Resident 1 ' s room (victim). This failure resulted in Resident 2 sexually assaulting Resident 1 on 6/10/2025. This failure had the potential to cause psychosocial harm to Resident 1. Findings: a). During a review of Resident 1 ' s admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE], with a diagnoses including schizophrenia (a mental illness that is characterized by disturbances in thought), major depressive disorder (mental illness characterized by persistent sadness, loss of interest in activities, and significant impairment in daily life), and anxiety disorder (feelings of worry,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 an act of sexual abuse (a non-consensual sexual contact of any type with a resident) for two of four sampled residents (Resident 1 and Resident 2), within two (2) hours as indicated in the facility ' s Policy and Procedure (P&P) titled Abuse Prevention and Management. This failure delayed the investigation by the California Department of Public Health (CDPH) and placed the other residents at risk for abuse. Findings: a). During a review of Resident 1 ' s (victim) admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE], with a diagnoses including schizophrenia (a mental illness that is characterized by disturbances in thought), major depressive disorder (mental illness characterized by persistent sadness, loss of interest in activities, and significant impairment in daily life), and anxiety disorder (feelings of worry, nervousness, or unease.) During a review of Resident 1 ' s History and Physical (H&P)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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. Implement its policy and procedures (P&P), for one of 5 sampled residents. (Resident 3). This deficient practice resulted in Resident 3 sustaining unknown bruises and skin tears. Findings: During a review of Resident 3's face sheet, indicated Resident 3 was admitted to the facility on [DATE] with diagnoses which included urinary tract infection (UTI- an infection in the bladder/urinary tract), Alzheimer's disease (a disease characterized by a progressive decline in mental abilities), dementia (a progressive state of decline in mental abilities) and psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality). During a review of Resident 3's Minimum Data Set (MDS- a federally mandated resident assessment tool), dated 11/14/2024, the MDS Section C, indicated Resident 3 ' s cognitive skills was severely impaired. The MDS Section GG also indicated Resident 3 required supervision with activities…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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. Investigate all areas of skin discoloration (a change in the color, texture, or pigmentation of the skin) and skin tears for one of five sampled residents (Resident 3). This deficient practice had the potential to place Resident 3 and other vulnerable residents at increased risk of abuse. Findings: During a review of Resident 3 ' s face sheet (front page of the chart that contains a summary of basic information about the resident), the face sheet indicated Resident 3 was admitted to the facility on [DATE] with diagnoses which included urinary tract infection (UTI- an infection in the bladder/urinary tract), Alzheimer ' s disease (a disease characterized by a progressive decline in mental abilities), dementia (a progressive state of decline in mental abilities) and psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality). During a review of Resident 3 ' 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: 1. Implement its policy and procedure (P&P) titled Resident Right-Quality of Life revised 3/2017, which indicated the facility staff would not handle or move a resident ' s personal belongings without the resident ' s permission for one of three sampled residents (Resident 1). This deficient practice violated Resident 1 ' s rights and had the potential negatively impact Resident 1 ' s psychosocial well-being. Findings: During a review of Resident 1 ' s Face Sheet (front page of the chart that contains a summary of basic information about the resident), the face Sheet indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 1 ' s diagnoses included Parkinson ' s disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), schizophrenia (a mental illness that is characterized by disturbances in thought), and Diabetes Mellitus (DM-a disorder…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to notify the physician of a resident ' s refusal to take Olanzapine ([antipsychotic] medication to treat mental health condition) for one of three sampled residents (Resident 3). This deficient practice had the potential to result in Resident 3 delusional thoughts (false beliefs) and resulted in Resident 3 to engaging in physical abuse with Resident 2. Findings: A)During a review of Resident 3 ' s Face Sheet (front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated Resident 3 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses included schizophrenia (a mental illness that can affect thoughts, mood, and behavior), bipolar disorder, hypertension (HTN-high blood pressure), and muscle weakness (loss of muscle strength). During a review of Resident 3 ' s Minimum Data Set ([MDS] a resident assessment tool), dated 10/8/2024, the MDS indicated Resident 3 ' 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 implement its policy and procedure (P&P) titled Readmission, revised 10/01/2013, which indicated the facility would provide readmission of the residents who require skilled nursing care at the facility, and allow residents who were previously at the facility to be readmitted to the facility for one of three sampled residents (Resident 3). This resulted in the denial of Resident 3 ' s right to return to his home in the facility. Findings: A) During a review of Resident 3 ' s Face Sheet (front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated Resident 3 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 3 diagnoses included schizophrenia (a mental illness that can affect thoughts, mood, and behavior), bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), 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 implement resident-centered care plan interventions for one of three sampled residents (Resident 5), who was at risk for wandering (walk from place to place) and had physician orders for one-to-one sitter ([1:1]-a single staff member is assigned to constantly observe and supervise a patient). This deficient practice had the potential to negatively affect all resident ' s well-being and privacy at the facility. Findings: During an observation on 12/16/2024 at 10:35 a.m., Resident 5 was observed walking in and out from different residents ' room at the facility, and there was no observation of a staff 1:1 sitter. During an observation on 12/17/2024 at 11:36 a.m., Resident 5 was observed walking