Fountain View Subacute And Nursing Center

Based on interview and record review, the facility failed to ensure to complete the Advance Directive (written statement of a person's wishes regarding medical treatment made to ensure those wishes are carried out should the person be unable to communicate them to a doctor) Acknowledgement Form (a written documentation of request or refused formulation of advanced directives) for one of eight sampled residents (Resident 73). This failure violated Resident 73's rights to be fully informed of the option to request or refuse medical care and treatment.Findings:During a review of Resident 73's admission Record, the admission Record indicated the facility admitted the resident originally on 3/2/2024 and readmitted the resident on 4/24/2026 with diagnoses that included muscle weakness, abnormalities of gait (a person's specific manner or pattern of walking or moving on foot), end stage renal disease (irreversible kidney failure), and essential hypertension (high blood pressure). During a review of Resident 73's untitled history and physical document dated 8/3/2025, the untitled history…

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

Based on interview and record review, the facility failed to ensure one of three randomly selected residents (Resident 32) and/or resident representative received mandatory information on Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNFABN: a Skilled Nursing Facility [SNF] must issue this notice to a resident when it believes that Medicare (Federal health insurance) may not cover their care or stay. The SNF must provide the notice to the resident before providing the non-covered care) appeal process. This failure resulted in the facility denying Resident 32's right to accept or declined non-covered specific skilled services or ability to file an appeal placing Resident 32 at risk for unexpected financial burden/crisis.Findings:During a review of Resident 32's admission Record, the admission Record indicated the facility originally admitted Resident 32 on 11/10/2021 and readmitted Resident 32 on 3/23/2026 with diagnoses that included heart failure (a chronic condition where the heart muscle is too weak or stiff to pump enough oxygen-rich blood to meet 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 interview and record review, the facility failed to ensure adequate monitoring for the symptoms of anxiety (nervousness) and manifestations of verbalizing feeling anxious and/or nervous for one of five sampled residents (Resident 101) who had physician orders for Alprazolam (a medication used to treat anxiety) 0.25 milligrams (mg, a unit of weight and mass). This failure had the potential for Resident 101 to experience anxiety that was not treated, affecting the resident's quality of life. Findings:During a review of Resident 101's admission Record, the admission Record indicated the facility admitted the resident on 6/7/2026 with diagnoses that included intervertebral disc degeneration (a condition in which the cushioning in the spine begins to wear away), type 2 diabetes (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing), need for assistance with personal care, difficulty in walking, and hypertension (high blood pressure).During a review of Resident 101's Order Summary Report, the Order Summary Report indicated the resident had 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 provide and accurate Minimum Data Set (MDS - a resident assessment tool) for one of five sampled residents (Resident 6) by failing to: -Document Resident 6's diagnosis of deep vein thrombosis (a serious condition that occurs when a blood clot forms in a deep vein usually in the leg or thigh). This failure had the potential to result in a delay in the necessary care and treatment for Resident 6.Findings:During a review of Resident 6's admission Record, the admission Record indicated the facility originally admitted Resident 6 on 2/10/2024, and readmitted Resident 6 on 5/9/2026 with diagnoses that included encephalopathy (damage or disease that affects the brain), chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), reduced mobility, functional quadriplegia (a person is completely unable to move their arms and legs due to severe frailty or a non-spinal medical condition, not an injury), dementia (a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure an individualized care plan was in place for two of two sampled residents (Resident 12 and Resident 70): to monitor for side effects and effectiveness of mirtazapine (a tetracyclic antidepressant (TeCA) primarily prescribed to treat Major Depressive Disorder (MDD) for Resident 12.to monitor episodes of restlessness for Resident 70 every shift.These failures had the potential for Resident 12 and Resident 70's delaying of care and treatment to be unidentified. Findings: 1.During a review of Resident 12's admission Record, the record indicated that Resident 12 was originally admitted on [DATE] and readmitted on [DATE] with a diagnoses of metabolic encephalopathy (an altered mental state usually caused by organ failure or chemical imbalances); Alzheimer's disease (a disease characterized by a progressive decline in mental abilities); generalized muscle weakness, and depression (a mood disorder that causes persistent sadness, a loss 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 update and revise the care plan for one of eight sampled residents (Resident 73) for hemodialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney) by failing to: -Ensure the licensed nurses (in general) updated Residents 73's Care Plan Report to include hemodialysis orders on 4/25/2026 and change of hemodialysis days. This failure had the potential to result in a delay in nursing care for Resident 73.Findings: During a review of Resident 73's admission Record, the admission Record indicated the facility admitted the resident originally on 3/2/2024 and readmitted on [DATE] with diagnoses that included but not limited to muscle weakness, abnormalities of gait (a person's specific manner or pattern of walking or moving on foot), end stage renal disease (irreversible kidney failure), and essential hypertension (high blood pressure). During a review of Resident 73's Care Plan Report dated…

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

Based on observation, interview, and record review the facility failed to ensure one of three sampled residents (Resident 2) received the necessary treatment and services to promote healing of a pressure ulcer/injury (localized damage to the skin and/or underlying tissue usually over a bony prominence) by failing to:-Ensure the licensed nurses (in general) promptly identified Resident 2's Stage 2 pressure ulcer/injury (partial-thickness loss of skin, presenting as a shallow open sore or wound) to the right heel.-Ensure Treatment Nurse 1 (TN 1) was competent (having the necessary skill, knowledge, or ability to do something well enough to meet a specific standard or requirement) in identifying pressure ulcers/injuries.-Notify the wound specialist (a medical professional-such as a specialized physician or a nurse practitioner-with advanced training in managing and treating complex, non-healing wounds) of Resident 2's stage 2 pressure ulcer to the right heel.-Ensure the licensed nurses (in general) did not have no more than a bedsheet on Resident 2's Low Air Loss Mattress (LALM, 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 there was effective coordination and communication of hemodialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) care for one of nine sampled residents (Resident 73) reviewed for dialysis by failing to ensure to:-Obtain and maintain Resident 73's current hemodialysis orders in Resident 73's medical record following readmission on [DATE] and after changes to Resident 73's dialysis treatment schedule on 5/12/2026.-Place an identifiable dialysis emergency kit (a sudden, unexpected, and dangerous situation that poses an immediate threat to life and health) readily available.These failures had the potential to delay recognition of changes to Resident 73's hemodialysis treatment orders and emergency interventions. Findings:During a review of Resident 73's admission Record, the admission Record indicated the facility admitted the resident originally on 3/2/2024…

