Hyde Park Healthcare Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to meet professional standards of quality by failing to ensure the Complete Blood Count (CBC - laboratory blood test that measures the cells circulating in blood) ordered by the physician for one of three resident's (Resident 2), was done as ordered.This failure had the potential for delayed identification of the resident's current medical condition and delay the necessary care and interventions the resident will need and placed the resident at risk for worsening condition and hospitalization.Findings: During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was admitted on [DATE] with diagnoses including encephalopathy (disease, damage, or malfunction that affects the brain), dementia (a progressive state of decline in mental abilities), and schizophrenia (a mental illness that is characterized by disturbances in thought). During a review of Resident 2's Care Plan titled Resident 2 has nutritional problem. dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of four (4) residents (Resident 1), was provided with interventions to reduce the risk of recurrent fall, as indicated in the facility's policy and procedure (P&P) titled Fall Prevention Program. As a result, Resident 1 had a total of 4 fall incidents since admission on [DATE], 1/23/2026, 2/18/2026 and 2/21/2026, placing the resident at risk for severe injuries, including hospitalization and death.Findings: During a review of Resident 1's admission Record, dated 02/24/2026, the admission Record indicated Resident 1 was originally admitted on [DATE] and re-admitted [DATE]. Resident 1's diagnoses included chronic pulmonary edema (a condition caused by too much fluid in the lungs making it difficult to breathe), cirrhosis of liver (a condition in which the liver is scarred and permanently damaged), and morbid obesity (being over 100 pounds overweight, significantly impacting daily life and increasing risks for serious illness) due to excessive…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 a thorough investigation following an allegation of staff-to-resident sexual misconduct for one of four sampled residents (Resident 4). This deficient practice placed Resident 4, and all other facility residents, at risk for the occurrence of repeat staff-to-resident sexual misconduct. Findings: During a review of Resident 4's admission Record, the admission Record indicated Resident 4 was admitted to the facility on [DATE] and was most recently readmitted on [DATE]. Resident 4's diagnoses included chronic obstructive pulmonary disorder (COPD, a chronic lung disease causing difficulty in breathing) and type 2 diabetes mellitus (a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 4's Minimum Data Set (MDS, a resident assessment tool), dated 1/2/2026, the MDS indicated Resident 4 had some difficulty with daily decision making in new situations, but did not exhibit inattention,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 respiratory care and services consistent with professional standards of practice for one of seven Residents (Resident 1) by failing to ensure:Licensed nurses clarified Resident 1's oxygen (O2) orders when the physician ordered O2 3 liters per minute (l/min) every shift for Resident 1 without indicating frequency (to be administered continuously or as needed). This deficient practice had the potential to result in respiratory failure (a condition in which the respiratory system cannot maintain adequate gas exchange, leading to insufficient oxygen in the tissues [hypoxia]) for Resident 1 and could negatively impact the Residents' health and safety.Findings:During a concurrent observation and interview on 1/15/2026, at 11:00 a.m., in Resident 1's room, Resident 1 was observed sitting in her wheelchair without O2 on. No O2 concentrator (a medical device that provides supplemental oxygen) nor oxygen tubing (a flexible plastic tube 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 interview and record review, the facility failed to ensure telephone orders given by the ordering physician, telephone orders obtained by staff from the ordering physician and other orders given by the ordering physician, were entered under the prescriber's name. This failure resulted in the difficulty in identifying the ordering physician's name, had the potential to mislead the healthcare system and potential for fraud.Findings:During an interview on 1/5/2026 at 2:30 p.m. with the physician (MD 1), MD 1 stated when telephone orders were given to the facility by the medical team under her practice (MDs, Nurse Practitioners [NP]), the facility staff receiving the telephone order would use her name (MD1) as the ordering physician. MD1 stated she was informed that the electronic medical record system (the electronic program the facility used) does not have the options of the other medical team members' names to use being the ordering physician. During an interview on 1/8/2026 at 3:51 p.m. with MD 2, MD 2 stated the computer program used at the facility to enter orders does…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 California Department of Public Health (CDPH), when one of ten sampled residents (Resident 5), allegedly hit Resident 4 in the stomach since admission to the facility on [DATE].This deficient practice resulted in a delay in investigation by the CDPH and placed Resident 4 at risk for physical abuse (any intentional act causing injury or trauma to another person through bodily contact, including, but not limited to, hitting, slapping, punching, biting and kicking).Findings: a). During a review of Resident 4's admission Record, the admission Record indicated Resident 4 was admitted to the facility on [DATE], with diagnoses including Diabetes Mellitus (chronic condition