throughout facility ' s hallway, and there was no observation of a staff 1:1 sitter. During a review of Resident 5 ' s Face Sheet (front page of the chart that contains a summary of basic information about the resident), the face Sheet indicated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide one on one sitter ([1:1]-a single staff member is assigned to constantly observe and supervise a patient) as indicated in the resident care plan for one of three sampled residents (Resident 4). This deficient practice resulted Resident 4 falling, sustaining a laceration (a deep cut in the skin) on the forehead and had the potential to place Resident 4 at risk for recurrent falls. Findings: During a review of Resident 4 ' s Face Sheet (front page of the chart that contains a summary of basic information about the resident), the face Sheet indicated Resident 4 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 4 ' s diagnosis included Parkinson ' s disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), and Diabetes Mellitus (DM-a disorder…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the clinical records were maintained in accordance with accepted professional standards and complete the personal belongings inventory list for one of three sampled residents (Resident 1). This deficient practice resulted in incomplete medical records and misappropriation of Resident 1 ' s personal property. Findings: During a review of Resident 1 ' s Face Sheet (front page of the chart that contains a summary of basic information about the resident), the face Sheet indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 1 ' s diagnoses included Parkinson ' s disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), schizophrenia (a mental illness that is characterized by disturbances in thought), and Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to: 1. Provide a privacy bag on a foley catheter for one of five sampled residents (Resident 2). 2. Ensure one out of six sampled residents (Resident 72) dignity was maintained after placing bilateral bedrails (metal rails that are attached to the side of a bed to help to prevent patients from falling out). This deficient practice had the potential to affect resident's sense of self-worth and self-esteem. Findings: a. During a review of Resident 2's face sheet (front page of the chart that contains a summary of basic information about the resident), the face sheet indicated Resident 2 was re-admitted to the facility on [DATE] and had an initial admission date of 6/24/2024. The face sheet indicated Resident 2 had diagnoses which included benign prostatic hyperplasia (a noncancerous condition that causes the prostate gland to grow larger than normal), parkinsonism (a progressive disease of the nervous system marked by tremor, muscular rigidity,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 updated Physician's Order for Life Sustaining Treatment (POLST-(POLST- a form that contains written medical orders for healthcare professionals regarding specific medical treatments that can or cannot be done at the end-of life) form was transferred to the hospital for one out of three sampled residents (Resident 38). 2. Ensure an Advance Directive (a legal document indicating resident preference on end-of-life treatment decisions) acknowledgement form was obtained for one of three sampled residents (Resident 90). 3. Ensure one out of six sampled residents (Resident 17) had an updated code status (a patient's documented wishes regarding what life-saving measures should be taken if their heart stops beating or breathing ceases). This deficient practice had the potential to result in a conflict with residents' wishes regarding health care services. Findings: a. During a review of Resident 38's face sheet (front page 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: 1. Ensure one out of six sampled residents (Resident 28) misssing glasses and dentures both were replaced. 2. Provide a homelike environment for two of five sampled residents (Residents 10 and 6). This failure resulted in Resident 28 not having a pair of eyeglasses to see and dentures to chew and Resident 10 and 6 not being in a homelike environment. Findings: a. During a review of Resident 28's admission Record (Face Sheet- front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated Resident 28 was initially admitted to the facility on [DATE] and readmitted on [DATE]. The face sheet indicated, Resident 28's diagnoses included end stage renal disease (a chronic condition where the kidneys permanently stop working), diabetes mellitus (a disorder characterized by difficulty in blood sugar control and poor round healing), and heart failure (a serious condition that occurs when the heart is unable 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 interview and record review, the facility failed to create an individualized comprehensive nursing care plan (a document that summarizes the care and treatment) for two of two sampled resident (Resident 90 & 28). This failure resulted in Resident 90's gastrostomy tube (G-tube-a plastic tube inserted into the stomach to provide nutrition) being dislodged three times and Resident 28 not able to chew without dentures. Findings: During a review of Resident 90's admission record dated 8/2023, it indicated Resident 90 had the following diagnosis but not limited to a having a G-tube. During a review of Resident 90's MDS (a standardized assessment tool) record dated 8/16/2023, it indicated the resident has a G-tube. During a record review of Resident 90's nursing progress notes dated 7/25/2024 through 8/18/2024, the nursing progress notes indicated Resident 90's G-tube was dislodged on 7/25/2024, 7/30/2024, and 8/17/2024. The nursing notes also did not indicate Resident 90 used an abdominal binder (a device…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 prevent the hospitalization for one of one sampled resident (Resident 90). This failure resulted in Resident 90's going to the hospital for treatment due to a dislodged gastrostomy tube (G-tube-a plastic tube inserted into the stomach to provide nutrition). Findings: During a review of Resident 90 ' s admission record dated 8/2023, it indicated Resident 90 had the following diagnosis but not limited to a having a G-tube. During a review of Resident 90 ' s MDS (a standardized assessment tool) record dated 8/16/2023, it indicated the resident has a G-tube. During a record review of Resident 90's nursing progress notes dated 7/25/2024 through 8/18/2024, the nursing progress notes indicated Resident 90 was sent to the hospital due to a dislodged G-tube on 7/25/2024 and 7/30/2024. The nursing notes also did not indicate Resident 90 used an abdominal binder (a device placed around the abdomen to keep the G-tube in place). During an interview on 12/5/2024 at 8:17 a.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated 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.