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

Based on observation, interview, and record review, the facility failed to ensure one of three Treatment Nurses (TN 1) was competent in wound care services by failing to ensure:- TN 1 identified a Stage 2 pressure ulcer/injury (partial-thickness loss of skin, presenting as a shallow open sore or wound) on Resident 2's right heel.This failure had the potential for Resident 2's pressure ulcer/injury (localized damage to the skin and/or underlying tissue usually over a bony prominence) to worsen and develop an infection, and/or for the resident to develop new pressure ulcers.Findings:During a review of Resident 2's admission Record, the admission Record indicated the facility admitted the resident on 12/24/2025 with diagnoses that included chronic respiratory failure (a long-term condition where the respiratory system cannot adequately supply oxygen to the blood or clear carbon dioxide from the body), chronic obstructive pulmonary disease (a chronic lung disease causing difficulty in breathing), dependence on the respirator (ventilator, a mechanical device to help support or replace…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 an open Trelegy Ellipta inhaler (a medication used to treat breathing problems) with a complete open date affecting Resident 19 in one of three inspected medication carts (SNF North Cart). This failure increased the risk for Resident 19 to receive medication that has become ineffective or toxic due to improper storage, potentially leading to health complications that could result in hospitalization or death. Findings: During a concurrent observation and interview on [DATE] at 11:53 AM with Licensed Vocational Nurse 1 (LVN 1) in the hallway, SNF North Cart was inspected. The SNF North Cart contained Resident 19's opened Trelegy Ellipta inhaler with an incomplete open date of 5/2026. According to the product labeling, Trelegy Ellipta should be used or discarded within six weeks of opening. LVN 1 stated the Trelegy Ellipta inhaler for Resident 19 only contained the month and year when it was opened. LVN 1 stated the day must also 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 observations, interview, and record review, the facility failed to maintain infection control practices (the set of everyday habits and rules used to stop germs such as viruses and bacteria from spreading) necessary to prevent the spread of infections for two of two sampled residents (Resident 60 and Resident 67) by failing to:-Ensure Certified Nursing Assistants (CNA 1 and CNA 2) performed hand hygiene (the act of cleaning your hands to remove germs, dirt, and viruses) when feeding the residents (Resident 60 and Resident 67). These failures had the potential to increase the risk of infection among the residents (Resident 60 and Resident 67).Findings:During review of Resident 60s's admission Record (a document containing demographic and diagnostic information), the admission Record indicated the facility admitted the resident on 4/14/2026, with the diagnoses that included cerebral infarction (a blood vessel carrying oxygen and nutrients to the brain is blocked by a clot or fatty buildup.), dementia…

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

Based on observations, interviews, and record reviews, the facility failed to ensure one of two residents' rooms (Resident 31's room) were free of insects.This failure had the potential to increase the risk of a bacterial and/or respiratory infection in the residents.Findings:During an observation on 6/9/2026 at 10:57 AM, in Resident 31's room, a brown insect resembling a cockroach was on the floor adjacent to a wall that had cracks and a missing section of the baseboard.During a concurrent observation and interview on 6/9/2026 at 11:19 AM with Maintenance Director (MND) in Resident 31's room, a brown insect was on the floor. The MND stated that routine monthly pest control services had been completed within the past three months and was not aware of any current insect issue.During a concurrent observation and interview on 6/9/2026 at11:22 AM with Infection Preventionist (IP) in Resident 31's room, the insect was on the floor. The IP stated they had never seen any insects in the facility before and acknowledged that such insects pose infection control risks. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1) were free from abuse by failing to ensure alleged abuse reported by Resident 1 on 1/26/2026 was immediately reported, investigated, and addressed by facility staff.This failure resulted in delayed intervention by the facility, placing Resident 1 and other residents at risk for continued abuse.During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnosis of heart failure (the heart muscle isn't pumping blood as well as it should, failing to meet the body's needs for oxygen and nutrients, leading to fluid buildup (swelling) and symptoms like shortness of breath and fatigue) and need for assistance with personal care.During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool) dated 10/21/2025, indicated Resident 1 had intact cognition (ability to think, remember and reason) for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1) was safe through the implementation of its abuse prevention and reporting policies, resulting in failure to identify, report, and investigate alleged abuse on 1/26/2026.This failure resulted in the alleged perpetrator Certified Nursing Assistant 1 (CNA1) to continue to work at the facility and come in contact with Resident 1, placing Resident 1 and other residents at risk for continued abuse.During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnosis of heart failure (the heart muscle isn't pumping blood as well as it should, failing to meet the body's needs for oxygen and nutrients, leading to fluid buildup (swelling) and symptoms like shortness of breath and fatigue) and need for assistance with personal care.During a review of Resident 1's Minimum Data Set (MDS- a resident assessment 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 observation, interview, and record review, the facility failed to ensure one of three sampled residents' (Resident 1) allegations of abuse, were immediately reported to facility administration on 1/26/2026 in the required time frame of two hours and appropriate authorities in accordance with federal requirements. This failure resulted in placing Resident 1 and other residents at risk for continued abuse by allowing alleged perpetrator to continue coming in contact with residents.During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnosis of heart failure (the heart muscle isn't pumping blood as well as it should, failing to meet the body's needs for oxygen and nutrients, leading to fluid buildup (swelling) and symptoms like shortness of breath and fatigue) and need for assistance with personal care.During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool) dated 10/21/2025, indicated Resident 1…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure timely follow-up and communication with one of four sampled residents (Resident 2) regarding Resident 2's request to transfer to another facility. This failure resulted in Resident 2 experiencing frustration and dissatisfaction with communication and care and impeded Resident 2's request to transfer. During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was admitted to the facility on [DATE] with diagnosis of heart failure (the heart muscle isn't pumping blood as well as it should, failing to meet the body's needs for oxygen and nutrients, leading to fluid buildup (swelling) and symptoms like shortness of breath and fatigue), obesity (excessive body fat), and reduced mobility. During a review of Resident 2's Minimum Data Set (MDS- a resident assessment tool) dated 2/8/2025, indicated Resident 2 had intact cognition (ability to think, remember and reason) for decisions of daily living, and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to:Ensure one of four sampled residents (Resident 1) attended scheduled physician appointments outside the facility on 11/6/2025, 10/21/2025, 12/3/2025, and 12/23/2025.Document nursing progress notes following outside medical visits to address new orders and follow up care. These deficient practices resulted in missed appointments, delay in treatment, unmet care needs, and did not support the resident's highest practicable physical well-being for Resident 1. During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnosis of colon cancer (abnormal cell growth in the large intestine), cognitive (ability to think, remember and reason) communication deficit, and epilepsy (a chronic brain disorder characterized by recurrent, unprovoked seizures, which are sudden surges of abnormal electrical activity in the brain, causing temporary disruptions in behavior, movement,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 timely follow-up and communication with one of four sampled residents (Resident 2) regarding Resident 2's request to transfer to another facility. This failure resulted in Resident 2 experiencing frustration and dissatisfaction with communication and care and impeded Resident 2's request to transfer and maintain his highest practicable physical, mental and psychosocial well-being. During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was admitted to the facility on [DATE] with diagnosis of heart failure (the heart muscle isn't pumping blood as well as it should, failing to meet the body's needs for oxygen and nutrients, leading to fluid buildup (swelling) and symptoms like shortness of breath and fatigue), obesity (excessive body fat), and reduced mobility. During a review of Resident 2's Minimum Data Set (MDS- a resident assessment tool) dated 2/8/2025, indicated Resident 2 had intact…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to develop a Comprehensive Care Plan (a personalized document that outlines a resident's needs, goals, and the specific services required to achieve them, ensuring consistent and holistic care) for one of three sampled residents (Resident 3), to address Resident 3's left eye blindness.This failure resulted in the absence of individualized interventions and assessments to manage Resident 3's reported pain of 7/10 and eye dryness in her left eye. During a review of Resident 3's admission Record, the admission Record indicated Resident 3 was admitted to the facility on [DATE] with diagnosis that included left eye blindness, and low vision on right eye.During a review of Resident 3's Minimum Data Set (MDS- a resident assessment tool), dated 11/14/2025, the MDS indicated Resident 3 had cognitive skills for daily decision making. The MDS indicated Resident 3 required set up assistance (Helper sets up or cleans up; resident completes activity.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 administer an ordered 6 AM eye medication on 11/24/2025 to one of three sampled resident (Resident 3), and failed to document reason for the omitted dose, and endorse the omission with the oncoming licensed nursing staff. This failure resulted in lack of continuity of care and left eye discomfort for Resident 3, and the potential for unresolved symptoms and further medication errors. During a review of Resident 3's admission Record, the admission Record indicated Resident 3 was admitted to the facility on [DATE] with diagnosis of left eye blindness, and low vision on right eye.During a review of Resident 3's Minimum Data Set (MDS- a resident assessment tool), dated 11/14/2025, the MDS indicated Resident 3 had cognitive skills for daily decision making. The MDS indicated Resident 3 required set up assistance (Helper sets up or cleans up; resident completes activity. Helper assists only prior to or following the activity) for eating and…

