Hollywood Presbyterian Medical Center D/P SNF

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a resident, who was receiving feeding through a gastrostomy tube ([GT] a soft tube surgically placed into the stomach to provide nutrition and medications), did not have a significant weight loss (a weight loss greater than five percent (%) in one month, or greater than 7.5% in three months, and greater than 10% in six months) for one of 3 sampled residents (Resident #12). The facility failed to ensure: 1. The licensed nurses initiated a change of condition (COC- internal document) assessment and monitored Resident 12 for weekly weights, and signs and symptoms of malnutrition (condition that develops when the body is deprived of vitamins, minerals and other nutrients it needs to maintain healthy tissues and organ function), and dehydration (a dangerous loss of body fluid caused by illness, sweating, or inadequate intake) to address the nutritional need of Resident 12 on 11/19/2025.2. The licensed nurses notified Resident 12's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of eighteen sampled residents (Resident60): Failed to ensure Resident 60 were assessed for risk of entrapment from bed rails prior to installation was completed. Failed to review the risk and benefits of bed rails with the resident representative and obtain consent prior to installation. These failures had the potential to result in compromised resident safety associated with unassed bed rail use.Findings: During a record review of Resident 60's admission record indicated Resident 60 was admitted on [DATE] with a diagnoses of chronic respiratory failure (condition in which your blood does not get enough oxygen or has too much carbon dioxide), basal cell carcinoma of the skin (a type of skin cancer that most often develops on areas of skin exposed to the sun), chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), and Alzheimer's disease (a disease characterized by a progressive…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 interviews and record reviews, the facility failed to ensure adequate oversight of the Food and Nutrition Services by qualified personnel, by failing to: 1. Ensure the Director of Food Services met the state and federal requirements for the position and did not have other leadership responsibilities outside of the Dietetics Services department. The Dietary Manager (DM) did not receive at least six hours of in-service training on the specific California dietary service requirements contained in CCR title 22 (health and safety code 1265.4). 2. Ensure the hours dedicated to the oversight of the Food and Nutrition Services by the Director of Food Services were adequate for the scope and complexity of the food service operation. The DM was the Director of Food Services and was also overseeing patient transport, environmental services and overhead operations. These deficient practices had the potential to compromise the safety and nutritional status of residents via cross contamination (transfer of germs and/or bacteria from one surface to another), and decreased meal…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 that one of eighteen sampled residents (Resident 71) had access to a functional call light. This deficient practice had the potential to result in negative impact on Resident 71 safety.Findings:During a review of admission record , the admission Record indicated that Resident 71 was admitted initially on the facility on 08/03/2024 with diagnoses including chronic respiratory failure (condition in which your blood does not get enough oxygen or has too much carbon dioxide) with tracheostomy (a surgical opening through your neck and into your windpipe to establish a direct airway for breathing), on ventilator (a medical device to help support or replace breathing), diabetes (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), cerebral ischemic stroke (loss of blood flow to a part of the brain), muscle weakness and gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 record review, observation and interview, the facility failed to ensure 1 of 3 sampled residents (Resident 1), when Resident 1 did not have access to an appropriate call light (remote with button used to call staff for help) system in accordance with the facility's policy and procedure titled Call Light System.This deficient practice had the potential for Resident 1's self-esteem, emotions, and physical care to be affected. Findings:During a review or Resident 1's History and Physical (H&P), dated 6/16/2025, the H&P indicated Resident 1's medical history included quadriplegia (paralysis [no movement] from the neck down, affecting all four limbs) and chronic respiratory failure (long term condition in which not enough oxygen passes from the lungs into the blood) with tracheostomy (an artificial opening through the neck usually for the relief of difficulty in breathing) on a ventilator (a medical device to help support or replace breathing).During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 6/23/2025, 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 observation, interview, and record review, the facility failed to ensure two of three sampled residents (Resident 1 and 2) received the appropriate services to prevent a decline in range of motion (ROM, full movement potential of a joint) and mobility by failing to: -Ensure Resident 1 received hand rolls (devices used to assist with finger extension [the act of straightening a finger at its joints] and prevent finger flexion contractures [a condition where one or more fingers become permanently bent in a flexed position]) in both her hands as ordered by the physician. -Ensure Resident 2 received a hand roll in her right hand as ordered by the physician. These deficient practices had the potential for Resident 1 and Resident 2 to develop worsened contractures and injury. Findings: During a review of Resident 1's admission Record, the admission Record indicated the facility re-admitted the resident on 1/20/2025 with diagnoses that included chronic respiratory failure (a condition in which the lungs are…

