Grand Park Convalescent Hospital

Based on observation, interview, and record review, the facility failed to develop and implement a resident specific comprehensive care plan (a plan of care that summarizes a resident's health conditions, specific care needs, and current treatments) for two of 27 sampled residents (Resident 10 and Resident 14) reviewed for care plans by failing to: -Ensure to implement and revise Resident 10's smoking care plan to prevent smoking accidents. -Ensure to develop a specific individualized care plan for Resident 14 who had a diagnosis of dementia (a progressive state of decline in mental abilities) and was at a high risk of falling. These failures resulted for Resident 10 to sustain a cigarette burn to her right hand and had the potential for Resident 14 to fall and sustain an injury and/or fracture (broken bones). Findings: a. During a review of Resident 10's admission Record (a single-page summary document containing a resident's personal, medical, and insurance information), the admission Record indicated the facility originally admitted Resident 10 on 6/16/2026 and readmitted…

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

Based on observation, interview, and record review, the facility failed to provide necessary treatment and services to minimize risk of development and worsening of pressure injuries/ulcers (PI/PU-localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device) for one of two sampled residents (Resident 111) reviewed for PI/PU by failing to: -Ensure to have the correct weight setting of a low air loss mattress (LALM-operates using a blower-based pump that was designed to circulate a constant flow of air) when the machine setting did not match Resident 111's weight. This failure had the potential for placing Resident 111 at risk for skin breakdown and PI/PU. Findings:During a review of Resident 111's admission Record, the admission Record indicated the facility admitted Resident 111 on 2/26/2026 and readmitted the resident on 5/5/2026 with diagnoses including pneumonia (lung infection), sepsis (medical emergency when the body overreacts to an infection), hypertension (HTN-high blood pressure), and dementia ((a decline…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 care, assistance, and supervision to ensure an environment free of risks and hazards for three out of six residents (Resident 10, Resident 14, Resident 15) by failing to:1. Provide direct supervision to Resident 10 when smoking in the facility's smoking patio as indicated in the facility's policy and procedure (P&P) titled Smoking Policy & Procedures, last reviewed by the facility on 1/23/2026. 2. Ensure Resident's 14 who was identified as at risk for falls had floor mats (thick, cushioned pads placed on the floor next to a bed to soften the impact if a person falls) placed on both sides of the bed as per physician's orders dated 4/13/2026. 3. Ensure Resident 15 had a smoking safety evaluation (a check to see if a resident can smoke or vape without hurting themselves or others, covering mental clarity, physical coordination, and safety rules) assessed and documented as indicated in the facility's policy and procedure (P&P) titled…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 update and post daily staffing information for three of six sample days (7/18/2026, 7/19/2026, and 7/20/2026).This failure had the potential to cause inadequate staffing and for the residents (in general) needs to go unmet.Findings:During a concurrent observation and interview on 7/20/2026 at 9:02 AM with the Assistant Director of Nursing (ADON) in front of Nursing Station 1, the Direct Care Services Hours Per Patient Hours (DHPPD, the actual hours of work performed per patient day by a direct caregiver) for 7/15/2026, 7/16/2026, and 7/17/2026 were posted on the announcement board. The ADON stated the posted DHPPD needed to be updated daily to reflect any changes with the census and staffing.During an interview on 7/22/2026 at 3:41 PM with the Director of Nursing (DON), the