Based on interview and record review the facility failed to secure a gastrostomy tube (G-tube-a plastic tube inserted into the stomach to provide nutrition) to prevent dislodgement for one of one sampled resident (Resident 90). This failure resulted in Resident 90's G-tube being dislodged three times. Findings: During a review of Resident 90's admission record dated 8/2023, it indicated Resident 90 had the following diagnosis but not limited to a having a G-tube. During a review of Resident 90's MDS (a standardized assessment tool) record dated 8/16/2023, it indicated the resident has a G-tube. During a record review of Resident 90's nursing progress notes dated 7/25/2024 through 8/18/2024, the nursing progress notes indicated Resident 90's G-tube was dislodged on 7/25/2024, 7/30/2024, and 8/17/2024. The nursing notes also did not indicate Resident 90 used an abdominal binder (a device placed around the abdomen to keep the G-tube in place). During an interview on 12/5/2024 at 8:17 a.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated Resident 90 should have had an abdominal…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 residents (Resident 72) had the call light within reach. This deficient practice on not having the call light within reach placed the resident at risk for not receiving goods and services. Findings: During a review of Resident 72's admission Record (Face Sheet- front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated Resident 72 was initially admitted to the facility on [DATE] and readmitted on [DATE]. The face sheet indicated, Resident 72's diagnoses included metabolic encephalopathy (a brain dysfunction caused by a chemical imbalance in the blood that affects the brain), major depressive disorder (a mental health condition that causes a persistently low mood and a loss of interest in activities), and spinal stenosis (a narrowing of the spinal canal that compresses the spinal cord, nerves, and resulting in pain in the back and legs). During a review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to: 1. Ensure a Pre-admission Screening Resident Review (PASRR- a federal assessment requirement to help ensure that individuals who have a mental disorder or intellectual disabilities are placed in facilities that can provide the appropriate care) was submitted for one of five sampled residents (Resident 84). This deficient practice had the potential to result in residents not receiving mental health care and services needed. Findings: During a review of Resident 84's face sheet (front page of the chart that contains a summary of basic information about the resident), the face sheet indicated Resident 84 was admitted on [DATE]. The face sheet indicated Resident 84's diagnoses included psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality), altered mental status (a noticeable change in a person's mental function), violent behavior (any action that intentionally harms, injures, or threatens 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 interview and record review, the facility failed to: 1. Ensure a Pre-admission Screening Resident Review (PASRR- a federal assessment requirement to help ensure that individuals who have a mental disorder or intellectual disabilities are placed in facilities that can provide the appropriate care) was resubmitted for one of five sampled residents (Resident 10). This deficient practice had the potential to result in resident not receiving mental health care and services needed. Findings: During a review of Resident 10's face sheet (front page of the chart that contains a summary of basic information about the resident), the face sheet indicated Resident 10 was re-admitted on [DATE] and initially admitted on [DATE]. The face sheet indicated Resident 10's diagnoses included bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), schizophrenia (a mental illness that is characterized by disturbances in thought),…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 residents (Resident 42) toenails were trimmed. This deficient practice of not trimming Resident 42's toenails had the potential to cause discomfort. Findings: During a review of Resident 42's admission Record (Face Sheet- front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated Resident 42 was initially admitted to the facility on [DATE]. The face sheet indicated, Resident 42's diagnoses included metabolic encephalopathy (a brain dysfunction caused by a chemical imbalance in the blood that affects the brain), major depressive disorder (a mental health condition that causes a persistently low mood and a loss of interest in activities), and left/right knee contracture (the muscles, tendons, and tissue around the knees have become tightened and shortened limiting range of motion). During a review of Resident 42's History and Physical (H&P), dated 3/6/2024,…

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 the facility failed to ensure one out of six sampled residents (Resident 9) had the correct settings for low air loss mattress ([LAL]-a type of mattress used to help prevent and treat pressure wounds). This deficient practice of not having the correct LAL mattress setting placed Resident 9 at risk for pressure injuries (a localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence). Findings: During a review of Resident 9's admission Record (Face Sheet- front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated Resident 9 was initially admitted to the facility on [DATE] and readmitted on [DATE]. The face sheet indicated, Resident 9's diagnoses included osteomyelitis (a serious bone infection), adult failure to thrive (a decline in physical and mental), and methicillin resistant staphylococcus aureus ([MRSA] a type of bacterial infection that is resistant to many…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 residents (Resident 17) splints (a medical device used to gradually