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

Based on observation, interview, and record review, the facility failed to ensure that proper personal protective equipment (PPE) was supplied and utilized by staff when showering a patient (Patient 1). This deficient practice regarding infection control protocols increases the risk of cross-contamination. Without proper PPE, staff and patients may be exposed to blood, bodily fluids, or other potentially infectious materials, increasing the likelihood of transmitting infections. This poses a potential threat to the safety and health of both patients and staff. Findings: During a review of Patient 1's History and Physical (H&P), dated , the H&P indicated, Patient 1 past medical history and present illness include neuromuscular disease (a wide-range of diseases affecting the peripheral nervous system, which consists of all the motor and sensory nerves that connect the brain and spinal cord to the rest of the body), functional quadriplegia (the complete inability to move due to severe disability or frailty), wheelchair limited since eight years old, severe scoliosis (abnormal lateral…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 safety of fourteen of fourteen sampled Patients (Patient 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, and 14) was compromised when the facility failed to utilize an appropriate shower gurney designed specifically with safety features for use in a wet environment. This deficient practice placed Patient 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, and 14 in an unsafe situation, creating a risk of falling off the gurney, as standard gurneys may lack the necessary safety features to secure a patient during showering. Regular gurneys are not engineered to provide the requisite support for patients in wet conditions. If the gurney becomes slippery due to water exposure, it may not offer adequate stability to keep the patient securely in place. Findings: During a review of Patient 1's History and Physical (H&P), dated , the H&P indicated, Patient 1 past medical history and present illness include neuromuscular disease (a wide-range of diseases affecting the peripheral nervous system, which consists of all 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 administration services as the facility's administrator did not have an administrator's license and failing to ensure the facility had a designated administrator. The deficient practice had the potential for the facility resident's to not have their concerns and needs addressed in a timely manner. Cross Reference F725 Findings: A review of the Administrator's Job Description dated 3/20/2023, indicated she held the title of Chief Nursing Officer (CNO). The Job Description indicated the CNO coordinated and directed the operations of the Nursing Departments, ensured quality patient care was given across the continuum with appropriate level of care, and was actively involved, at the executive level, in the leadership of the organization. The CNO organized and administered areas of Patient Care services to attain the hospital's objectives established by the Governing Body, identified and articulates the vision and strategic direction for the discipline of Nursing and collaborates on the implementation 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 ensure its residents with or without limited range of motion (ROM - movement of the joints) received appropriate treatment and services to increase, prevent, or maintain the ROM mobility for two of three sampled residents (Resident 6 and 72). -The facility failed to provide Resident 6 with Restorative Nursing Aide program (RNA, nursing aide program that help residents to maintain their function and joint mobility) treatments for passive range of motion (PROM, movement at a given joint with full assistance from another person) exercises on both lower extremities (BLE, hip, knee, ankle, feet) five times a week, both upper extremities (BUE, shoulder, elbow, wrist and hand) five times a week, and bilateral knee and elbow splints five times a week for three to four hours as ordered by the physician. -The facility failed to provide Resident 72 with RNA treatment for PROM on BUE and BLE five times a week, bilateral elbow splints five times a week for three to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide adequate and sufficient nursing staff to ensure Restorative Nursing Aide program (RNA, nursing aide program that help residents to maintain their function and joint mobility) treatments and services were completed for two of two sampled residents (Residents 6 and 72) as indicated on the physician's order. This deficient practice had the potential to decrease the residents' range of motion and mobility, which could affect the residents' overall function. Cross Reference to F688 Findings: a. A review of Resident 6's admission