where the body cannot regulate sugar in the body and blood sugar can become too low or too high), and hypertension (high blood pressure). During a review of Resident 4's History and Physical (H&P) dated 12/12/2025, the H&P indicated Resident 4 did not have the capacity to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow its policy and procedure (P&P) titled admission to the Facility, when the admission consent for one of three residents (Resident 4), was not obtained from the resident or family representative. This deficient practice resulted in the resident's admission to the facility without consent and had the potential that the affected resident will not receive the necessary care and services the resident need.Findings:During a review of Resident 4's admission Record, the admission Record indicated Resident 4 was admitted to the facility on [DATE], with diagnoses including Diabetes Mellitus (chronic condition where the body cannot regulate sugar in the body and blood sugar can become too low or too high), and hypertension (high blood pressure). During a review of Resident 4's History and Physical (H&P) dated 12/12/2025, the H&P indicated Resident 4 did not have the capacity to understand and make decisions. During a review of Resident 4's Minimum Data Set…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide Bed-Hold (refers to the practice where a resident's bed is reserved for 7 days while temporarily away from the facility, such as during hospitalization or therapeutic visits) written notification to one of three residents (Resident 1), when Resident 1 was transferred to the general acute care hospital on [DATE], 12/8/2025, 12/11/2025, and 12/14/2025, as indicated in its policy and procedure (P&P) titled, Bed-Hold.This failure had the potential for Resident 1 not to exercise the option to use the facility's bed-hold policy and lose their bed at the facility.Findings:During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and was readmitted on [DATE]. Resident 1's diagnoses included seizures (a sudden, uncontrolled electrical disturbance in the brain) and conversion disorder with seizures (a condition in which a mental health issue disrupts how the brain…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure care and services for two of three sampled residents (Residents 1 and 3) who had seizure disorders (a sudden, uncontrolled electrical disturbance in the brain), met professional standards of quality care. These failures had the potential for recurring seizures, injuries, hospitalization and death.Findings:During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and was readmitted on [DATE]. Resident 1's diagnoses included seizures included seizures and conversion disorder with seizures (a condition in which a mental health issue disrupts how the brain works).During a review of Resident 1's History and Physical (H&P), dated 12/2/2025, the H&P indicated Resident 1 had the capacity to understand and make decisions.During a review of Resident 1's Minimum Data Set ([MDS], a resident assessment tool) dated 12/4/2025, the MDS indicated Resident 1 required…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 admission orders (orders containing treatment and medications to be administered to the resident being admitted to the facility) for one of three newly admitted residents (Resident 4), were obtained from a physician, as indicated in its policy and procedures (P&P) titled, admission to the Facility. This deficient practice resulted in Resident 4's admitting orders not verified from the physician.This deficient practice had the potential for wrong name of medications ordered, wrong dosage, wrong route and placing the resident at risk receiving the wrong drugs, that could affect the resident's medical condition, leading to injuries, hospitalization or death. Findings:During a review of Resident 4's admission Record, the admission Record indicated Resident 4 was admitted to the facility on [DATE], with diagnoses including Diabetes Mellitus (DM- chronic condition where the body cannot regulate sugar in the body and blood sugar can become too low or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the physician was called to follow up admission medication orders for one of three newly admitted residents (Resident 4), for timely administration. This deficient practice resulted in the delayed administration of medications due and had the potential to affect the resident's medical condition, leading to complications, hospitalization and death. Findings:During a review of Resident 4's admission Record, the admission Record indicated Resident 4 was admitted to the facility on [DATE], with diagnoses including Diabetes Mellitus (chronic condition where the body cannot regulate sugar in the body and blood sugar can become too low or too high), and hypertension (high blood pressure).During a review of Resident 4's History and Physical (H&P) dated 12/12/2025, the H&P indicated Resident 4 did not have the capacity to understand and make decisions. During a review of Resident 4's Minimum Data Set (MDS - a resident assessment tool) dated 12/14/2025,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure licensed nurses followed up with the facility's contracted pharmacy on a physician's order dated 11/23/2025 for Seroquel (antipsychotic [medication that manage psychosis {hallucinations, delusions, disordered thinking}] medication primarily used to treat schizophrenia [a mental illness that is characterized by disturbances in thought] and bipolar [mood swings that range from the lows of depression to elevated periods of emotional highs] disorder) 25 milligrams (mg-unit of weight measurement) for one of three sampled residents (Resident 2) to ensure the medication was obtained and administered to