stretch and prevent further tightening of a muscle or joint to improve range of motion) were placed on by the Restorative Nurse Assistant (RNA) as scheduled. This deficient practice of not placing splints on Resident 17 as scheduled had the potential to cause contractures (a permanent tightening of the muscles tenon, ligaments, or skin that limits normal movement of a body part). Findings: During a review of Resident 17's admission Record (Face Sheet- front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated Resident 17 was initially admitted to the facility on [DATE] and readmitted on [DATE]. The face sheet indicated, Resident 17's diagnoses included dementia (a progressive state of decline in mental abilities), major depressive disorder (a mental health condition that causes 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 provide supervision to Resident 89 when she wandered into Resident 34's room and was pushed by him after facility's knowledge of her wandering behavior. This failure had the potential for Resident 89 to be injured. Findings: A review of Resident 89's Order Summary Report indicated on June 18, 2024, an order to monitor Resident 89's behavior every shift bipolar disorder manifested by mood swing as evidenced by angry outbursts. A review of Resident 89's care plan initiated on November 13, 2024, indicated the resident wanders aimlessly and significantly intrudes on others privacy or activities. Interventions indicated to distract resident from wandering. A review of the Incident Intake Report, intake number CA00933127, the report indicated on November 30, 2024, at 9:45 am, Resident 89 entered Resident 34's room. Resident 34 yelled at Resident 89 to get out of his room hitting on her shoulder causing Resident 89 to stumble out of the room. A review of Resident 89's Order Summary Report dated December 1, 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, the facility failed to: 1. Ensure oxygen tubing was dated for one of five sampled residents (Resident 63). This deficient practice had the potential for the resident to develop a Respiratory Infection. Findings: During a review of Resident 63's face sheet (front page of the chart that contains a summary of basic information about the resident), the face sheet indicated Resident 63 was admitted on [DATE]. The face sheet indicated Resident 63's diagnoses included Chronic Obstructive Pulmonary Disease (COPD- a chronic lung disease causing difficulty in breathing), chronic respiratory failure (a long-term condition that makes it difficult for the body to exchange oxygen and carbon dioxide), Type 2 Diabetes Mellitus (a disorder characterized by difficulty in blood sugar control and poor wound healing) and anemia (a condition where the body does not have enough healthy red blood cells). During a review of Resident 63's Minimum Data Set (MDS- a federally mandated…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 out of six residents (Resident 72) had a consent (the process in which a health care professional educates a patient about the risk, benefits, and alternatives of a given procedure or intervention) for bedrails (bars attached to the side of a bed to help patients move and reduce the risk of falling out of the bed). This deficient practice of not having a consent for the risk and benefits for bedrails use placed Resident 72 at risk for entrapment. Findings: During a review of Resident 72's admission Record (Face Sheet- front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated Resident 72 was initially admitted to the facility on [DATE] and readmitted on [DATE]. The face sheet indicated, Resident 72's diagnoses included metabolic encephalopathy (a brain dysfunction caused by a chemical imbalance in the blood that affects the brain), major depressive disorder (a mental…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to: 1. Ensure one out of six residents (Resident 72) had a physician order for bedrails. This deficient practice of not having a physician order for bedrails for Resident 72 placed the resident at risk for entrapment (when a patient gets trapped in a hospital bed, usually in the side rails). Findings: During a review of Resident 72's admission Record (Face Sheet- front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated Resident 72 was initially admitted to the facility on [DATE] and readmitted on [DATE]. The face sheet indicated, Resident 72's diagnoses included metabolic encephalopathy (a brain dysfunction caused by a chemical imbalance in the blood that affects the brain), major depressive disorder (a mental health condition that causes a persistently low mood and a loss of interest in activities), and spinal stenosis (a narrowing of the spinal canal that compresses the spinal cord,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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. Food in the kitchen was not stored in the kitchen past the used by date. 2. Food was labeled with the dates it was opened and to be used by. The failure had the potential to result in a foodborne illness (an illness that comes from eating contaminated food) in the residents. Findings: During a concurrent observation and interview on 12/3/2024 at 9:03 a.m. with Dietary Manager (DM), in the kitchen, two bowls of ice cream were kept inside the freezer past the indicated use by date of 12/2/2024. DM stated the bowls of ice cream should be thrown away because one day has passed since the ice cream's use by date of 12/2/2024. DM stated this can prevent foodborne illness. During a concurrent observation and interview on 12/3/2024 at 9:09 a.m. with DM, in the kitchen, an opened package of tapioca pudding mix was not labeled with the date it was opened and to be used by. DM stated all food items should be labeled with date opened and date to be used by to prevent foodborne illness. During a 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.