DON stated the Director of Staff Development (DSD) was responsible for posting the projected (beginning of shift) and actual (end of day) DHPPD. The DON stated the DSD was not available for interview due to a family emergency. The DON…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 medications were administered in accordance with physician orders and professional standards of practice for two of eight sampled residents (Residents 100 and Resident 131) reviewed for medication administration by failing to: -Ensure Licensed Vocational Nurse 4 (LVN4) followed Resident 100's physician's order instructions to flush Resident 100'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) with 50 milliliters (mL- a unit of measurement for volume) of water before and after medication administration. -Ensure Resident 131's lidocaine patch (a medication in the form of a patch used to treat inflammation and pain) was removed from application site (right knee) as per physician's orders. -Ensure Resident 131's lidocaine patch was only applied to the right knee and the right thigh in accordance with physician's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to: 1. Ensure medications in one of two medication rooms' refrigerator (Station 1 Medication Room Refrigerator) requiring refrigeration were stored at temperatures between 2 Celsius [( C) is a unit of temperature] (36-degree Fahrenheit [ F] is a unit of temperature] and 8 C (46 F) in accordance with manufacturer specifications and as per facility's policy and procedure (P&P) titled Medication Storage in the Facility - Storage of Medications, dated 01/2025. 2a. Ensure Resident 155's unopened prefilled syringe of Lantus Solostar ([generic name - insulin glargine] a type of insulin [a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication] used to treat high blood sugar) in one of two inspected medication carts (Station 1 Medication Cart 1B) was stored in a refrigerator and/or labeled with an open date.2b. Ensure Resident 54's opened foil pack of budesonide (a medication used to treat…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to: Maintain a safe and functional environment for one of three sampled residents (Resident 1) by monitoring Resident 1's whereabouts in the facility as indicated in Resident 1 comprehensive care plan for elopement (the act of leaving a facility unsupervised without prior authorization) precaution.Properly evaluate one of three sampled residents (Resident 1)'s Elopement Risk Evaluation (ERE - a numerical score used to determine the likelihood of a person, often a patient in a care setting, leaving a facility without authorization or staff knowledge) dated 6/4/2026.Reevaluate Resident 1's ERE after Resident 1 had eloped from the facility on 6/4/2026, 6/22/2026 and 7/15/2026 according to facility's policy and procedures (P&P) titled, Wandering, Unsafe Resident.Revised Resident 1's Care Plan (CP) for elopement after Resident 1 had a change of condition on 6/4/2026 and 6/22/2026.These deficient findings resulted in Resident 1 eloping on 7/15/2026 and missing…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to revise a care plan for at risk of elopement (leaving the facility unsupervised and without staff knowledge) for one of three sampled residents (Resident 1), who left the facility unsupervised and without staff assistance and knowledge on 6/8/2026 and 6/22/2026.This deficient practice had the potential to place Resident 1 at risk for recurrent elopement. During a review of the admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnosis including metabolic encephalopathy (a disease in which the functioning of the brain is affected by some agent or condition-such as viral infection or toxins in the blood), unspecified dementia (a progressive state of decline in mental abilities) and altered mental status (refers to a significant disturbance in a person's perception, thinking, memory, or level of consciousness). During a review of Resident 1's History and Physical (H&P) dated 6/5/2026, the H&P…