Record indicated the resident was originally admitted to the facility on [DATE] with diagnoses including anoxic brain injury damage (occurs when the brain is completely deprived of oxygen, which results in brain cell death) and dependent on ventilator (when a patient cannot breathe independently and requires a mechanical ventilator [machine that helps people breathe]). A review of Resident 6's physician's order 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 observations, interview, and record review, the facility failed to ensure the medication error rate would not be five (5) percent or greater. The facility had three errors out of 25 opportunities for the wrong time, which produced an error rate of 12%. This deficient practice had the potential of increased risks for adverse effect and / or worsening of resident's health condition. Findings: During an observation on 12/10/2024 at 10:34 AM, a licensed vocational nurse (LVN) 2 was pouring medications in preparation of a medication administration for Resident 59. At 10:57 AM, there were 14 medications poured in medicine cups on top of the medication cart. Eleven (11) of the 14 medications were in tablet forms and LVN 2 started crushing those medications individually and added 10 milliliters of water to each medicine cup to dissolve the crushed medication powder. At 11 AM, LVN 2 checked the placement of Resident 59's gastrostomy tube (aka G-tube, a tube inserted through the belly that brings nutrition and medication directly to the stomach) and proceeded to start medication…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, interview, and record review, the facility failed to prevent three (3) significant wrong time errors for 1 of 2 residents (Resident 59) observed during medication administration observations. This deficient practice had the potential of adverse effects on resident's health condition. Findings: (Refer to F-755) A review Resident 59's admission record indicated the admission date was on 10/13/2023 with diagnoses included chronic respiratory (breathing) failure with hypoxia (lack of oxygen), acute embolism (obstruction or blockage in a blood vessel) and of deep veins thrombosis (DVT, blood clots blocking veins or arteries) of left upper extremity, hypertension (high blood pressure), and atherosclerotic heart disease (a condition that occurs when plaque builds up in the walls of arteries which can lead to serious health problems). During an observation on 12/10/2024 at 11:25 AM, a licensed vocational nurse (LVN 2) completed the administration of Resident 59's 14 medications. During an interview on 12/10/2024 at 1:29 PM, the Director of Nursing (DON) stated 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 the call light device was within reach and answered in a timely manner for one of four sampled residents (Resident 65). These deficient practices had the potential to result in Resident 65 not being able to have their needs met leading to potential resident harm or injury. Findings: A review of Resident 65's admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses including chronic respiratory failure (a serious condition that occurs when the lungs have difficulty getting enough oxygen into the blood), poly neuropathy (a disease that affects the peripheral nerves, causing weakness, numbness, and pain in similar areas on both sides of the body), acute embolism (a life-threatening condition that occurs when a blood clot or other foreign object blocks a pulmonary artery), gastrostomy (G-Tube, a tube inserted through the abdomen that delivers nutrition directly to the stomach), neuromuscular…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 complete and submit the Minimum Data Set (MDS, a federally mandated resident assessment tool) upon discharge for one of 17 sampled residents (Resident 62). This deficient practice had the potential to negatively affect the provision of necessary care and services for Resident 62. Findings: A review of Resident 62's admission Record indicated the facility admitted the resident on 3/21/2024 with diagnoses including chronic respiratory failure (a serious condition that occurs when the lungs have difficulty getting enough oxygen into the blood), cachexia (a general state of ill health involving great weight loss and muscle loss), tracheostomy (an opening created at the front of the neck so a tube can be inserted into the windpipe to help you breathe), gastrostomy (g-tube - an opening to the stomach from the abdominal wall made surgically for the introduction of food), dependence on respirator (dependence on a respirator (a serious medical condition that…

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