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

Based on observation, interview, and record review, the facility failed to ensure the standardized recipes for lunch menu were followed on 5/5/2025 by failing to: 1. Ensure to follow the lunch menu and portion sizes as written for residents on a pureed diet. Six residents who were on a pureed diet (foods that have a soft, pudding-like consistency) received half a cup of enchilada instead of one cup per the spreadsheet (food portion and serving guide). 2. Ensure the 23 residents who were on CCHO diet (Controlled Carbohydrate Diet-diet for blood sugar control for residents with diabetes) received four ounces (oz., a unit of weight) of rice instead of two oz. according to the spreadsheet's instruction. 3. Ensure six residents who were on a soft and bite size diet (diet used in residents with swallowing difficulty the food should be no greater than ½ inch pieces, biting is not required) received enchilada texture in form that met their needs when the enchilada was cut into inconsistent sizes during service instead of cut into ½ x ½ inch pieces per facility policy and the IDDSI…

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

Based on observation, interview and record review, the facility failed to ensure safe and sanitary food storage and preparation practices when: -The facility stored unpasteurized shell eggs (raw eggs) in the facility's reach in refrigerator (a vertical storage unit commonly found in commercial kitchens). The Residents received fried eggs with unpasteurized shell eggs. Salmonella (bacteria) may be present in raw shell eggs that were not pasteurized. One tray with seven single serving containers of brown color pureed food was stored with no label. This failure had the potential to result in harmful bacteria growth and cross contamination (transfer of harmful bacteria from one place to another) that could lead to food borne illness in 64 out of 74 residents who received food from the facility. Findings: During an observation in the walk-in refrigerator on 5/5/2025 at 8:30AM there were seven previously prepared pureed desserts stored in small individual serving containers. The pureed dessert had dates 5/1/2025-5/14/2025. During a concurrent interview with the Dietary Supervisor (DS),…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 to provide privacy to one of three sampled residents (Resident 50) by failing to pull the privacy curtain during the administration of medication through Resident 50's gastrostomy tube (g-tube, a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems). This failure had the potential for the staff not to uphold Resident 50's dignity. Findings: During a review of Resident 50's admission Record, the admission Record indicated the facility re-admitted the resident on 11/28/2023 with diagnoses that included pneumonia (an infection/inflammation in the lungs), type 2 diabetes (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing), foot drop (a condition where a person has difficulty lifting the front part of their foot) of the left and right foot, muscle weakness, quadriplegia (paralysis from the neck down, including legs and arms, usually due to a spinal cord injury), gastrostomy, and…

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

Based on interview and record review, the facility failed to develop a care plan for one of three sampled residents (Resident 73) who had a ventilator (life support technique where a machine assists or replaces a person's natural breathing)/tracheotomy (a surgical procedure to create an opening in the trachea [windpipe] to facilitate breathing). This failure had the potential for Resident 73 not to receive effective tracheostomy care. Findings: During a review of Resident 73's admission Record, the admission Record indicated the facility admitted Resident 73 on 2/11/2025 with diagnoses including chronic respiratory failure (a long-term condition where the lungs cannot adequately exchange oxygen and carbon dioxide), obesity, and encephalopathy (any disease or condition that affects the brain's normal function or structure). During review of Resident 73's Progress Notes dated 2/24/2025, the Progress Notes indicated one of Resident 73's goals was to have better health and to come off the trach and ventilator. During a review of Resident 73's Minimum Data Set (MDS, a 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.

Based on observation, interview, and record review the facility failed to ensure to review and revise the care plan quarterly for one of one sampled resident (Resident 46) who used hand mitten (a type of glove that encloses all the fingers together). This failure had the potential for Resident 46 not to receive nursing interventions. Findings: During a review of Resident 46's admission Record, the admission Record indicated the facility admitted Resident 46 on 11/19/2021 with diagnoses including acute respiratory failure with hypoxia (a condition where the lungs cannot adequately deliver oxygen to the blood, resulting in low oxygen levels in the tissues) and epilepsy (abnormal electrical brain activity, kind of like an electrical storm inside your head). During a review of Resident 46's Minimum Data Set (MDS, a resident assessment tool) dated 2/12/2025, the MDS indicated Resident 46 had short and long-term memory problems and was severely impaired in cognitive skills for daily decision making. The MDS indicated Resident 46 used a limb (arms or legs) restraint (restrict movement)…