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

Based on interview and record review the facility failed to ensure Utility Nurses (licensed or unlicensed nursing support staff) had competency and skills assessment done upon hire and yearly for two of six sampled employees hired as Utility Nurses.This deficient practice had the potential to compromise the residents' safety when the Utility Nurses are not adequately trained.During a concurrent interview and record review on 1/7/26 at 11:19 a.m., the employee file of Utility Nurse 1 and Utility Nurse 2 was reviewed with the Director of Staff Development (DSD). The DSD stated Utility Nurse 1 was hired initially in the dietary department and started working as Utility Nurse on 2/25/25. DSD stated Utility Nurse 2 was initially hired in the dietary department and started working as Utility Nurse on 8/19/25. DSD stated Utility Nurse 1 and Utility Nurse 2 had competency/checklist for the dietary department but there was no checklist/competency for working as Utility Nurse. DSD stated the competency should be done upon hire and yearly to ensure Utility Nurse 1 and Utility Nurse 2 were…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to set the low air loss mattress (LALM - a specialized air mattress designed to prevent bedsores) to the correct settings for two out of two sampled residents (Resident 1 and Resident 36) This deficient practice placed the Resident 1 and Resident 36 at risk of discomfort, slow wound healing, and development of new pressure ulcers (localized damage to the skin and/or underlying tissue usually over a bony prominence related to a medical or other device). Findings: 1. During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was originally admitted on [DATE] and readmitted on [DATE] with diagnoses that included need for assistance with personal care (getting help with daily activities that involve taking care of yourself and your well-being, especially when you find it difficult to do those things on your own), pressure induced deep tissue damage (occurs when sustained pressure on the skin and underlying…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure call lights (a device that alerts healthcare providers that the patient needs assistance) were within residents' reach and easily accessible for two of two sampled residents (Resident 13, Resident 114). This deficient practice had the potential to result in delays in meeting the Resident 13 and Resident 114's needs for assistance, which could lead to accidents including falls. Findings: 1. During a review of Resident 13's admission Record, the admission Record indicated the facility re-admitted the resident on 12/9/2024 with diagnoses that included metabolic encephalopathy (a brain disorder caused by chemical imbalances in the blood), need for assistance with personal care, dementia, psychosis (a severe mental condition in which thought and emotions are so affected that contact is lost with reality), chronic kidney disease (a condition in which the kidneys are damaged and cannot filter blood as well as they should), and a history…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to develop a comprehensive and resident-centered dental care plan for one of one sampled resident (Resident 81). This deficient practice had the potential to result in delay in necessary dental care and services for Resident 81. Findings: During a review of Resident 81's admission Record, the admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses that included, but not limited to encephalopathy (a change in brain function due to injury or disease), compression fracture (when a bone in your spine breaks and collapses) of the ninth to tenth thoracic vertebrae (bones that make up the middle part of your spine), bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), panic disorder (an anxiety disorder that involves multiple unexpected panic attacks), and malnutrition (an imbalance between the nutrients 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 conduct quarterly review and revise a care plan for one of six residents (Resident 107) who was on Remeron (medication to treat treatment of major depressive disorder [MDD-persistent feeloing of sadness, loss of interest in activities, and changes in sleep, appetite, and energy levels). This failure had the potential to cause confusion related to the dosage of Remeron for Resident 107. Findings: During a review of Resident 107's admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses that included MDD, muscle weakness, and need for assistance with personal care. During a review of Resident 107's Care Plan Report dated 6/12/2024, the Care Plan Report indicated the resident uses antidepressant (used to treat depression) related to feelings of hopelessness and worrying about his life status. The Care Plan Report interventions included to administer antidepressants medications (Remeron) as ordered by physicians,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 insulin (a hormone that works by lowering levels of glucose-sugar in the blood) injection sites were rotated when administered (given) to one of four sampled residents (Resident 99). This deficient practice had the potential to result in injection site reactions such as pain, redness, itching, hives (red and sometimes itchy bumps on the skin), swelling, inflammation, lipodystrophy (defect in the breaking down or building up of fat below the surface of the skin, resulting in lumps or small dents in the skin surface which may be caused by repeated injections of insulin in the same spot), lipoatrophy (wasting of fat under the skin which can be unsightly), and lipohypertrophy (buildup of fat under the skin which can slow the absorption of insulin) that may result in ineffective management of the residents' diabetes mellitus (DM - high blood sugar). Findings: During a review of Resident 99's admission Record, the admission Record indicated…

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

Based on observation, interview, and record review, the facility failed to complete the smoking risk assessment (smoking safety evaluation, an assessment that helps determine a resident's ability to smoke safely, whether independently or with supervision, and to identify potential fire hazards) for one of eight sampled residents (Resident 133). This failure had the potential to affect Resident 133's safety, causing a smoking related injury and fire hazard in the facility. Findings: During a review of Resident 133's admission Record, the admission Record indicated the facility admitted the resident on 4/28/2025 with diagnoses that included encephalopathy (a condition that causes dysfunction to the brain, affecting its structure or function), type 2 diabetes (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing), need for assistance with personal care, hypertension (high blood pressure), 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). During a review of Resident…

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

Based on observation, interview, and record review, the facility failed to ensure one (1) of four (4) medication carts was locked and secured when it was unattended in the hallway. This deficient practice had the potential for unauthorized access to medications, drug diversion, and/or drug pilferage. Findings: During an observation on 7/1/2025 at 8:25 AM, the licensed vocational nurse (LVN 2) was at the doorway of Resident 96's room preparing medication for administration. During an observation on 7/1/2025 at 8:30 AM, LVN 2 walked into Resident 96's room and left the medication cart unlocked in the hallway. During an observation and concurrent interview on 7/1/2025 at 8:34 AM, LVN 2 exited Resident 96's room and acknowledged that she did not lock the medication cart. During a review of the facility's Policy and Procedures (P&P), Storage of Medication (dated 3/1/2025), the P&P indicated that . Compartments . containing drugs and biologicals are locked when not in use. Unlocked medication carts are not left unattended .