Resident 2 in timely manner and as ordered to manage Resident 2's aggressive behavior to prevent Resident 2's angry outburst resulted in Resident 1's physical abuse. Resident 2 did not receive Seroquel for eight days. These deficient practices resulted in Resident 2 not receiving Seroquel for eight days and contributing to the resident's anger outburst 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure Registered Nurses (RN), RN 1, RN 2, and Licensed Vocational Nurses (LVN), LVN 3, LVN 4, LVN 5, LVN 6, LVN 7 did not willfully falsify Resident 2's medical records when the staff documented administration, resident refusal, and awaiting pharmacy of ordered psychotropic medication that was not available in the facility for Resident 2. This deficient practice resulted in Resident 2 having inaccurate medical records that did not reflect the actual care provided or his actual clinical condition. Findings: During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 2's diagnoses included bipolar disorder (mood swings that range from the lows of depression to elevated periods of emotional highs), Alzheimer's disease (a disease characterized by a progressive decline in mental abilities), schizophrenia (a mental illness that is…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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.Follow Enhanced Barrier Precautions ([EBP] - an infection control intervention designed to reduce transmission of multi-drug-resistant organisms) for one of four sampled residents (Resident 4).This deficient practice had the potential to result in cross contamination (the process by which bacteria or other microorganisms are unintentionally transferred from one substance or object to another, with harmful effect) and an increased risk of developing and spreading infection to Resident 4 and other residents and staff in the facility. Findings: During a review of Resident 4's admission Record, the admission Record indicated, Resident 4 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 4's diagnoses included hepatic encephalopathy (condition that occurs when the liver is unable to properly filter toxins from the blood), chronic obstructive pulmonary disease ([COPD] - a chronic lung disease causing…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of four sampled residents (Resident 1) personal possessions were properly inventoried and accounted during admission to the facility. This failure had the potential to violate the resident's right to respect residents' personal possessions.Findings:During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including hypertension (high blood pressure), benign prostatic hyperplasia with lower urinary tract symptoms (BPH with LUTS, condition where the prostate gland [walnut-shaped gland located in the male reproductive system, just below the bladder] enlarges, which can put pressure on the urethra [tubular structure that carries urine from the bladder to the outside of the body] and cause frequent urination and urgency), and Intractable with status epilepticus severe, life-threatening condition where continuous or very frequent seizures [temporary disruption…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 Ombudsman's (Patient advocate) allegation of neglect (failure of the facility to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress, which occurs when the facility is aware of, or should have been aware of goods or services that a resident[s] requires but the facility fails to provide them to the resident[s], resulting in, or may result in, physical harm, pain, mental anguish, or emotional distress) to the California Department of Public Health (CDPH), for one out of four sampled residents (Resident 1), alleging staff did not provide basic services such as bathing, shaving and offering urinal.This deficient practice resulted in delayed investigation by the CDPH and placed Resident 1 and other residents at risk for further neglect. Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement its policy and procedure (P&P) titled, Pharmaceutical Services Policy and Procedure Manual, by failing to ensure one of three sampled residents' (Resident 1) medications ordered by the physician, were administered within 60 minutes of scheduled time.This deficient practice resulted in the delay for Resident 1 to receive scheduled medications and had the potential for the medications to be ineffective.This deficient practice also had the potential to administer hypertension [HTN], high blood pressure) medications ordered twice a day, close to the next dose, causing the blood pressure to drop lower, resulting in hospitalization and death.Findings:During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including hypertension, benign prostatic hyperplasia with lower urinary tract symptoms (BPH with LUTS, condition where the prostate gland [walnut-shaped…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 its Policy and Procedure (P&P) titled, Scope of Infection Control Program, which indicated standard precaution (the basic level of infection prevention and control practices used in healthcare settings to minimize the transmission of infections) and hand hygiene should be followed to prevent the spread of infections to 1 of 3 sampled residents, (Resident 1) during wound care procedure.This failure had the potential to result in cross contamination and spread of bacteria and other microorganisms causing wound infections and other complications of infections leading to hospitalization.Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including hypertension (HTN- high blood pressure), benign prostatic hyperplasia with lower urinary tract symptoms (BPH with LUTS, a condition where the prostate gland [walnut-shaped gland located…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, for three (3) of 3 sampled residents (Residents 1, 3 and 4), the facility failed to:1). Ensure Resident 3's call light was in working condition.2). Ensure Residents 1 and 4's call lights were placed within reach.3). Ensure Resident 4, who needed staff assistance and whose call light was turned on, was answered in a timely manner. These deficient practices had the potential that the needs of the residents will not be attended to timely.These deficient practices had the potential to result in falls and injuries, and other severe complications in cases of an emergency situation.This deficient practice resulted in Resident 4's needs not assisted timely and had the potential to affect the resident's psychosocial well-being causing the resident's feeling of desperation (despair) and neglect. Findings: 1). During a review of Resident 3's admission Record, the admission Record indicated Resident 3 was admitted to the facility on [DATE] with diagnoses including muscle…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 safe discharge planning process for one of four sampled residents, Resident 1. This failure had the potential for unsafe discharge by not identifying the resident's discharge needs and not thoroughly planned and prepared, and communicated to the receiving facility. This failure caused Resident 1 to feel anxious and sad and had the potential to affect the resident's highest practicable physical, mental and psychosocial well-being.Findings:During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE], with diagnoses including metabolic encephalopathy (a condition where the brain does not function properly due to underlying metabolic disturbances,) mood disorders (mental health conditions that affect a person's emotions, thoughts, and behaviors) and cellulitis of left lower limb (a bacterial infection of the skin and the tissue beneath.) During a review of Resident 1's care plan…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to: 1. Ensure PRN (as needed) orders for Zyprexa (antipsychotic medications used to treat mental illness) were limited to a 14-day duration between 3/6/25 and 4/16/25 in one of five residents sampled for unnecessary medications (Resident 118.) 2. Monitor and document the target behavior of inability to relax and adverse effects (unwanted or dangerous side effects of medication) related to the use of Ativan (an anti-anxiety medication used to treat mental illness) in the Medication Administration Record (MAR - a record of all medication administration and monitoring done for a resident) in one of five residents sampled for unnecessary medications (Resident 13.) The deficient practices of failing to limit PRN orders for antipsychotic medications to 14-days and monitor target behaviors and adverse effects related to the use of psychotropic medications (medications that affect brain activities associated with mental processes and behavior) increased the risk…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to: 1. Complete and re-submit the Preadmission Screening and Resident Review ([PASARR - a tool to determine if the person had, or was suspected of having a mental illness, intellectual disability, or related condition) Level one (I) screening and refer to the appropriate state-designated authority for PASARR Level two (II) evaluation and determination for two of seven sampled residents (Resident 13 and Resident 46). This deficient practice had the potential to result in Resident 13 and 46 to not receive the appropriate medical treatments for mental illness diagnosis. Findings: A. During a review of Resident 13's admission Record (front page of the chart that contains a summary of basic information about the resident), the admission Record indicated, Resident 13 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 13's diagnoses included metabolic encephalopathy (a change in how your brain works due to an 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 interview and record review, the facility failed to: 1. Develop a comprehensive plan of care (resident-specific plans of care developed to address a specific problem or resident need) to address a diagnosis of anxiety (a mental illness characterized by constant worries persistent enough to interfere with everyday life) and behaviors of inability to relax related to the use of Ativan (an anti-anxiety medication used to treat mental illness) in one of five residents sampled for unnecessary medications (Resident 13.) The deficient practices of failing to create a comprehensive care plan to address Resident 13 ' s diagnosis of anxiety and behavior of inability to relax related to the use of psychotropic medications (medications that affect brain activities associated with mental processes and behavior) increased the risk that Residents 13 could have experienced adverse effects related to psychotropic medication therapy, such as drowsiness, dizziness, constipation, or increased risk of fall, possibly leading…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 B. During a review of Resident 56's admission Record (front page of the chart that contains a summary of basic information about the resident), the admission Record indicated, Resident 56 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 56's diagnoses included metabolic encephalopathy (a change in how your brain works due to an underlying condition), dementia (a progressive state of decline in mental abilities), and nicotine (substance found in tobacco products). During a review of Resident 56's History and Physical (H&P), the H&P indicated, Resident 56 could make needs known but did not have the capacity to consent. During a review of Resident 56's annual Minimum Data Assessment ([MDS] - a resident assessment tool), dated 1/14/2025, the MDS indicated, Resident 56's cognitive (ability to think and reason) skills for daily decision making was severely impaired (never/rarely made decisions). The MDS indicated, Resident 56 required supervision (helper provides verbal cues) from…