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

Based on observation, interview, and record review, the facility failed to maintain the appropriate Low Air Loss Mattress (LALM - a pressure-relieving mattress used to prevent and treat pressure injuries) settings for one of four sampled residents (Resident 59). This failure had the potential to place Resident 59 at risk for discomfort and the development of pressure ulcers/injuries (localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device). Findings: During a review of Resident 59's admission Record, the admission Record indicated the facility re-admitted the resident on 10/28/2024 with diagnoses that included pressure ulcer of the sacral region (tailbone area) Stage 4 (Full-thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage, or bone). During a review of Resident 59's Order Summary Report, the Order Summary Report indicated the resident had a physician order dated 3/11/2025, for the resident to have a LALM for wound management. The Order Summary indicated for the staff to check…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain infection control practices for two of five sampled residents (Resident 3 and Resident 33) by failing to: -Ensure Certified Nursing Assistant 1 (CNA1) performed hand hygiene and changed the protective personal equipment (PPE, protective clothing, gloves, face shields, goggles, facemasks and/or respirators or other equipment designed to protect the wearer from the spread of infection or illness) before and after CNA1 provided personal hygiene care to Resident 3 and Resident 33 on 5/7/2025 at 2:17 pm. This failure had the potential to spread infections to Resident 3 and Resident 33. Findings: During a review of Resident 3's admission Record, the admission Record indicated the facility admitted Resident 3 on 3/22/2016, and readmitted the resident on 10/10/2023, with diagnoses including chronic respiratory failure (a long-term condition where the lungs are unable to adequately exchange oxygen and carbon dioxide) with hypoxia…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 care plan interventions were followed for one of five sampled residents (Residents 3). This failure had the potential to negatively impact the delivery of care and services to Resident 3. Cross reference with F842 Findings: A review of Resident 3 ' s admission Record dated 11/29/24, indicated Resident 3 was admitted to the facility on [DATE] with diagnoses including end stage renal disease (ESRD – kidney failure), dependence on renal dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed), hemiplegia (paralysis on one side of the body and hemiparesis (weakness on one side of the body) following cerebral infarction (stroke) affecting the left non-dominant side, and diabetes mellitus type two (DMII -- a disorder characterized by difficulty in blood sugar control and poor wound healing). A review of Resident 3 ' s Minimum Data Set (MDS, a resident assessment 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 medical record for two of four sampled residents (Resident 1 and 3) was accurate and compete for: 1. Resident 1 ' s ventilator (a machine or device used medically to support or replace the breathing of a person) administration record, 2. Resident 3 ' s vital sign summary and late entry nurse progress note. This failure resulted in an inaccurate and incomplete medical record for Resident 1 and 3. Cross reference with F626 for Resident 3. Findings: 1. A review of Resident 1 ' s admission Record dated [DATE], indicated Resident 1 was admitted to the facility on [DATE], with diagnoses including ventilator dependent respiratory failure (serious condition where a patient is unable to breathe independently and requires a ventilator [machine that assists or breaths for you]), tracheostomy (surgical procedure where a hole is created through your neck and into your windpipe so you can breath) and gastrostomy (a surgical opening fitted with a device to allow…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 they are compliance with professional standards of care by failing to ensure its policy and procedure are implemented and followed according to their agreement regarding staff ' s meal-break policy. This finding infringed upon the employee's agreement and acknowledgment. Findings: During an interview with Licensed Vocational Nurse 1 (LVN 1) on 10/16/2024 at 10:03 a.m., LVN 1 stated, they are schedule to work 12 hours per shift as a full-time employee. LVN 1 stated, their hours are being flexed when the census is low in the sub-acute area. LVN 1 stated, they either have them take an hour lunch break with no pay or they go home early. During an interview with Licensed Vocational Nurse 2 (LVN 2) on 10/16/2024 at 11:23 a.m., LVN 2 stated she works full time, 12-hour shift per day and when the census in the subacute is less than 21, they are asked to go home early or have them take an hour of lunch break with no pay and they would end up working less than 12 hour shift a day. LVN 2 stated, this caused them to have a…

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

Based on observation, interview and record review, the facility failed to ensure the actual hours worked by licensed and unlicensed nursing staffing directly responsible for resident care per shift were posted for two of two sampled days (10/15/2024 and 10/16/2024). This deficient practice resulted in the actual staffing information not being readily accessible and available to residents and visitors and had the potential to cause inadequate staffing. Findings: During an observation of the facility on 10/16/2024 at 9:55 a.m., observed Direct Care Services Hours Per Patient Day (DHPPD) posted on the wall with the projection hours information. No actual hours were posted in the DHPPD posting. During a follow-up observation of the facility on 10/16/2024 at 3:27 p.m., observed DHPPD posted on the wall with the projection hours information. No actual hours were posted in the DHPPD posting. During an interview with Director of Nursing (DON), on 10/16/2024 at 3:35 p.m., DON stated, the projection hours are posted for the current day and the actual hours should be posted for the previous…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 the Infection Preventionist Nurse (IP) completed the required specialized training related to infection control on an annual basis. This deficient practice resulted in contact precautions not being maintained for Resident 1, who was diagnosed with scabies (a highly contagious skin condition caused by the itch mite that infests and irritates your skin) and had the potential to spread infection and disease throughout the facility. Findings: A review of Resident 1's admission record indicated the facility re-admitted Resident 1 on 6/7/2024 with diagnoses that included chronic respiratory failure (a condition in which your lungs have a hard time loading your blood with oxygen or removing carbon dioxide), pneumonia and heart failure (condition in which the heart muscle is unable to pump enough blood to meet the body's needs for blood and oxygen). A review of Resident 1's General Body care plan initiated 3/22/2024, indicated the resident was diagnosed with dermatitis unspecified and had a positive skin scraping for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the certification requirements were up to date, for one of three certified nurse assistants (CNA 2). This deficient practice had the potential for a knowledge, training, and certification deficit among the CNA, leading to inadequate resident care. Findings: A review of CNA 2 ' s employee profile indicated CNA 2's certificate had an effective date of [DATE] and expiration of [DATE]. A review of CNA 2 ' s employee timecard dated 3/1 through [DATE], indicated CNA 2 worked on the days of 3/12 - [DATE], 3/19 - [DATE], and 3/25 - [DATE]. A review of CNA 2 ' s employee timecard dated 4/1 through [DATE] indicated CNA 2 worked on the days of 4/1 - 4/3, 4/6, 4/7, 4/9 - [DATE] and [DATE]. During an interview on [DATE] at 12:30 PM, the Director of Staff Development (DSD) stated she was responsible to ensure the CNAs were certified, qualified, and the credentials were up to date for the facility staff. The DSD stated CNAs should not be allowed to provide…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop a comprehensive care plan for four of 18 sampled residents (Resident 31, Resident 70, Resident 188, and Resident 25) as evidenced by: 1.Failing to ensure that Resident 31's care plan included measurable goals for monitoring cerebrovascular accidents ([CVA] - an interruption in the flow of blood to cells in the brain] by thinning the blood) and aspirin (medication used to prevent CVA) use. 2. Failing to develop and implement a care plan to monitor the adverse effects (undesired harmful effect) of a psychotropic medication (a drug that can affect how the brain works) for Resident 70. 3. Failing to develop and initiate a care plan for transmission-based precautions (TBP, specific steps healthcare providers take to prevent the spread of infections from one person to another) for Resident 188. 4. Failing to develop and implement a care plan to monitor and provide interventions for Resident 25's diagnosis of disorder of the skin and subcutaneous…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide a complete Restorative Nursing Assistant (RNA - assists patients with long-term treatment and recovery after an accident, surgery, or illness) treatment per physician's orders for three of four sampled residents (Residents 2, 53, and 71) and accurately document treatment provided/refused by failing to: a. Provide range of motion (ROM - extent of movement of a joint) exercises to the left and right lower extremities (legs) as ordered for Resident 2. b. Provide ROM exercises to the left lower extremity and to the left and right upper extremities (arms) as ordered for Resident 53. c. Provide ambulation using a platform walker (PW - allows a person to bear weight on your forearms instead of your wrists) and providing Range of Motion (ROM - refers to how far a paerson can move or stretch a part of his/her body, such as a joint or a muscle) exercises to the left and right upper extremities as ordered for Resident 71. d. Document RNA treatment…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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. Account for two doses of Controlled Substances ([CS]- medications which have a potential for abuse and may also lead to physical or psychological dependence) for Residents 24 and 63 in one of three inspected medication carts (Medication Cart South.) 2. Account for two doses of CS's for Residents 39 and 56 in one of three inspected medication carts (Medication Cart North.) 3. Include the verifying signatures of either the Director of Nursing (DON) or a Registered Nurse (RN) along with Licensed Vocational Nurse (LVN) on the Controlled or Antibiotic Drug Record accountability logs for two sampled month records (3/2024, 4/2024). As a result, control and accountability of CS awaiting final disposition (process of returning and/or destroying unused medications) did not follow the facility policy and procedures. These deficient practices increased the opportunity for CS diversion (the transfer of a controlled substance or other medication from a lawful 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.