Based on observation, interview, and record review, the facility failed to maintain the correct Low Air Loss Mattress (LALM, a mattress designed to distribute the patient's body weight over a broad surface area and help prevent skin breakdown) settings for one of three sampled residents (Resident 10). This deficient practice had the potential to lead to poor circulation (reduced blood flow to various body parts) and cause a pressure injury (also known as pressure ulcer, localized skin and soft tissue injuries that form because of prolonged pressure and shear, usually exerted over bony prominences) for Resident 10. Findings: A review of Resident 10's admission Record indicated the facility admitted the resident on 7/24/2024 with diagnoses that included anoxic brain damage (an injury to the brain caused by a lack of oxygen to the brain), neuromuscular dysfunction (a condition that affects the muscles, nerves, or the communication between them causing muscle weakness), epilepsy (a brain disorder that causes people to have recurring seizures, abnormal electrical brain 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 ensure residents environment remained free of accident hazards for two of two sampled residents (Resident 1 and 66). Resident 1 and 66, who had diagnosis of epilepsy (a chronic brain disorder that causes seizures, which are abnormal electrical activity in the brain) did not have padded side rails. This deficient practice may result in injuries during a seizure (a disorder in which nerve cell activity in the brain is disturbed, causing seizures/convulsions) if bed side rail remained unpadded. Findings: a. A review of Resident 1's admission Record indicated the resident was originally admitted to the facility on [DATE] with diagnoses including epilepsy and anoxic brain damage (occurs when the brain is completely deprived of oxygen, which results in brain cell death). A review of Resident 1's physician's order dated 4/1/2024 indicated padded side rails x 2 for seizure precaution every shift. 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 ensure two of two sampled residents (Resident 44 and 46), who are fed by enteral means, received appropriate treatment and services. -For Resident 44 who was receiving nutrition by gastrostomy tube (GT - a flexible tube surgically inserted through the abdomen into the stomach for feeding, fluid, and medication administration), the resident's head of the bed was not elevated more than 30 degrees while the tube feeding was on. -For Resident 46, the gastrostomy tube dressing was not dated. This deficient practice placed Resident 44 at risk for aspiration (inhaling small particles of food or drops of liquid into the lungs) that can lead to lung problems such as pneumonia; and had the potential to cause infection to Resident 46. Findings: A review of Resident 44's admission Record indicated the resident was originally admitted to the facility on [DATE] with diagnoses including gastrostomy (surgical procedure that creates an opening 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 interview and record review, the facility failed to complete an annual Sub Acute Registered Nurse (SARN, a health professional who provides care and treatment for chronically hospitalized patients in their home or skilled nursing facility [a place that provides short or long-term medical and rehabilitation care for people who need more care than they can get at home]) competency assessment (an ongoing process of initial development, maintenance of knowledge and skills) for one of six sampled staff members (Registered Nurse [RN] 2). This deficient practice had the potential to affect the quality-of-care facility residents receive causing potential resident harm. Findings: During a concurrent interview and record review on 12/12/2024 at 11:14 AM, RN 2's employee file was reviewed with Human Resources (HR) 1. HR 1 stated RN 2 had their last SARN competency assessment on 3/21/2023. HR 1 stated RN 2 did not have a SARN competency assessment on file for 2024. During a concurrent interview and record review on…

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

Based on interview and record review, the facility failed to ensure that their policy on drug disposition (process of returning or destroying unused medications) designated the person responsible for performing the dispositions and the person serving as the witness. The facility's policy also indicated the facility should be in compliance with state and federal laws, however, the policy did not refer to the correct regulation. Findings: During an interview on 12/10/2024 at 3:13 PM, Registered Nurse (RN) 1 stated a nurse performs the disposition of discontinued medications that did not belong to the class of controlled substances (medications that the use and possession of are controlled by the federal government). RN 1 stated the process did not require a witness. A review of the facility's policy and procedures titled, Discontinued Medications in the Chalet (last revised 8/2019) indicated discontinued medications are disposed or destroyed in compliance with state and federal laws. This policy did not indicate the process and the person responsible for performing the drug…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 clarify the physician's orders for Creon (a prescription medicine used to treat people who cannot digest food normally because their pancreas does not make enough enzymes) as recommended by the facility's pharmacy consultant during the monthly medication regimen review for one of two sampled residents (Resident 45), who was taking the medication for pancreatic insufficiency (a condition that occurs when the pancreas can't produce enough digestive enzymes to break down food, causing symptoms of abdominal discomfort). This deficient practice had the potential to place Resident 10 at increased risk of experiencing symptoms such as diarrhea, pain in the abdomen, bloating, and excessive gas. Findings: A review of resident 45's admission Record indicated the facility re-admitted the resident on 8/19/2022 with diagnoses that included chronic respiratory failure (a serious condition that occurs when the lungs have difficulty getting enough oxygen into the blood) with hypoxia (a condition where the body's tissues do not