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to ensure: 1.The nursing staff (Licensed Vocational Nurse 3 [LVN 3] and Licensed Vocational Nurse 4 [LVN 4]) followed its enhanced barriers precautions (EBP, an infection prevention protocol to reduce the spread of certain drug-resistant bacteria, particularly in nursing homes) policy during the medication administration observation for two (2) of six sampled residents (Resident 36 and 23). 2. One of six residents (Resident 119) was provided with a proper identifier for enhanced barrier precautions. These deficient practices had potential to cause cross contamination, spreading the infection among residents, visitors and staff. Findings: 1. During a medication administration (med pass) observation on 7/01/2025 at 9:01 AM, on the wall behind Resident 36's bed, there was a sign indicating enhanced barrier precautions. LVN 3 was observed performing hand hygiene prior to proceeding to measure Resident 36's blood pressure and heart rate 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 interview and record review, the facility failed to ensure resident records were complete and accurate in accordance with accepted professional standard and practice for one of three sampled residents (Resident 1). For Resident 1, the facility failed to ensure Resident 1's discharge plan was reflected in Resident 1 ' s medical record. This deficient practice resulted in incomplete and inaccurate record for Resident 1 ' s discharge plan and goals. Findings: During a review of the admission Record indicated Resident 1 was admitted on [DATE] and was re-admitted on [DATE] with diagnoses including osteoarthritis (progressive disorder of the joints, caused by a gradual loss of cartilage) and abnormities of gait and mobility. During a review of the Minimum Data Set (MDS, a federally mandated resident assessment tool) dated 9/15/24 indicated Resident 1 was cognitively intact. Resident 1 moderate assistance (helper does less than half the effort) with toileting hygiene, shower/bathe self, lower body dressing,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, and record reviews the facility failed to implement its abuse policy and procedures when the facility failed to report to the Survey State Agency (SSA) an injury of unknown origin with 24 hours for one of three sampled residents (Resident 1). On 8/16/2024 at 12:22 pm, Resident 1 was found on the floor with discoloration to the left of his face and a 0.5-centimeter (cm-unit of measurement) scratch to the right side of the nose. On 8/20/2024, the hemodialysis (a medical procedure to remove fluid and waste products from the blood) center reported to Resident 1's physician that the resident had bruising and swelling to the left side of the face. The physician ordered for Resident to be transferred to a General Acute Care Hospital (GACH) for further evaluation and management. The facility never reported Resident's 1 injuries to the SSA. This deficient practice resulted in delayed investigation of Resident 1's injuries by the SSA. Findings: A review of Resident 1 ' s admission Record indicated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to maintain an infection prevention and control program designed to help prevent the development and transmission of Coronavirus – 19 (COVID-19, COVID, a virus that causes respiratory illness that can spread from person to person) as evidenced by: 1. Failing to ensure that two of the four sampled residents (Residents 1 and 3) were wearing a mask while interacting with other residents in the hallway and at the nurses station. 2. Failing to ensure that Registered Nurse (RN) 1 were wearing N95 respirators (is a respiratory protective device designed to achieve a very close facial fit and very efficient filtration of airborne particles) they were fit tested for (RN 1). These deficient practices had the potential to place both residents and staff at a risk for infection to COVID-19. Findings: 1. A review of Resident 1 ' s admission record indicated the resident was initially admitted to the facility on [DATE] and readmitted on [DATE] with…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 policies and procedures for ensuring the reporting of a reasonable suspicion of an abuse in accordance with state and federal law for one of one sampled resident (Resident 1). This resulted in a delay of an onsite inspection by the State Agency (SA) to ensure the safety of the residents and had the potential to result in unidentified abuse in the facility as well as failure to protect residents from any possible abuse. Findings: During a review of Resident 1 ' s admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and was re-admitted on [DATE] with diagnoses including chronic respiratory failure (condition in which your blood does not get enough oxygen or has too much carbon dioxide), congestive heart failure (CHF-a chronic condition in which the heart does not pump blood as well as it should) and dysphagia (difficulty swallowing food or liquid). During a review of Resident 1 ' s Minimum Data Set (MDS - a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to address the resident's pain level before, during, and after Restorative Nursing Assistant application (RNA - a Certified Nursing Assistant [CNA] who helped patient's regain physical and cognitive ability after an injury or illness) for three of four sampled residents (Resident 52, Resident 92, and Resident 129). This deficient practice had the potential for residents to experience pain when not properly assessed. Findings: a. A review of Resident 52's admission Record indicated the facility initially admitted the resident on 10/31/2018 and re-admitted the resident on 4/27/2024, with diagnoses including polyarthritis (a condition that causes inflammation, pain, and stiffness in five or more joints at the same time), neuralgia (severe, sharp, and often shock-like pain that follows the path of a nerve) and need for assistance with personal care. A review of the Physician's Order dated 7/13/2023, indicated for Resident 52 to receive RNA 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.