Based on observation, interview, and record review, the facility failed to ensure a medication error rate of less than five percent (%) during medication administration affecting two of five sampled residents (Resident 43 and 83) out of 26 total opportunities (medications ordered for administration during observations). This contributed to an overall medication error rate of 7.69%. The medication errors were as follows: 1. Resident 43 received vitamin D3 (form of vitamin D called cholecalciferol that helps the body absorb the vitamins calcium and phosphorus) 5000 iu instead of vitamin D2 (a form of vitamin D called ergocalciferol) 50000 iu as per physician's order. 2. Resident 83 received folic acid (a medication used to treat or prevent folic deficiency) 400 micrograms ([mcg]-a unit of measure of mass) instead of folic acid 1 mg tablet as per physician's order. These failures had the potential to result in Residents 43 and 83 to experience medication adverse effects (unwanted, uncomfortable, or dangerous effects that a medication may have) and the potential to result in Residents…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 medications were safely stored as per facility policy and procedures titled Storage of Medications, dated November 2020, by failing to ensure medications were not left on a bedside table unattended, for one of five residents (Resident 83) observed during medication administration. These deficient practices had the potential to result in unsafe medication administration, improper administration, overdose, interactions with prescribed medications, and serious injury or harm. These deficient practices also had the potential to affect medication efficacy (the power to produce the desired effect) and reduce the therapeutic (intended to treat diseases or disorders) effects of medications administered. Findings: During a medication administration observation in Resident 83's room on 04/16/2024 at 09:45 AM, LVN 4 was observed placing 4 medication cups on Resident 83 's bedside table. LVN 4 was observed administering folic acid (vitamin that promotes red blood cell formation) 400 microgram ([mcg]-a unit of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure that infection control procedures were maintained for two of 18 sampled residents (Resident 41 and Resident 188) as evidenced by: 1.Not disinfecting (cleaning with a solution that destroys organisms) resident care items and equipment, for Resident 41. 2. Failing to ensure the correct transmission-based precautions (TBP, specific steps healthcare providers take to prevent the spread of infections from one person to another) sign was posted for Resident 188 who required contact isolation (a type of transmission-based precautions used to reduce transmission of germs for residents with a suspected or known infection) due to a history of carbapenem-resistant Enterobacterales (CRE, a group of bacteria difficult to treat with antibiotics) and immunocompromisation (having a weakened immune system). These deficient practices increased the risk that Resident 41 could have been exposed to infective pathogens (a bacteria, virus or other…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 have the call light (a device used by the residents to notify the facility's staff for assistance) within reach for one of four sampled residents (Resident 7). This failure had the potential not to address needs and delay of services for Resident 7 . Findings: During a review of Resident 7's admission Record dated 4/17/2024, indicated the resident was admitted on [DATE] with diagnoses of acute respiratory failure (a condition where your lungs cannot release enough oxygen into your blood) with hypoxia (an insufficient amount of oxygen in your body tissues), chronic obstructive pulmonary disease (COPD - a chronic disease that blocks airflow and makes it difficult to breathe), epilepsy (a brain disorder that causes seizures), and tracheostomy (a surgically created hole in your windpipe that allows air to reach your lungs) and uses a ventilator (breathing machine) to breathe. A review of Resident 7's Minimum Data Set (MD -, a standardized…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 one of three sampled residents (Resident 67) had an Advance Directive (written statement of a person's wishes regarding medical treatment made to ensure those wishes are carried out should the person be unable to communicate them to a doctor or to facility staff) on file as part of the resident's medical record as stated in the facilities policy and procedures (P&P) titled Advanced Directive dated 3/23/2022. This failure had the potential for Resident 67 to be denied the right to request or refuse medical care and treatment. Findings: A review of Resident 67's admission Record indicated the facility admitted the resident on 11/28/2023, with diagnoses including traumatic brain injury (occurs when a sudden trauma causes damage to the brain), cerebral infarction (occurs because of disrupted blood flow to the brain due to problems with the blood vessels that supply it), and quadriplegia (when you cannot deliberately control or move your muscles - that can affect a person from the neck down). A review of Resident 67'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 accurately complete the minimum data set (MDS- standardized data collection tool used to assess cognitive and functional status, and care needs) assessment Section I (active diagnoses) on 03/08/2024 for one of two residents sampled for unnecessary medications (Resident 31) by omitting (not including) a diagnosis of cerebrovascular accidents ([CVA] - an interruption in the flow of blood to cells in the brain) in the clinical record. This deficient practice had the potential to negatively affect Resident 31's plan of care and delivery of necessary care and services. Findings: A review of Resident 31's admission Record (a document containing demographic and diagnostic information) dated 04/17/2024, indicated the resident was originally admitted to the facility on [DATE] with diagnoses including peripheral vascular disease (a condition in which narrowed blood vessels reduce blood flow.) A review of Resident 31's General Acute Community Hospital (GACH) 1…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure staff properly assessed and document one out of six sampled residents (Resident 5's) medical diagnosis listed on admission Record, (a medical record that includes past and present medical history and findings), and on Preadmission Screening and Resident Review (PASARR- a federally required screening to help identify individuals with possible serious mental illnesses requiring a specialized follow up evaluation). The deficient practice resulted in Resident 5 not receiving a PASARR II (assessment that determines if resident's mental condition could be met in the nursing facility or if the individual requires specialized services) and subsequent follow up. Findings: A review of Resident 5's admission Record indicated Resident 5 was initially admitted to the facility on [DATE] and readmitted on [DATE] with a diagnoses that included schizophrenia, unspecified (a mental illness that affects your thoughts, mood, and behavior), chronic obstructive…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 skin and pressure ulcer (injuries to the skin and underlying tissue, primarily caused by prolonged pressure on the skin) preventative care consistent with professional standards of practice and per physician's orders for one of 18 sampled residents (Resident 72). By Failing to: 1. Provide weekly skin assessments, monitoring, and care needed to prevent Resident 72 who was at risk for skin breakdown from developing a left heel pressure injury while residing in the facility. 2. Complete an initial wound assessment upon discovery of a left heel pressure injury on 2/19/2024. 3. Obtain physician's orders to treat and provide treatment to Resident 72's left heel pressure ulcer from 2/21/2024 to 2/29/204. 4. Document wound care provided for the left heel pressure injury on the Treatment Administration Record and wound care notes. These deficient practices resulted in resident 72 developing a new facility acquired pressure ulcer 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 provide necessary respiratory care services for two of five sampled Residents (Resident 238 and Resident 5) by failing to administer oxygen therapy (administration of oxygen at concentrations greater than that in the air with the intent of treating or preventing the symptoms of low oxygen), per physician's order. This deficient practice had the potential to result in Resident 238 and Resident 5 experiencing hypoxia (insufficient amount of oxygen reaching the body's tissues) and respiratory distress (difficulty breathing). Findings: a.A review of Resident 238's admission Record indicated the facility admitted the resident on 8/30/2016 and readmitted the resident on 4/9/2024 with diagnoses that included metabolic encephalopathy (permanent brain damage that causes severe confusion and forgetfulness), peripheral vascular disease (PVD - a slow and progressive circulation disorder) and dementia (decline in mental ability severe enough 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.