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

Based on observation, interview, and record review, the facility failed to maintain complete records of non-narcotic (medications other than those controlled for an increased risk of abuse) destruction logs by failing to have a licensed nurse and a witness sign the destruction logs in one of one inspected medication rooms (Station 1 Medication Room.) The deficient practice of failing to ensure a licensed nurse and witness sign off on the non-narcotic destruction logs increased the risk of drug diversion (any use of a medication for reasons other than those intended by the prescriber) or accidental exposure to the facility ' s residents possibly leading to medical complications. Findings: During an observation on 6/25/25 at 11:32 AM of Station 1 Medication Room, the non-narcotic medication destruction logs were found to be kept in a three-ring binder inside the medication room. During a review of the available Facility Medication Destruction Form records dating from 3/6/25 to present indicated none of the available records contained signatures from licensed staff, witnesses, or any…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that its medication error rate was less than five percent (%). Three errors out of 26 opportunities contributed to an overall error rate of 11.54 % affecting two of four residents observed for medication administration (Resident 32 and Resident 40.). The errors noted were as follows: 1. Incorrect dose of calcium carbonate (a supplement) administered to Resident 32 2. Incorrect formulation of multivitamins (a supplement) administered to Resident 40 3. Incorrect dose of Seroquel (a medication used to treat mental illness) administered to Resident 40. The deficient practice of failing to administer medications in accordance with the physician ' s orders increased the risk that Residents 32 and 40 may have experienced medical complications possibly resulting in hospitalization. Findings: During an observation of medication administration on 6/25/25 at 8:08 AM with the Licensed Vocational Nurse (LVN 1), LVN 1 was observed preparing 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: 1. Store one unopened vial of latanoprost eye drops (a medication used to treat eye conditions) in the refrigerator according to the manufacturer's instructions affecting Resident 2 in one of two inspected medication carts (Station 2 Cart.) 2. Store two unopened Lantus insulin pens (a medication used to treat high blood sugar) in the refrigerator according to the manufacturer's instructions affecting Residents 30 and 216 in one of two inspected medication carts (Station 1 Cart.) The deficient practices of failing to store medications per the manufacturers ' requirements increased the risk that Residents 2, 20, and 216 could have received medication that had become ineffective or toxic due to improper storage possibly leading to health complications resulting in hospitalization or death. Findings: During a concurrent observation and interview on [DATE] at 11:24 AM of Station 2 Cart with the Licensed Vocational Nurse (LVN 2), the following…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to: 1. Ensure one of 17 sampled residents (Resident 167) participated in care plan meetings. This deficient practice violated Resident 167's rights to be fully informed of the resident's plan of care and had the potential to result in delay of care and services. Findings: During a review of Resident 167's admission Record (front page of the chart that contains a summary of basic information about the resident), the admission Record indicated, Resident 167 was admitted to the facility on [DATE]. Resident 167's diagnoses included cerebral infarction (also known as stroke, the death of brain tissue due to a lack of blood flow), dysphagia (difficulty swallowing), and liver cirrhosis (a condition where healthy liver tissue is replaced by scar tissue, leading to impaired liver function). During a review of Resident 167s Minimum Data Assessment ([MDS] - a resident assessment tool), dated 6/15/2025, the MDS indicated, Resident 167 had the ability to express ideas…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to: 1. Ensure a foley catheter (a flexible plastic tube inserted into the bladder to provide continuous urinary drainage) privacy drainage bag was provided for one of one sampled resident (Resident 20). This deficient practice had the potential for Resident 20 to feel embarrassed. Findings: During a review of Resident 20's admission Record (front page of the chart that contains a summary of basic information about the resident), the admission Record indicated, Resident 20 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 20's diagnoses included benign prostatic hyperplasia (enlargement of the prostate), other specified diseases of bladder (a muscular, hollow organ in the lower abdomen that stores urine until it is eliminated from the body) and metabolic encephalopathy (a change in how your brain works due to an underlying condition). During a review of Resident 20's Minimum Data Assessment ([MDS] - a resident assessment…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to: 1. Report to the California Department of Public Health (CDPH- the state department responsible for public health in California) of a resident-to-resident altercation in a timely manner to CDPH for 2 of 3 sampled residents (Resident 118 and Resident 59). This deficient practice resulted in a delay in investigation by CDPH and placed