receive…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 observe infection control measures for one of three sampled residents (Residents 60), as Resident 60's condom catheter (a medical device used to collect urine from men who have difficulty or are unable to urinate on their own into a bag) drainage bag was closed. This deficient practice resulted in Resident 60's urine to leak out of the drainage bag onto the floor and placed the resident at risk for infection. Findings: A review of the admission record indicated Resident 1 was admitted to the facility on [DATE], with diagnoses including chronic respiratory failure (a condition where the lungs are unable to adequately exchange oxygen and carbon dioxide over an extended period), muscular dystrophy (progressive weakness and loss of muscle mass), quadriplegia (partial or complete loss of function in all four limbs (arms and legs) and the torso), dysphagia (difficulty swallowing), and tracheostomy (a surgical procedure that creates an opening…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide one of three sampled residents (Resident 55) an adaptable call light. This deficient practice had the potential to result in staff delay in meeting Resident 55's needs for hydration, toileting, and activities of daily living. Findings: A review of Resident 55's admission record indicated the resident was originally admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses including chronic respiratory failure (a condition where the lungs are unable to adequately exchange oxygen and carbon dioxide over an extended period), chronic obstructive pulmonary disease (COPD, a chronic lung disease causing difficulty in breathing), Guillain-Barré syndrome (GBS, an autoimmune disease that occurs when the body's immune system attacks the peripheral nervous system), tracheostomy (a surgical procedure that creates an opening in the trachea [windpipe] to insert a tube and provide an airway for breathing), ventilator dependence…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 properly manage a resident on restraints (any method, physical or chemical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move or access any part of his/her body) and to provide ongoing nursing assessment and monitoring on one of one sampled resident (Resident 1) in accordance with the facility's policy and procedure of restraints when: 1. The restraints order was not renewed daily from 5/3/2024 to 6/30/2024 2. There was no restraints assessment done from 6/25/2024 to 6/30/2024 related to the bilateral (both) hand mitten restraints for Resident 1. This deficient practice has resulted in Resident 1 experiencing redness at the knuckle of both hands, swelling at the left knuckle, and mild pain upon touching left knuckle on 6/30/2024. Findings: 1. During a review of Resident 1's Face Sheet, dated 7/2/2024, the face sheet indicated Resident 1 was admitted to the facility with diagnoses of chronic respiratory failure (condition in which not enough oxygen passes from 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: 1. Inform family of the development of stage 2 (partial thickness skin loss involving epidermis, dermis, or both and presents clinically as an abrasion, blister, or shallow crater) pressure injury (injury to skin and/or underlying tissue resulting from prolonged pressure or friction on the skin) at sacral (lower back area) area for one of one sampled resident (Resident 1). 2. Explain the risk and benefits and obtain consent prior to performing wound debridement for the stage 2 pressure injury on one of one sampled resident (Resident 1). This deficient practice resulted in Resident 1's family not notified with Resident 1's pressure injury status and physician performing a procedure without Resident 1's family consent. Findings: During a review of Resident 1's History and Physical (H&P, a formal and complete assessment of the patient and the problem), dated 12/17/2023, the H&P indicated Resident 1 was admitted to the facility with diagnoses with stroke (CVA - stroke; damage to the brain from interruption of its blood…

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

Based on Interview and record review, the facility failed to ensure its nursing staff develop a comprehensive care plan (provides a framework for evaluating and providing resident care needs related to the nursing process) to address the pressure injury on one of one sampled resident (Resident 1) when Patient 1 developed stage 2 (partial thickness skin loss involving epidermis, dermis, or both and presents clinically as an abrasion, blister, or shallow crater) pressure injury (injury to skin and/or underlying tissue resulting from prolonged pressure or friction on the skin) at sacral (lower back) area. This deficient practice had resulted in nursing staff failing to provide adequate intervention and care to Resident 1 and led to Resident 1's sacral pressure injury to worsen and progressed to Stage 3 (full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscle is not exposed). Findings: During a review of Resident 1's History and Physical (H&P, a formal and complete assessment of the patient and the problem), dated 12/17/2023, the H&P 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 interview and record review, the facility failed to report to the Department an allegation of physical abuse involving one of one sampled resident (Resident 1) when staff became aware of an alleged physical abuse involving Resident 1 and a Licensed Vocational Nurse 1 (LVN 1), who