Based on observation, interview and record review, the facility failed to post the federally required daily actual hours worked by the staff in an area accessible to the public for two out of 17 days for the month of April 2024. As a result, the actual hours worked by the staff was not readily accessible to residents, family, or visitors. Findings: During an observation on 4/17/2024 at 8:29 AM, the Census and Direct Care Service Hours Per Patient Day (DHPPD: Refers to the actual hours of work performed per patient day by a direct caregiver) for SNF (skilled nursing facility) and Sub-Acute was dated for 4/15/2024. During a concurrent observation and interview on 4/17/2024 at 8:35 AM, the Director of Nursing (DON) stated the DHPPD was supposed to be posted daily, and confirmed by stating the posted DHPPD hours were for 4/15/2024 and not the date of observation (4/17/2024). The DON stated the posted DHPPD hours should have reflected the most current hours (4/17/2024). The DON stated the purpose of updating the DHPPD was to ensure the required number of staff were present to provide…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 include appropriate monitoring to ensure that residents drug regimen was free from unnecessary medications (any medication in excessive dose, excessive duration, without adequate monitoring) for one of two sampled residents (Resident 31). As a result, Resident 31's aspirin (medication used to prevent cerebrovascular accidents [CVA] - an interruption in the flow of blood to cells in the brain] by thinning the blood) did not include monitoring for sign and symptoms of bleeding for 36 days. This deficient practice had the potential to cause Residents 31 to receive suboptimal (less than the highest standard or quality) care, experience serious adverse consequences (unwanted, uncomfortable, or dangerous effects that a drug may have) possibly resulting in bleeding, hospitalization, or death. Findings: A review of Resident 31's admission Record (a document containing demographic and diagnostic information) dated 04/17/2024, indicated Resident 31 was…

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

Based on interview, and record review, the facility failed to ensure necessary care was provided consistently for a resident who was receiving hospice service (A program that gives special care to people who are near the end of life and have stopped treatment to cure or control their disease and offers physical, emotional, social, and spiritual support for residents and their families) for one of 18 sample residents (Resident 27), by failing to: 1. Provide Resident 27 hospice licensed nurse and hospice aide visits twice a week per the Integrated (working together) hospice and facility plan of care. 2. Ensure that the hospice agency provided a calendar of visits for the month of April 2024. These deficient practices had the potential to lead to the Resident 27 experiencing unnecessary pain and discomfort, and not receiving the needed and necessary services timely. Findings: A review of Resident 27's admission record indicated the facility admitted the resident on 11/9/2021 and readmitted the resident on 11/14/2022, with diagnoses that included senile degeneration of the brain (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 maintain a working call light (a device used by residents to signal their needs for prompt assistance from staff) for one of one sampled resident (Resident 69). This deficient practice had the potential for Resident 69 to fall resulting in possible injury or death to the resident. Findings: A review of Resident 69's admission Record dated 4/17/2024 indicated Resident 69 was originally admitted to the facility on [DATE] with a diagnosis including, but not limited to, congestive heart failure (CHF, a weakened heart that causes fluid to build up in arms, legs, heart and lungs), anoxic brain injury (lack of oxygen to the brain causing the brain cells to die), repeated falls, asthma (a condition when the airway in the lungs get smaller, making it hard to breath) A review of Resident 69's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 2/4/24 indicated Resident 69 had severe cognitive (ability to think,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 that residents who have tracheostomy (opening created at the front of the neck so a tube can be inserted into the trachea (windpipe) to help with breathing) and ventilator (machine that helps with breathing or that breathes for you) received respiratory care and services in accordance with the residents' care plan and professional standards of practice for one of three sampled residents (Resident 1). For Resident 1, the facility failed to: 1.Provide two persons assistance when Resident 1 was repositioned on 12/15/23 at 9 p.m. 2.Ensure the ventilator circuit tubing (tubing that connects the ventilator to the patient) were properly secured before turning Resident 1 on 12/15/23 at 9 p.m. These deficient practices resulted in Resident 1's ventilator tubing being disconnected from the ventilator, tracheostomy tube being dislodged, causing Resident 1 to bleed in the tracheostomy site and Resident 1 stated he suffered pain. Findings: During a review of Resident 1's admission Record indicated the facility admitted Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to provide sufficient staffing to meet the care needs of two of three sampled residents (Resident 1 and Resident 2). The facility cut back the working hours for the certified nursing assistants (CNA) in the sub-acute unit (level of care needed by a patient who does not require hospital acute care but who requires more intensive licensed skilled nursing care than is provided to the majority of patients in a skilled nursing facility) during the afternoon and the night shift from seven hours to six hours on 12/9/23. This deficient practice resulted in Resident 1 stated he was not being turned regularly, his call light not being answered timely and Resident 2 ' s family member (FM 1) stated Resident 2 was not being changed two times a shift. Findings: 1.During a review of the admission Record indicated the facility admitted Resident 1 on 4/4/23 with diagnoses including chronic respiratory failure (serious condition that makes it difficult to breathe on your…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 documentation was complete and accurate for two of three sampled residents (Resident 1 and Resident 2). The facility failed to ensure the bowel movement for Resident 1 and Resident 2 were accurately recorded for the month of December. This deficient practice resulted in failing to accurately determine the bowel movements for Resident 1 and Resident 2. Findings: 1.During a review of the admission Record indicated the facility admitted Resident 1 on 4/4/23 with diagnoses including chronic respiratory failure (serious condition that makes it difficult to breathe on your own), quadriplegia (paralysis that affects all a person ' s limbs and body from the neck down) and tracheostomy. During a review of the Minimum Data Set (MDS, standardized care and screening tool) dated 10/9/23 indicated Resident 1 was cognitively intact (ability to think and reason). The MDS indicated Resident 1 was dependent (helper does all the effort or the assistance of two…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 regarding investigating and reporting of residents ' injuries and to submit a conclusion report of investigation within five days or in accordance with state or federal law for one of four sampled resident, Resident 1. This resulted in a delay of an onsite inspection by the Department of Public Health to ensure the residents' injuries were investigated which can also lead to a delay in prevention of further injury and potential abuse for Resident 1. Findings: A review of Resident 1's admission Record indicated the resident was admitted to the facility on [DATE] with diagnosis including Parkinson ' s disease (a disorder in the brain that affects movement, often including tremors), quadriplegia (paralysis of all four limbs [arms/legs]), difficulty in walking and muscle weakness. A review of Resident 1's Minimum Data Set (MDS - a comprehensive assessment and care screening tool), dated 1/14/2023, indicated Resident 1'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 their policy regarding investigating and reporting of accidents to the state agency (Department of Public Health) when one of four sampled resident (Resident 1) was found on the floor with a cut on left upper cheek and was bleeding profusely (to a great degree; in large amounts) and then transferred to General Acute Care Hospital (GACH 1) on 1/15/2023. This resulted in a delay of an onsite inspection by the Department of Public Health to ensure the residents' injuries were investigated which can also lead to a delay in prevention of further injury and potential abuse for Resident 1. Cross Reference F609 Findings: A review of Resident 1's admission Record indicated the resident was admitted to the facility on [DATE] with diagnosis including Parkinson ' s disease (a disorder in the brain that affects movement, often including tremors), quadriplegia (paralysis of all four limbs [arms/legs]), difficulty in walking and muscle weakness. 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 provide the care and services necessary to prevent urinary tract infections (UTI: infection in the urinary system) to one out of four sampled residents (Resident 2), by failing to ensure staffs provide all the preventative measures in order to prevent a UTI for Resident 2. This deficient practice resulted in Resident 2 developing a UTI while in the facility on 11/26/2023. Findings: A review of the admission Record indicated Resident 2 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses which included type II diabetes mellitus (DM-a chronic condition that affects the way the body processes blood sugar [glucose]), acute respiratory failure (condition in which your blood does not get enough oxygen or has too much carbon dioxide), and hemiplegia and hemiparesis (loss of the ability to move in one side of the body) following cerebral infarction (lack of blood flow resulting in severe damage to some of the brain tissue) affecting…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 necessary respiratory care consistent with professional standards of practice by failing to: 1. Ensure breathing treatment medications were administered timely and as per physician(s) order for five of 14 sampled residents (Resident 3, 4, 6, 8 and 9). 2. Ensure timely documentation of respiratory assessment and monitoring for four of 19 sampled residents (Resident 10, 11, 13 and 14 ' s) respiratory condition. These deficient practices can negatively impact the delivery of respiratory services provided to Resident 3, 4, 5, 6, 8, 9, 10, 11, 13 and 14. Findings: 1a. A review of Resident 3's admission Record indicated Resident 3 was originally admitted to the facility on [DATE], and was re-admitted on [DATE], with diagnoses including respiratory failure (condition in which your blood does not get enough oxygen or has too much carbon dioxide), chronic obstructive pulmonary disease (COPD-group of lung diseases that block airflow and make…