Resident 2, Resident 3 and other residents at risk for further abuse. Findings: A. During a review of Resident 118's face sheet (front page of the chart that contains a summary of basic information about the resident), the face sheet indicated Resident 118 was originally admitted on [DATE] and readmitted on [DATE] with diagnoses which included bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), anxiety (feelings of worry, nervousness, or unease), polyosteoarthritis (a form of osteoarthritis that affects multiple joints 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: 1. Transmit the Discharge Minimum Data Set ([MDS]- a resident assessment tool) Assessment within 14 days after completion to Center of Medicare and Medicaid Services (CMS) for one of one sampled resident (Resident 15). This deficient practice had the potential to result in billing error and inaccurate data on resident care needs. Findings: During a review of Resident 15's admission Record (front page of the chart that contains a summary of basic information about the resident), the admission Record indicated, Resident 15 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 15's diagnoses included metabolic encephalopathy (a change in how your brain works due to an underlying condition), epilepsy (a chronic brain disorder characterized by recurrent, unprovoked seizures), and chronic obstructive pulmonary disease ([COPD] - a chronic lung disease causing difficulty in breathing). During a review of Resident 15's MDS…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to: 1. Submit a Pre-admission Screening and Record Review (PASARR) for one of four sampled residents (Resident 47). This deficient practice had the potential to result in a delay of necessary care and mental health services. Findings: During a review of Resident 47's face sheet (front page of the chart that contains a summary of basic information about the resident), the face sheet indicated Resident 46 was admitted on [DATE] with diagnoses which included schizophrenia (a mental illness that is characterized by disturbances in thought), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), anxiety (feelings of worry, nervousness, or unease) and other persistent mood disorders. During a review of Resident 47's Minimum Data Set (MDS- a federally mandated resident assessment tool), dated 5/12/2025, the MDS indicated Resident 47's cognitive skills were severely impaired. The MDS 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 interview and record review, the facility failed to: 1. Develop a baseline care plan for one of 17 sampled residents (Resident 167). This deficient practice had the potential for Resident 167 to not receive appropriate care and treatment specific to her needs. Findings: During a review of Resident 167's admission Record (front page of the chart that contains a summary of basic information about the resident), the admission Record indicated, Resident 167 was admitted to the facility on [DATE]. Resident 167's diagnoses included cerebral infarction (also known as stroke, the death of brain tissue due to a lack of blood flow), dysphagia (difficulty swallowing), and liver cirrhosis (a condition where healthy liver tissue is replaced by scar tissue, leading to impaired liver function). During a review of Resident 167s Minimum Data Assessment ([MDS] - a resident assessment tool), dated 6/15/2025, the MDS indicated, Resident 167 had the ability to express ideas and wants and the ability to understand others.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 and interview, the facility failed to: 1. Ensure a low air loss mattress (a specialized type of medical air mattress designed to prevent and treat pressure injuries (bedsores) by reducing moisture and heat buildup on the skin) was provided for one of four sampled residents (Resident 46). This deficient practice had the potential to result in further skin breakdown. Findings: During a review of Resident 46's face sheet (front page of the chart that contains a summary of basic information about the resident), the face sheet indicated Resident 46 was originally admitted on [DATE] and readmitted on [DATE] with diagnoses which included Stage 4 pressure ulcer of the right buttock(a wound over bony prominences characterized by full-thickness tissue loss, exposing muscle, bone, or tendon), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), bradycardia (slow heart rate) and sepsis (a life-threatening blood infection). During a review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to: 1. Ensure an appointment for urology (branch of medicine that focuses on surgical and medical diseases of the urinary system and the reproductive organs) evaluation/referral was completed for one of one sampled resident (Resident 20). This deficient practice had the potential to result in the delay of necessary care and services. Findings: During a review of Resident 20's admission Record (front page of the chart that contains a summary of basic information about the resident), the admission Record indicated, Resident 20 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 20's diagnoses included benign prostatic hyperplasia (enlargement of the prostate), other specified diseases of bladder (a muscular, hollow organ in the lower abdomen that stores urine until it is eliminated from the body) and metabolic encephalopathy (a change in how your brain works due to an underlying condition). During a review of Resident 20'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 interview and record review, the facility failed to ensure the initial and annual competency checklists were completed for one of four sampled employees (Certified Nurse Assistant [CNA] 3). This failure had the potential to negatively affect the