Based on observation, interview, and record review, the facility failed to ensure for one of four trash dumpsters had their lid closed completely. This failure had the potential to attract pests (like flies and rodents) that could spread diseases and bacteria to the residents. Findings: During a concurrent observation and interview on 12/3/2024 at 9:25 a.m. with Dietary Manager (DM), the lid of one trash dumpster was open and not closed completely flat. DM stated trash container lids should be closed completely to prevent pests from getting inside the container and creating an infestation. During a review of the facility's policies and procedures (P&P) titled, Waste Management Administrative Manual, dated 4/21/2022, the P&P indicated waste container must be closable.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to assist one of three sampled residents (Resident 2) in exercising the resident ' s right to vote by failing to provide voting materials to the resident. This failure resulted in Resident 2 feeling frustrated and sad due to not being able to exercise the right to vote. Findings: During a review of Resident 2 ' s admission Record, the admission Record indicated Resident 2 was initially admitted to the facility on [DATE] and readmitted on [DATE]. The admission Record indicated Resident 2 ' s diagnoses included cerebral infarction ([stroke] loss of blood flow to a part of the brain), Diabetes Mellitus ([DM] a disorder characterized by difficulty in blood sugar control and poor wound healing), and hypertension ([HTN] high blood pressure). During a review of Resident 2 ' s Minimum Data Set ([MDS] a federally mandated resident assessment tool) dated 10/22/2024, the MDS indicated Resident 2 was able to understand others and make self understood. During an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to notify the physician of a resident's refusal to take Risperdal ([antipsychotic] medication to treat mental health condition) for one of four sampled residents (Resident 10). This deficient practice resulted in Resident 10 experiencing auditory hallucinations (an experience involving the perception of something not present and/or hearing voices that don ' t exist) and engaged in physical abuse to Resident 9. Findings: a) During a review of Resident 10 ' s Face Sheet (front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated Resident 10 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including 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) and hypertension (HTN-high 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 ensure one of four sampled residents (Resident 1), was spoken to, and treated with respect and dignity. This deficient practice had the potential for Resident 1 to have decreased feelings of self-worth. During a review of Resident 1 ' s admission Record, the admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 1 ' s diagnoses included schizophrenia (a mental illness that can affect thoughts, mood, and behavior) and bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs). During a review of Resident 1 ' s Minimum Data Set ([MDS]- a federally mandated assessment tool), dated 8/28/2024, the MDS indicated Resident 1 was cognitively intact (ability to reason, understand, remember, judge, and learn). During an interview on 10/25/2024 at 8:59 AM with Resident 1, Resident 1 stated a staff member…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to ensure residents were free from physical abuse for one of four sampled residents, (Resident 9). This deficient practice resulted in Resident 9 being choked by Resident 10 and had the potential for Resident 9 to have psychological and/or psychosocial distress. Findings: A. During a review of Resident 9 ' s Face Sheet (front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated Resident 9 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Alzheimer ' s Disease (a disease characterized by a progressive decline in mental abilities), dementia (a progressive state of decline in mental abilities), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and muscle weakness (loss of muscle strength). During a review of Resident 9 ' s Minimum Data Set ([MDS] – a federally mandated resident assessment…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to report an alleged physical abuse for two of four sampled residents (Resident 9 and Resident 10), by failing to: 1. Ensure facility staff report no later than two hours, the alleged resident to resident physical abuse to the California Department of Public Health (CDPH). 2. Ensure the facility report the results of the investigations within five (5) working days. These deficient practices resulted in a delay of an onsite investigation by CDPH and had the potential to place all residents in the facility at risk for further abuse. Findings: a) During a review of Resident 9 ' s Face Sheet (front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated Resident 9 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Alzheimer ' s Disease (a disease characterized by a progressive decline in mental abilities), dementia (a progressive state of decline in mental…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review the facility failed to implement its abuse policy and procedure (P&P) by failing to investigate a resident-to-resident physical abuse between two of four sampled residents (Resident 9 and Resident 10). This deficient practice resulted in unidentified abuse in the facility to Resident 9 and failed to protect other residents in the facility from abuse. Findings: a) During a review of Resident 9 ' s Face Sheet (front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated Resident 9 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Alzheimer ' s Disease (a disease characterized by a progressive decline in mental abilities), dementia (a progressive state of decline in mental abilities), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and muscle weakness (loss of muscle strength). During a review of Resident 9 ' 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: 1. Ensure one of four sampled residents (Resident 4), had a fall risk reassessment done again after Resident 4 was found on the floor on 10/12/2024 and on 10/19/2024. 