Based on observation, interview, and record review, the facility failed to store food in accordance with professional standards for food service safety by not labeling: -one plastic container of Aji- Mirin Sweet Cooking [NAME] seasoning with open and use by dates. -one plastic bag of carrots with open and use by dates. -one plastic bag of ginger with open and use by dates. -one plastic bag of Dried [NAME] with open and use by dates. -one plastic container of Salted Shrimp with no open and used by dates. In addition, the facility failed to discard several items by the use by date. These deficient practices had the potential to cause food-borne illnesses. Findings: During a concurrent observation and interview on 6/17/2024 at 8:03 A.M., the Dietary Assistant (DA) observed one plastic container of Aji-Mirin Sweet Cooking [NAME] seasoning, one bag of carrots, one plastic container of Salted Shrimp, one plastic bag of ginger, and one plastic bag of Dried [NAME] with no open or use by dates. There was one bottle of [NAME] vinegar with an open date of 2/7/2024 and a use by date of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide care in a manner that maintained or enhanced residents' dignity and respect for two of 12 sampled residents (Resident 87 and 93), by standing over the residents while assisting them during a meal. These deficient practices had the potential to affect residents' sense of self-worth, self-esteem, and psychosocial wellbeing. Findings: a. A review of Resident 87's admission Record (Face Sheet) indicated the facility admitted the resident on 8/6/2020, and readmitted on [DATE], with diagnoses including Alzheimer's disease (a brain disorders the slowly destroys memory and thinking skills and eventually, the ability to carry out the simplest tasks), bipolar disorder (a serious mental illness that causes unusual shifts in mood, ranging from extreme high manic episodes to low depression episodes), and essential hypertension (a condition in which the blood vessels have persistently raised pressure). A review of Resident 87's History and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a copy of the resident's advance directive (a written instruction, recognized under State law, relating to the provision of health care when the individual is unable to make decisions for themselves) was in the resident's medical chart and the Advance Directive Acknowledgement form was completed thoroughly for two of seven sampled residents (Residents 92 and Resident 140). These deficient practices had the potential for the facility to not honor the residents' medical decisions regarding end-of-life treatment. Findings: A review of Resident 92's admission Record (Face Sheet) indicated the facility admitted the resident on 2/2/2024, with diagnoses including abnormalities in gait and mobility (a change to your walking pattern), osteoarthritis (a degenerative joint disease, in which the tissues in the joint break down over time), and fibromyalgia (a disorder characterized by widespread musculoskeletal pain accompanied by fatigue, sleep, memory, and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to report the following incidents to the State Survey Agency (SSA, the Bureau of Health Facility Licensing) within the appropriate timeframe for two of six sampled residents (Resident 13 and Resident 195) as evidenced by: -For Resident 13, the facility failed to report an injury of unknown origin (an injury that the source was not observed by any person or could not be explained by the resident). -For Resident 195, the facility failed to report a fall with injury. These deficient practices resulted in a delay of an onsite inspection by the California Department of Public Health (CDPH) to ensure Resident 13's injury of unknown origin and Resident 195's fall with injury were investigated. Findings: a. A review of Resident 13's admission Record (face sheet) indicated the facility readmitted on [DATE], with diagnoses including dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life),…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 comprehensive care plan for hospice (a specialized type of care that provides physical comfort and emotional, social, and spiritual support for people nearing the end of life) one of six sampled residents (Resident 123). This deficient practice had the potential for Resident 123 to not be provided with necessary and personalized care. Findings: A review of Resident 123's admission Record indicated the facility readmitted the resident on 5/31/2024 with diagnoses that included malignant neoplasm of the stomach (cancer [a disease in which abnormal cells divide uncontrollably and destroy body tissue] of the stomach), encounter for palliative care (specialized medical care for people living with a serious illness, such as cancer or heart failure [occurs when the heart muscle doesn't pump blood as well as it should]), severe protein-calorie malnutrition (a nutritional status in which reduced availability of nutrients leads to changes in body composition and function), and sepsis (a serious condition in which the body…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure safety measures were assessed and implemented for one of six sampled residents (Resident 134) by failing to initiate a smoking risk assessment when the facility was aware the resident was a smoker. This deficient practice had the potential for Resident 134 to be at risk for injury or burns without a proper assessment. Findings: A review of Resident 134's admission Record indicated the facility admitted the resident on 5/16/2024, with diagnoses including