worked at the facility. This deficient practice had the potential for the underreporting of abuse incidents and a delay in an investigation of an abuse allegation, placing Resident 1 and other residents at risk for further potential abuse. Findings: A review of Resident 1's admission Record, (undated), indicated Resident 1 was admitted on [DATE] with a primary diagnosis of chronic respiratory failure with hypoxia (a long-time serious condition that makes it difficult to breathe on your own without enough oxygen). Other active diagnoses include tracheostomy (helps air and oxygen reach the lungs by creating an opening from outside a person's neck), anxiety disorder (feelings of worry, nervousness, or unease), blindness (unable to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that an allegation of abuse was thoroughly investigated for one of one sampled resident (Resident 1), when the facility failed to obtain a statement or interview from Resident 1 as well as CNA 1, who reportedly witnessed the incident. This deficient practice had the potential for the facility to not appropriately determine necessary interventions that may be implemented for the protection of residents. Findings: A review of Resident 1's admission Record, (undated), indicated Resident 1 was admitted on [DATE] with a primary diagnosis of chronic respiratory failure with hypoxia (a long-time serious condition that makes it difficult to breathe on your own without enough oxygen). Other active diagnoses include tracheostomy (helps air and oxygen reach the lungs by creating an opening from outside a person's neck), anxiety disorder (feelings of worry, nervousness, or unease), blindness (unable to see), and diabetes mellitus (abnormal break down 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 ensure a current copy of the resident's advance directive (AD, a written instruction, recognized under State law, relating to the provision of health care when the individual is unable to make decisions for themselves) and/or advance directive acknowledgement form (document provided by the facility that indicates whether a resident has an advance directive, would like information regarding creation of an advance directive, or refusal to create an advance directive) was complete and in the resident's medical chart for four of seven sampled residents (Residents 10, 17, 36 and 60). This deficient practice had the potential for the facility to not honor the resident's medical decisions regarding end-of-life treatment. Findings: a. A review of Resident 10's admission Record indicated the facility admitted the resident on 7/23/2019, with diagnoses including chronic respiratory failure (a condition where there's not enough oxygen or too much carbon dioxide in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure three out of three sampled residents (Resident 29, 69, and 126) were provided with a Notice of Medicare Non-Coverage (NOMNC - a notice that is provided to beneficiaries that indicates when their Medicare covered services are ending) and/or a Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNF ABN, a notification that is provided to a resident when it believes Medicare will not pay for extended care services or items that have been ordered by a physician). This deficient practice had the potential to result in the residents not being informed of their coverage end date and not being able to exercise their right to file an appeal. Findings: a. A review of Resident 29's admission Record indicated the resident was originally admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses including chronic respiratory failure (a condition where there's not enough oxygen or too much carbon dioxide in the body), Type II…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement accident risk and hazard interventions for three of five sampled residents (Residents 54, 60 and 67). These deficient practices had the potential to place Residents 54, 60, and 67 at risk for injuries. Findings: a.A review of Resident 54's admission Record indicated the facility admitted Resident 54 on 1/6/2022 and readmitted on [DATE] with diagnoses including epilepsy (a brain condition that causes recurring seizures[a sudden, uncontrolled burst of electrical activity in the brain]), and chronic respiratory failure ( a condition in which your lungs have a hard time loading your blood with oxygen or removing carbon dioxide). A review of Resident 54's Minimum Data Set (MDS - a standardized assessment and screening tool) dated 9/13/2023, indicated Resident 54 had mildly impaired cognition (some difficulty in new situations only). The MDS further indicated Resident 54 required extensive assistance with one-person physical assist…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 and date the humidifiers (a device that adds moisture to the air to prevent dryness that can cause irritation) for two of seven sampled residents (Resident 36, 50 and 64). This deficient practice had the potential to result in staff not knowing when to change the humidifier leading to resident discomfort and/or infection. Findings: a. A review of Resident 64's admission Record indicated the facility admitted the resident on 1/7/2023 with diagnoses that included chronic respiratory failure (a condition where there was not enough oxygen or too much carbon dioxide in the body), dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), and encephalopathy (any disturbance of the brain's functioning that affects how well an individual