2. Ensure one of four sampled residents (Resident 5), had floor mats at the bedside to prevent injury from a fall. These deficient practices resulting in Resident 4 ' s fall risk assessment not being re-evaluated to prevent future falls and had the potential for injury if Resident 5 were to have a fall. Findings: 1. During a review of Resident 4 ' s admission Record, the admission Record indicated Resident 4 was admitted to the facility on [DATE] with diagnoses that included muscle weakness, difficulty in walking, hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body), and hemiparalysis (a condition that causes partial weakness or an inability to move on one side of the body). During a review of Resident 4 ' 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 implement its abuse Policy and Procedure (P&P) titled, Abuse Reporting and Investigations which indicated the facility would report allegations of abuse to the California Department of Public Health (CDPH) within two hours of initial report, after one of six sampled residents (Resident 1) alleged Certified Nurse Assistant (CNA) 1 hit him. The deficient practice resulted in a delay in the investigation by the CDPH. Findings During a review of Resident 1 ' s admission Record, the admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE]/ Resident 1 ' s diagnoses included psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality), schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), and type II diabetes mellitus ([DM] a disorder characterized by difficulty in blood sugar control and wound healing). During…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to ensure licensed nurses accurately assessed and monitored one of one sampled resident (Resident 1) according to the physician ' s order and the resident ' s Care Plan. This deficient practice had the potential to result in Resident 1 not receiving the care and interventions needed to address his behaviors and placed facility residents at risk of harm by Resident 1. Findings: During a review of Resident 1 ' s admission Record, the admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE] Resident 1 ' s diagnoses included psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality), schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), and type II diabetes mellitus ([DM] a disorder characterized by difficulty in blood sugar control and wound healing). During a review of Resident 1 ' 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, record review and interview, the facility failed to ensure the call light was within reach for one out of six sampled residents (Resident 2). This deficient practice had the potential to result in Resident 2 not being able to call for assistance and a delay in care for the resident. Findings: During a review of Resident 2 ' s admission Record, the admission Record indicated Resident 2 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 2 ' s diagnoses included chronic obstructive pulmonary disease [(COPD), a chronic lung disease causing difficulty in breathing], epilepsy (a chronic brain disorder that causes seizures [episodes of abnormal electrical activity in the brain]), and schizophrenia (a mental illness that is characterized by disturbances in thought). During a review of Resident 2 ' s history and physical (H&P), dated 8/5/2024, the H&P indicated Resident 2 could not make medical decisions but could make needs known. During 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 interview and record review, the facility failed to ensure one of four residents (Resident 2) who was receiving enteral feeding (a way of delivering nutrition directly to the resident ' s stomach), was provided care and services to prevent aspiration (food or liquid entering the airway or lungs) by failing to ensure the resident ' s head of the bed (HOB) was elevated. This failure had the potential to result in aspiration, difficulty in breathing, lung infection and hospitalization. Findings: During a review of Resident 1 ' s admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease ([COPD] a common lung disease that makes it difficult to breathe), gastrostomy ([G-tube] artificial opening to stomach), and muscle weakness. During a review of Resident 1 ' s Minimum Data Set ([MDS] a standardized assessment and care planning tool) dated 7/29/2024, the MDS indicated Resident 1 could understand and be…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure call lights were in reach for two of three sampled residents (Resident 2 and Resident 3). This deficient practice created the potential for Resident 2 and Resident 3 to be unable to call staff for assistance or alert staff of a medical emergency. Findings: 1. During a review of Resident 2's admission Record, the admission record indicated Resident 2 was originally admitted to the facility on [DATE] and was most recently readmitted on [DATE]. Resident 2's admitting diagnoses included hemiplegia and hemiparesis (inability to move the extremities on one side of the body, muscle contractures (when the muscles, tendons, joints, or other tissues tighten or shorten causing a deformity), osteoporosis (brittle bones), generalized muscle weakness, history of falling, and lack of coordination. During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2 had severely impaired cognition (difficulty remembering things, 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 ensure the call light was functional for one of three sampled residents (Resident 1). This deficient practice led to a delay in Resident 1 having her incontinence brief changed, and created the potential for Resident 1 to be unable to call staff for additional assistance or alert staff of a medical emergency. Findings: During a review of Resident 1's admission Record, the record indicated Resident 1 was originally admitted to the facility on [DATE]. Resident 1's admitting diagnoses included generalized muscle weakness, difficulty walking, osteoporosis (a condition in which bones become weak and brittle), and history of falling. During a review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care-planning tool), dated 7/23/2024, the MDS indicated Resident 1 was cognitively intact (someone with sufficient judgment, planning, organization, self-control, and the persistence needed to manage the normal demands 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 follow their policy and procedure (P&P) titled Abuse Prevention and Management , dated 6/12/2024, for two of two sampled residents (Resident 1 and Resident 2), when the following occurred: 1. Staff failed to report an allegation of Resident 2 touching Resident 1's neck without permission on 6/12/2024 to the State Agency (SA) within two hours. 