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

Based on interview and record review, the licensee failed to ensure that the facility was administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident in the facility by failing to: 1. Ensure facility reported a disease outbreak on COVID-19 (Coronavirus- a deadly respiratory disease transmitted from person to person) to the state or federal agencies per facility policy. 2. Ensure facility assessment (FA) was updated with respiratory therapist staffing ratio in the subacute unit. These deficient practices had the potential to result in an increased risk of not meeting needs of all residents residing in the facility. Findings: 1. During an interview with the Infection Preventionist Nurse (IPN) on 11/29/2023 at 10:51 a.m., IPN stated that they were currently in an outbreak due to COVID-19 infection since 11/17/2023. IPN stated and verified that she (IPN) had notified the Los Angeles County Department of Public Health (LAC DPH) and not the state…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 update the Facility Assessment (FA) annually to reflect the current census and its staffing plan to meet the resident care needs by ensuring that respiratory therapist staffing ratio was included in subacute (provided on an inpatient basis for those individuals needing services that are more intensive than those typically received in a skilled nursing facilities but less intensive that an acute care) staffing plan. This deficient practice had the potential to result in the facility failure to identify specific factors that would require a change to the assessment and had the potential to affect the resident care and decline in quality of care. Findings: During a concurrent interview and record review with the Interim Director of Nursing (IDON) on 11/29/2023 at 11:33 a.m., the FA was reviewed. The FA indicated missing respiratory therapist staffing plan in the subacute unit. IDON stated and verified missing staffing plan. IDON stated importance of respiratory therapist staffing ratio being addressed in the FA. IDON also…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide sufficient staffing in order to accommodate resident needs for three of six sampled residents (Residents 1, 3, and 5). For Resident 1, five medications were administered over three hours late. For Resident 3, the Humalog (insulin) Kwik pen (disposable pre-filled medication for lowering blood sugar) was not administered per Physician's Order and the resident was frustrated. For Resident 5, the Restorative Nursing treatment was not performed three times per week, as ordered by the physician. These deficient practices resulted in residents not receiving timely and efficient care and needed services. Cross Reference: F835, F838 Findings: a. A review of Resident 3's admission Record indicated the facility readmitted the resident on 6/9/2022 with diagnoses including diabetes mellitus (a disease that results in too much sugar in the blood), and tracheostomy (a procedure to help air and oxygen reach at lungs by creating an opening from outside 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 interview and record review, the facility failed to obtain informed consent (a process by which residents or their responsible parties have the choice to accept or decline certain medication therapy or treatments once they are educated about the risks and benefits) prior to administering psychotropic medications (medications that affect brain activities associated with mental processes and behavior) for one of six sampled residents (Resident 5). Resident 5 received psychotropic medication for 13 days without consent. This deficient practice denied Resident 5 the right to be informed regarding the risks and benefits of psychotropic medication therapy possibly resulting in diminished overall physical, mental, and psychosocial well-being. Cross Reference: F835 Findings: A review of Resident 5's admission Record indicated the facility admitted the resident on 6/26/2023, with diagnoses including anxiety disorder (a mental health condition with feeling of worry, anxiety, or fear interfering with one's daily activities), and depression (a mood disorder with feeling of sadness 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.