thinks). A review of Resident 64's Minimum Data Set (MDS, a standardized assessment and care screening tool) dated 10/13/2023, indicated the 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 implement its policies and procedures related to the influenza (a high contagious viral infection of the respiratory passages) and the pneumonia / pneumococcal (PNA-lung inflammation caused by infection) vaccines for four of six sampled residents (Residents 25, 73, 50, and 58). These deficient practices placed Residents 25, 73, 50, and 58 at increased risk of acquiring and transmitting the flu and pneumonia viruses to other residents in the facility. Findings: a. A review of Resident 25's admission Record indicated the facility originally admitted Resident 25 on 11/1/2023, and readmitted on [DATE], with diagnoses including anxiety disorder (a mental health condition with feeling of worry, anxiety, or fear interfering with ones daily activities), and dependence on respirator ( cannot breathe without a machine). A review of Resident 25's Minimum Data Set (MDS - a standardized assessment and screening tool) dated 11/8/2023, indicated the resident was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on 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 five sampled residents (Resident 25). This deficient practice denied Residents 25 and /or his Responsible Party's (RP) right to be informed regarding the risks and benefits of psychotropic medication therapy possibly resulting in diminished overall physical, mental, and psychosocial well-being. Findings: A review of Resident 25's admission Record indicated the facility originally admitted Resident 25 on 11/1/2023, and readmitted on [DATE], with diagnoses including anxiety disorder (a mental health condition with feeling of worry, anxiety, or fear interfering with one's daily activities) 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 notify the Ombudsman (a representative that helps families and residents in long-term care facilities by investigating and resolving complaints and serving as an advocate) of the transfer/discharge of one of three sampled residents (Resident 39). This deficient practice had the potential for Resident 39 to be improperly discharged from the facility. Findings: A review of Resident 39's admission Record indicated the facility originally admitted Resident 39 on 1/25/2023 and readmitted on [DATE] with diagnoses including chronic respiratory failure (a condition where there's not enough oxygen or too much carbon dioxide in the body), Type II diabetes (disease in which there is a high level of sugar (glucose) in the blood), anoxic brain damage (brain injury caused by a complete lack of oxygen to the brain), gastrostomy (a surgical procedure used to insert a tube, often referred to as a G-tube, through the abdomen and into the stomach and used to provide 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 follow its Interdisciplinary Care Plan, policy and procedure for two of seven sampled residents (Residents 25, and 71). These deficient practices had the potential to lead to the inadequate care of Residents 25 and 71. Findings: a. A review of Resident 25's admission Record indicated the facility originally admitted Resident 25 on 11/1/2023, and readmitted on [DATE], with diagnoses including anxiety disorder (a mental health condition with feeling of worry, anxiety, or fear interfering with one's daily activities), and dependence on respirator ( cannot breathe without a machine). A review of Resident 25's Minimum Data Set (MDS - a standardized assessment and screening tool) dated 11/8/2023, indicated the resident was comatose (in a coma [deep sleep], unconscious [unable to respond to people and activities] and unable to communicate).The MDS indicated the resident was total dependent for oral and toileting hygiene, dressing and personal hygiene. 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 revise and update the care plan to reflect current unstageable pressure ulcer (a type of bed sore that occurs due to prolonged pressure on a specific area of the skin, resulting in the lack of blood flow and oxygen to the tissue. It is a full thickness tissue loss where the depth of the wound or bed sore is completely obscured by eschar [a dark scab] in the wound bed) treatment orders for one of three sampled residents (Resident 17). This deficient practice had the potential to cause worsening of Resident 17's pressure ulcer. Findings: A review of Resident 17's admission Record indicated the facility originally admitted the resident on 11/15/2022 and readmitted on [DATE] with diagnoses including chronic respiratory failure (a condition where there's not enough oxygen or too much carbon dioxide in the body), type 2 diabetes (disease in which there is a high level of sugar (glucose) in the blood), epilepsy (a brain disorder that causes recurring,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 residents who were not able to carry out activities of daily living (ADLs) received the necessary services to maintain personal hygiene for one of 23 sampled residents (Resident 73). Residents 73 who was totally dependent upon staff for all ADLs was left soiled for more than 40 minutes. This deficient practice had the potential for Resident 73 to develop more pressure ulcers or an infection. Findings: A review of Resident 73's admission Record indicated the facility admitted the resident on 11/21/2023, with diagnoses including respiratory failure (a serious condition that