2. Facility failed to report the findings of their investigation into the alleged incident within five working days to the SA. These deficient practices had the potential to cause a delay in the notification of necessary agencies and the timeliness of their investigations, and the potential for further abuse to occur between Resident 2 and other facility residents and staff. Findings: A review of Resident 1's admission Record indicated the facility admitted Resident 1 on 1/20/2024, and most recently readmitted Resident 1 on 6/7/2024. Resident 1's admitting diagnoses included dementia (loss of memory, language,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 address one of 3 residents ' (Resident 1) refusal with Restorative Nurse Assistant (RNA, nurse that assist residents with range of motion exercise) program in the plan of care. This deficient practice had the potential to to contribute to Resident 1 ' s decline in both upper and lower extremities range of motion and not identify alternate interventions to maintain the highest practicable physical, mental and psychosocial well-being of the resident. Findings: During a review of Resident 1 ' s admission record, the admission record indicated Resident 1 was admitted to the facility on [DATE], with a diagnosis that included chronic embolism (clot obstruction) and thrombosis (blood clot) of left lower extremity, chronic kidney disease, and muscle weakness. During a review of Resident 1 ' s history and physical (H&P) dated 1/2/2023, the H&P indicated Resident 1 had the capacity to understand and make medical decisions. During 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 interview and record review, for 1 of 3 residents (Resident 1), the facility failed to: 1. Provide documentation on the explained risks and benefits when Resident 1 refused to participate with the Restorative Nurse Assistant (RNA, nurse that assist residents with range of motion exercise) treatment. 2. Ensure an accurate documentation in the RNA flow sheet for three consecutive months (December 2022-February 2023). This deficient practice had the potential to contribute to Resident 1 ' s decline in both upper and lower extremities range of motion. Findings: During a review of Resident 1 ' s admission record, the admission record indicated Resident 1 was admitted to the facility on [DATE], with a diagnosis that included chronic embolism (clot obstruction) and thrombosis (blood clot) of left lower extremity, chronic kidney disease, and muscle weakness. During a review of Resident 1 ' s history and physical (H&P) dated 1/2/2023, the H&P indicated Resident 1 had the capacity to understand and make medical…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a care plan (the process of identifying a patient's needs and facilitating holistic care and ensures collaboration among nurses, patients, and other healthcare providers) was formulated for seven of 20 sampled residents (Residents 1, 21, 30, 47, 88, 3, and 83). These deficient practice had the potential for the affected residents not to receive the care and services they need and the provision of a poor quality care. 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 readmitted to the facility on [DATE]. Resident 1's diagnoses included depression (a common and serious medical illness that negatively affects how you feel, the way you think and how you act.), chronic obstructive pulmonary disease (COPD, lung disease that causes blocked airflow from the lungs), myocardial infarction (when the flow of blood to the heart is severely reduced or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure: 1. The hot water/coffee machine water filter were monitored and maintained for safe operation to help prevent sediments build up in the water. 2. Perishable food items for one of 20 sampled residents (Resident 28), were placed in the refrigerator. This failure had the potential to result in an unsafe water used to supply residents with hot water or coffee when needed. This failure had the potential to result in foodborne illnesses (food poisoning caused by eating contaminated food) for Resident 28. Findings: a) During a concurrent observation and interview on 11/28/2023 at 9:54 a.m., with Dietary Service Supervisor (DSS), in the kitchen, the water filter for the hot water and coffee machine was not labeled with a date when replaced or when it needed to be replaced. The Dietary Service Supervisor stated, the water filter does not have a date so, unsure when maintenance personnel last replaced the water filter or when it needed 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 implement infection prevention and control program by failing to: 1. Follow its policy and procedure, titled Resident Isolation-Categories of Transmission- Based Precautions, to keep room doors closed while residents are in the room and to post a sign by the resident's door to check in at the nursing station before entering a resident's room, for two (2) of six residents, (Residents 81 and 83). Resident 81, COVID-19 confirmed (a virus to potentially cause severe respiratory illness) and Resident 83, who had Candida Auris (a type of yeast that can cause severe illness and spreads easily among patients in health care facilities). This failure placed the facility at a high risk for an increase in COVID-19 and C. Auris cases, and placed residents, staff, and the community at risk for contracting the COVID-19 and C. Auris virus. 2. Ensure five of 5 residents' COVID-19 confirmed cases (Residents 37, 81, 200, 201, 202 and 203), was reported 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 interview and record review, the facility failed to follow-up the durable power of attorney (DPOA) or conservator (a person appointed by the judge to act or make decisions for the person who needs help) for one of 21 residents, Resident 41 who cannot make healthcare decisions. This failure had the potential to result in conflict of interest between the facility and the resident's wellbeing and resulted in a resident representative not notified nor having a resident advocate for Resident 41. Findings: During a concurrent interview and record review on 12/1/2023, at 3:48 p.m., with Social Services Director (SSD), of Resident 41's admission Record, dated 12/1/2023, the admission Record indicated, Resident 41 was originally admitted to the facility on [DATE] with diagnoses of metabolic encephalopathy (chemical imbalance in the blood that affects the brain) and extended spectrum beta lactamase (ESBL, a chemical produced by bacteria to make some antibiotics ineffective in treating infections) resistance. 