abnormalities of gait and mobility (a change to your walking pattern), hypertension (high blood pressure) and diabetes mellitus (chronic metabolic disease that occurs when the body did not produce enough insulin or cannot use insulin properly). A review of Resident 134's admission Nursing Risks assessment dated [DATE], indicated the resident did not smoke, which did not prompt the document to allow safety measures to be reviewed and implemented. A review of Resident 134's History…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents were provided care and nutrition consistent with their weight loss assessment and the Registered Dietitian's (RD) recommendations for one of four sampled residents (Residents 133). This deficient practice had the potential to result in the resident's weight loss. Findings: A review of Resident 133's admission Record indicated the facility admitted the resident on 2/7/2024 and readmitted him on 4/7/2024 with diagnoses including end stage of renal disease (final, permanent stage of chronic kidney disease, where kidney function declined to the point that the kidneys can no longer function on their own), dependence on renal dialysis (a procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly) and depression (an illness characterized by persistent sadness and a loss of interest in activities, accompanied by an inability to carry out daily activities). A review of Resident 133'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 a new tube feeding (a way to provide nutrition when you cannot eat or drink safely by mouth, delivered through a gastric tube [G-tube, a tube inserted through the abdomen that delivers nutrition directly to the stomach]) set was used when starting a new tube feeding bottle for one of six sampled residents (Resident 124). This deficient practice had the potential for Resident 124 to experience infection control issues and experience tube feeding intolerance symptoms such as nausea, vomiting, and abdominal discomfort. Findings: A review of Resident 124's admission Record indicated the facility admitted the resident on 1/17/2024 with diagnoses that included Parkinson's Disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination), aftercare following surgery on the digestive system, gastrostomy (G-Tube, a tube inserted through the abdomen that delivers nutrition directly to the stomach), dysphagia (difficulty…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide sufficient staffing to accommodate resident needs for two of two sampled residents (Resident 28 and 99). This deficient practice had the potential for the residents to not receive timely and efficient care and needed services. Findings: a. A review of the Certified Nursing Assistant's (CNA) Assignments for 5/19/2024, indicated that on 5/19/2024, eight CNAs were working during the 11 PM-7 AM shift attending 147 residents. On 5/19/2024, one CNA was no call, no show and was not replaced. Her assignment was split between eight working CNAs during the 11 PM-7 AM shift, each CNA was assigned to 17-19 residents. A review of Resident 99's admission Record indicated the facility re-admitted the resident on 1/31/2024 with diagnoses that included need for assistance with personal care, severe morbid obesity (a disorder that involves having too much body fat, which increases the risk of health problems), hypertension (high blood pressure), and chronic…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 include verbiage in the Arbitration Agreement (a contractual agreement to settle disputes out of court using a neutral third party called an arbitrator) that allowed residents the freedom to choose a venue to meet. This deficient practice had the potential for residents who have entered into a binding arbitration agreement to have a say in a convenient meeting place for both parties. Findings: A review of the facility's undated Arbitration Agreement form, indicated there were no residents who entered into a binding arbitration agreement for selection of a venue of choice that was convenient. During an interview on 6/20/2024 at 11:10 AM, the Admissions Coordinator (AC) stated the form did not indicate where the residents would meet. The AC stated having that verbiage would be a good thing to add so the residents who have entered into a binding arbitration agreement would have a say in where the meeting spot would be. During an interview on 6/20/2024 at 11:57 AM, the Business Office Manager (BOM) stated the form did not…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 re-admit one of one sampled resident (Resident 1). Resident 1 who was ready to be discharged from the general acute hospital (GACH 2) on 1/19/24, the facility refused to re-admit Resident 1. This deficient practice resulted in Resident 1 not given his right to return to the facility. Findings: During a review of the admission Record indicated the facility admitted Resident 1 on 9/22/23 with diagnoses including morbid obesity (more than 80 to 100 pounds [lbs., unit of measurement] of their ideal body weight) and chronic obstructive respiratory disease (COPD, group of diseases that cause airflow blockage and breathing related problems). During a review of the Minimum Data Set (MDS, standardized care and screening tool) dated 9/25/23, indicated Resident 1 was cognitively intact (mental process involved in knowing, learning, and understanding). Resident 1 needed two-person physical assistance with eating, personal hygiene and three-person physical assistance with bed mobility, dressing, toilet use and bathing. During a review…

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