The licensee failed to ensure the facility was administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. As a result, for all residents in the facility there was an increased risk that their needs were not met while residing in an unsafe environment. Cross Reference: F838, F758, F725 Findings: A review of the facility's Daily Census Report dated 9/26/2023 indicated a total of 70 residents in-house. a. During a record review on 9/28/2023 at 2:17 PM, the Facility Assessment was reviewed. The Facility Assessment was last reviewed in August 2022 and the assessment was completed for resident census of 76-82. The facility had a census lower than 76 on 9/28/2023, and the change in census (currently 70) was not reflected on the current Facility Assessment. During an interview on 9/28/2023 at 2:24 PM, the facility Administrator (ADM) stated the Facility Assessment was not reviewed or updated annually. The last time it was updated was August 2022. 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 This is a Repeat Deficiency from a previous investigation dated 9/14/2023. Based on observation, interview, and record review, the facility failed to follow its policy and procedure titled, Answering the Call Light, for two of six sampled residents (Residents 2 and 4). Resident 2 and Resident 4 did not have the call light within reach. This deficient practice had the potential to result in a delay in care and services and the resident's inability to ask for assistance. Findings: a. A review of Resident 2's admission Record indicated the facility originally admitted Resident 2 on 9/27/2022, and readmitted on [DATE], with diagnoses including quadriplegia (loss of ability to move below the neck that affects all of a person's limb), and tracheostomy (a procedure to help air and oxygen reach at lungs by creating an opening from outside the neck). A review of the History and Physical dated 4/5/2023, indicated Resident 2 had the capacity to understand and make decisions. A review of Resident 2's Quarterly Minimum Data…

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

Based on observation and interview, the facility failed to ensure residents were provided a homelike environment for one of six sampled residents (Resident 6). Resident 6's mattress was unclean and in poor condition. This deficient practice had the potential to spread infection and negatively impact the resident's quality of life, as Resident 6 was frustrated because the mattress smelled like urine. Findings: A review of Resident 6's admission Record indicated the facility admitted Resident 6 on 6/28/2023, with diagnoses including obesity, and muscle weakness. A review of the History and Physical dated 6/30/2023, indicated Resident 6 had the capacity for medical decision making. A review of Resident 6's Quarterly Minimum Data Set (MDS - a standardized assessment and care screening tool) dated 7/5/2023, indicated the resident had intact cognition (decisions consistent/reasonable) and required extensive assistance with one-person physical assistant for bed mobility, transfer, dressing, personal hygiene, and toilet use. During an observation on 9/27/2023 at 2:30 PM, Resident 6's…

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

Based on observation, interview, and record review, the facility failed to ensure the posted staffing information was accurate and current. As a result, the total number of staff directly responsible for resident care for that day was not made available to residents and visitors. Findings: During an observation on 9/27/2023 at 9 AM, the staffing information posted at the nurses station was not updated. The staffing information was for 9/13/2023 and did not indicate the current resident census or the total number of licensed and un-licensed staff working during the posted shift. During an interview on 9/27/2023 at 9:10 AM, the Administrator (ADM) stated that the current staffing information posted at the nurses station applied to 9/13/2023 and was not updated today. The ADM stated the facility was required to post the actual number of staff responsible for providing direct care to residents on a daily basis at the beginning of each shift. The ADM stated the potential outcome of not posting accurate and updated staffing information was that residents and their visitors would not have…

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

Based on interview and record review, the facility failed to update the facility-wide assessment annually to reflect the current census and their staffing plan to meet the resident care needs. This deficient practice may result in the facility failing to identify specific factors that would require a change to the assessment and had the potential to affect the resident care and decline in quality of care. Cross Reference: F725 and F835 Findings: During a record review on 9/28/2023 at 2:17 PM, the Facility Assessment was reviewed. The Facility Assessment was last reviewed in August 2022 and the assessment was completed for resident census of 76-82. The facility had a census lower than 76 on 9/28/2023, and the change in census (currently 70) was not reflected on the current Facility Assessment. During an interview on 9/28/2023 at 2:24 PM, the facility Administrator (ADM) stated the Facility Assessment was not reviewed or updated annually. The last time it was updated was August 2022. The ADM stated the facility was required to review and update the assessment, as necessary, and at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow the policy and procedure titled, Answering the Call Light, for one of four sampled residents (Resident 1). Resident 1, who was at risk for pressure ulcer, was totally dependent on staff for bed mobility, and was always incontinent of stool, waited over 30 minutes to be changed after being soiled. This deficient practice caused an increased risk in Resident 1's dignity and the potential to develop worsening skin conditions. Findings: A review of Resident 1's admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses including chronic respiratory failure (a condition that occurs when the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body), tracheostomy (a procedure to help air and oxygen reach the lungs by creating an opening into the windpipe from outside the neck), gastrostomy (an opening into the stomach from the abdominal wall made surgically for 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 develop and initiate a care plan for moisture associated dermatitis (MASD - inflammation of the skin caused by prolonged exposure to various sources of moisture, including urine or stool, perspiration, wound exudate, mucus, saliva, and their contents) for one of four sampled residents (Resident 1). This deficient practice had the potential to cause Resident 1 further skin breakdown and harm. Findings: A review of Resident 1's admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses including tracheostomy (a procedure to help air and oxygen reach the lungs by creating an opening into the windpipe from outside the neck), gastrostomy (an opening into the stomach from the abdominal wall made surgically for the introduction of food) , hypertension (high blood pressure), dysphagia (difficulty swallowing), and quadriplegia (a form of paralysis that affects all four limbs). A review of Resident 1's Minimum Data Set (MDS -…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 an additional Respiratory Therapist (RT) at night in accordance with their facility assessment and Respiratory Therapist Schedule for one of four sampled residents (Resident 2). For Resident 2, who had chronic respiratory failure (a condition that occurs when the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body), there was one RT at night which caused an increased risk of not being suctioned timely or dressing remained soiled. This deficient practice had the potential to result in a delay in care and respiratory services for Resident 2 and other residents. Findings: A review of the facility's Facility assessment dated [DATE], indicated a staffing plan for respiratory care services staff to include one respiratory lead and other staff per staffing Per Patient Day (PPD - based on an average acuity level of residents. This level decides the amount of nursing hours allotted per day in the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to dispose of expired nursing supplies, as evidenced by: -77 expired latex foley catheters (flexible tube that passes through the urethra and into the bladder to drain urine) observed in the medication room by the south nurse ' s station. -20 expired leg bags (a bag that holds urine that drains from the foley catheter) observed in the medication room by the south nurse ' s station -35 expired hypodermic 25-gauge safety needles (needles used to provide injections under the skin) found in the medication room by the north nurse ' s station. This deficient practice had the potential to lead to infection, adverse reaction (an unexpected or unintended effect), and harm to residents. Findings: During an observation on [DATE] at 10:29 AM, with Registered Nurse (RN) 1, 77 latex foley catheters with various expiration dates of 3/2020, 7/2020, 3/2021, [DATE], [DATE], and [DATE]; and 20 leg bags with an expiration date of [DATE] were observed in 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 follow infection control practices as evidenced by: -Licensed Vocational Nurse (LVN) 1 and Respiratory Therapist (RT) 1 were observed wearing their N95 respirator mask (a respiratory protective device designed to achieve a very close facial fit and very efficient filtration of airborne particles) below their chin exposing their nose and mouth. -Housekeeper (HK) 1 was not N95 respirator mask fit tested (test protocol conducted to verify that a respirator is both comfortable and provides the wearer with expected protection). -HK 1 and Certified Nursing Assistant (CNA) 2 were observed not wearing full personal protective equipment (PPE) in droplet isolation (precautions that require care providers to use PPE that includes a mask, gown, gloves, and protective eyewear) rooms. -CNA 5 was observed wearing her N95 respirator mask wrapped around her ears, not around her head. These deficient practices had the potential expose residents, staff, and the community to Coronavirus (COVID-19, a virus that spreads from…

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