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 two of 20 sampled residents (Resident 41 and Resident 8) had an Advance Directive (written statement of a person's wishes are carried out should the person be unable to communicate them to a doctor). This failure had the potential to result residents' health care instructions will not be honored and will affect the quality of life. Findings: During a review of Resident 8's admission Record, dated 12/1/2023, the admission Record indicated Resident 8 was admitted to the facility on [DATE], with diagnoses of but not limited to polyneuropathy (damage to many nerves in the body), type 2 diabetes mellitus (abnormal blood sugar), muscle weakness, and obesity (excess body fat). During a review of Resident 8's History and Physical Examination (H&P) dated 3/8/2023, the H&P indicated Resident 8 had the capacity to understand and make decisions. During a review of Resident 8's Minimum Data Set ([MDS] a standardized assessment and screening tool) dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed ensure the physician was promptly notified when one of one sampled resident (Resident 47), had a change of condition (a change in resident's normal physical, mental, or behavioral state). Resident 47 had an aggressive behavior. This deficient practice had the potential for a delay in providing care and interventions necessary to maintain the highest practicable physical, mental and psychosocial well-being of the resident. Findings: During a review of Resident 47's admission Record, the admission Record indicated Resident 47 was admitted on [DATE] with diagnoses including unspecified psychosis (a severe mental condition in which thought and emotions are so affected that contact is lost with external reality), major depressive disorder (a condition of feeling sad and/or loss of interest in activities), and unspecified dementia (general term for the impaired ability to remember, think, or make decisions that interferes with doing everyday activities). During…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to revise the care plan for one of 21 sampled resident, Resident 60. This failure had the potential to place Resident 60 to not receive appropriate care and/or services. Findings: During a review of Resident 60's admission Record, dated 12/1/2023, the admission Record indicated, Resident 60 was originally admitted to the facility on [DATE], and was re-admitted on [DATE] with diagnoses of malignant neoplasm (abnormal growth of tissue that invades other sites) of the pancreas (an organ that produces juices that breakdown food), anxiety (feeling worried), and depression (mood disorder of feeling sadness and loss of interest). The admission Record indicated; Resident 60 was on hospice with a new hospice company. During a review of Resident 60's History and Physical (H&P), dated 7/7/2023, the H&P indicated, Resident 60 can make needs known but cannot make medical decisions. During a review of Resident 60's Order Summary Report, dated 12/1/2023, the Order…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, for one of 21 residents (Resident 56), the facility failed to ensure: 1. The oxygen (air) nasal cannula (a nasal device used to deliver supplemental oxygen) tubing was stored properly and changed every seven days per policy and procedure (P&P). 2. The humidifier (liquid that moistens the air) bottle was labeled with date of change and was changed every seven days per P&P 3. Resident 56 had a physician order for its oxygen use. These failures had the potential to cause respiratory infection, incorrect amount of oxygen delivered to Resident 56 and the potential to result in resident respiratory distress and hospitalization. Findings: During a concurrent observation and interview on 11/28/2023, at 3:34 p.m., with Licensed Vocational Nurse (LVN) 1, in Resident 56's room, the oxygen nasal cannula tubing was observed hanging on the right siderail of the bed and was not in the storage bag. The storage bag for the oxygen nasal cannula tubing was dated 9/29/2023. LVN 1…

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

Based on observation, interview and record review, the facility failed to provide behavioral health services in a timely manner for one of one sampled resident (Resident 47). This deficient practice had the potential to prevent Resident 47 from maintaining the highest practicable mental, physical, and psychosocial wellbeing. Findings: During a review of Resident 47's admission Record, the admission Record indicated the facility admitted Resident 47 on 8/29/2023 with diagnoses including unspecified psychosis (a severe mental condition in which thought and emotions are so affected that contact is lost with external reality), major depressive disorder (a condition of feeling sad and/or loss of interest in activities), and unspecified dementia (general term for the impaired ability to remember, think, or make decisions that interferes with doing everyday activities). During a review of Resident 47's History and Physical (H&P), dated 9/1/2023, the H&P indicated, Resident 47 had the capacity to understand and make decisions. During a review of Resident 47'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.

Based on observation, interview, and record review, the facility failed to: 1. Remove two multi-dose unopened vials of expired influenza vaccine (a vaccine that protect against infection by influenza viruses) from the facility's medication refrigerator room. 2. Label opened medication containers with date it was opened. This deficient practice had the potential for expired medications administered to the residents and can cause severe drug adverse reactions including hospitalization. Findings: During a concurrent observation and interview on 11/29/2023 at 10:57 a.m. of the medication room refrigerator, with Registered Nurse (RN 1), two expired multi-dose unopened vials of influenza vaccine, with expiration date of June 30, 2023, were observed. RN 1 stated it was the responsibility of the night nurse to check the medication refrigerator room for expired medications. RN 1 stated expired medication should be discarded in the incineration bin. RN 1 stated it was not safe to administer expired medication to the resident and can cause potential medical complications. During a concurrent…

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