makes it difficult to breathe on your own), urinary retention (inability to urinate), Stage II pressure ulcer (a wound that have a break in the top two layers of skin), and high blood pressure. A review of Resident 73's Minimum Data Set (MDS - an assessment and care screening tool) dated 11/28/2023, indicated Resident 73 was totally dependent upon staff for all activities of daily living (ADLs -essential and routine activities include…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide services that promote the prevention of pressure ulcer injury for two of six sampled residents (Resident 26 and Resident 33) as evidenced by: -Failing to maintain proper weight settings for the low air loss mattress (LALM-mattress designed to treat and prevent pressure ulcers) of Resident 26 and Resident 33. -Failing to perform weekly skin assessments for Resident 33. These deficient practices had the potential to cause harm to Resident 26 and Resident 33 by not providing services to promote the prevention pressure ulcer development. Findings: a. A review of Resident 26's Face Sheet (admission record) indicated the facility originally admitted the resident on 10/17/2023, and re-admitted on [DATE], with a diagnoses including but not limited to dementia (a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning), and Stage II…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 sufficient nursing staff in order to accommodate residents needs for two of seven sampled residents (Residents 67, and 73). These deficient practices resulted in residents not receiving timely and efficient care and needed services. Findings: a. A review of Resident 73's admission Record indicated the facility admitted the resident on 11/21/2023, with diagnoses including respiratory failure (a serious condition that makes it difficult to breathe on your own), urinary retention (inability to urinate), Stage II pressure ulcer (a wound that have a break in the top two layers of skin), and high blood pressure. A review of Resident 73's Minimum Data Set (MDS - an assessment and care screening tool) dated 11/28/2023, indicated Resident 73 was totally dependent upon staff for all activities of daily living (ADLs -essential and routine activities include eating, dressing, getting into or out of a bed or chair, taking a bath or shower, 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 post daily the actual hours and/or projected hours worked by licensed and unlicensed staff providing direct care to the residents per shift. This deficient practice had the potential to result in residents and visitors not knowing the accurate number of staff and staff hours worked. Findings: During an observation on 12/15/2023 at 8:03 PM, the facility posting of their Shift Staffing Form was observed. The Shift Staffing Form was observed to be dated 12/14/2023 and had a census of 71. The Shift Staffing Form was observed to list the number of Registered Nurses (RN), Licensed Vocational Nurses (LVN), and Certified Nursing Assistants (CNA) on the 7 AM to 7 PM shift. The form also indicated the number of CNAs for the 7 AM to 3 PM shift. The form did not indicate the number of RNs or LVNs working the 7 PM shift to 7 AM shift. The form did not indicate the number of CNAs working the 3 PM to 11 PM shift or the 11 PM to the 7 AM shift. The Shift Staffing Form also did not indicate the actual or projected hours worked…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 review, the facility failed to discard a bottle of Admelog (generic name lispro - a fast-acting medication used to treat high blood sugar) insulin with an opened date of 11/18/2023, according to the manufacturer's requirements affecting Resident 18 in one of two medication storage rooms inspected (West Medication Room). This deficient practice had the potential for the loss of efficacy of Ademalog and had the potential to cause ineffective management of Resident 18's diabetes mellitus (DM - high blood sugar). Findings: A review of Resident 18's admission record indicated the facility admitted the resident on 3/21/2017, with diagnoses including Type II diabetes mellitus (a disease that result in too much sugar in the blood), paraplegia (paralysis of the lower half of your body, including both legs) 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 18's Physician's Order dated 7/14/2023, indicated to administer lispro insulin per…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 all opened food items stored in facility refrigerators were labeled and dated. A container of green salad in the produce walk in, and a bag of parmesan cheese in the dairy walk in were not labeled. This deficient practice placed the facility residents at risk for foodborne illness. Findings: During a concurrent observation and interview on 12/15/2023 at 5 PM, with Regional Chef (RC) the kitchen was observed. In the produce walk-in, a prepared green salad in a stainless-steel deep pan and covered with plastic wrap was observed undated. The RC stated the salad should have a label with the date. In the dairy walk-in refrigerator, a large opened clear bag of parmesan cheese was observed undated. The RC stated the cheese should have been labeled and would be thrown out. The RC stated opened food was dated/labeled for food safety, to ensure no pathogens grow and it helped staff differentiate between best by and use by date. During an interview on 12/17/2023 at 4:36 PM, the Director of Nursing (DON) stated…

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