residents' quality of care. Findings: During a review of CNA 3's employee personnel file, the employee personnel file did not indicate an initial competency checklist was completed upon hire (5/10/2023) and an annual competency checklist in May 2025. During an interview on 6/26/2025 at 3:04 pm with the Director of Staff Development (DSD), the DSD stated she could not provide documentation of CNA 3's initial competency checklist for 2023 and her annual competency checklist for 2025. The DSD stated CNA 3's initial competency checklist should have been completed on the day she was hired (5/10/2023) and her annual competency checklist should have been completed in May 2025. The DSD stated the purpose of completing initial and annual competency checklists is to make sure staff are up to date with their skills and to ensure staff perform…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 respond to the consultant pharmacist ' s recommendation (monthly recommendations by a pharmacist concerning potential medication-related irregularities), dated 3/23/25, to limit PRN (as needed) orders for Zyprexa (antipsychotic medications used to treat mental illness) to a 14-day duration in one of five residents sampled for unnecessary medications (Resident 118.) The deficient practices of failing to respond to the consultant pharmacist ' s recommendation to limit PRN orders for antipsychotic medications to 14-days increased the risk that Resident 118 could have experienced adverse effects related to antipsychotic medication therapy, such as drowsiness, dizziness, constipation, or increased risk of fall, possibly leading to impairment or decline in his mental or physical condition or functional or psychosocial status. Findings: During a review of Resident 118 ' s admission Record (a document containing a resident ' s diagnostic and demographic…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 free of significant medication errors by administering the incorrect dose of Seroquel (a medication used to treat mental illness) on 6/25/25 to one of four residents observed for medication administration (Resident 40.) The deficient practice of failing to administer medications in accordance with the physician ' s orders increased the risk that Resident 40 may have experienced medical complications possibly resulting in hospitalization. Findings: During an observation of medication administration on 6/25/25 at 8:22 AM with the Licensed Vocational Nurse (LVN 1), LVN 1 was observed preparing the following medication for Resident 40: 1. One tablet of Seroquel 50 mg. During an observation on 6/25/25 at 8:29 AM, LVN 1 was observed offering the Seroquel 50 mg tablet to Resident 40. Resident 40 was observed taking the medication by mouth with water. A review of Resident 40 ' s admission Record (a document containing…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to: 1. Ensure one of five sampled residents (Resident 38) had a Levetiracetam level (a blood test to check the amount of this drug in your body) completed every three months. This deficient practice had the potential to result in Resident 38 having a seizure (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness) if the levels were not in range. Findings: During a review of Resident 38's admission Record, the admission Record indicated Resident 38 was admitted to the facility on [DATE], with a readmission on [DATE]. Resident 38's diagnoses included hypertension (HTN-high blood pressure), diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), and epilepsy (a brain condition that causes recurring seizures). During a review of Resident 38's History and Physical (H&P), dated 1/2/2025, the H&P indicated Resident 38 had the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to: 1. Ensure the documentation was complete and x-ray result for one of one sampled resident (Resident 56) was accessible and filed in medical records. This deficient practice had the potential to place Resident 56 at risk of not receiving appropriate care and delay in communication among staff due to incomplete medical records. Findings: During a review of Resident 56's admission Record (front page of the chart that contains a summary of basic information about the resident), the admission Record indicated, Resident 56 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 56's diagnoses included metabolic encephalopathy (a change in how your brain works due to an underlying condition), dementia (a progressive state of decline in mental abilities), and nicotine (substance found in tobacco products). During a review of Resident 56's History and Physical (H&P), the H&P indicated, Resident 56 could make needs known but 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 observation and interview, the facility failed to ensure staff disinfected blood pressure cuffs before and after use during medication administration affecting two of four residents observed for medication administration (Residents 32 and 40.) The deficient practice of failing to disinfect shared medical equipment before and after use on different residents increased the risk that Residents 32 and 40 could have developed an infection (the invasion and growth of germs in the body) causing medical complications possibly leading to hospitalization. Findings: During an observation of medication administration with the Licensed Vocational Nurse (LVN 1) on 6/25/25 at 8:09 AM, LVN 1 was observed taking Resident 32 ' s blood pressure with an automatic blood pressure machine with a Velcro-style cuff without first disinfecting it. When complete, LVN 1 was observed placing the blood pressure machine and cuff back into its case, closing it with a zipper, and placing it back in the bottom drawer of the medication cart without first disinfecting it. During an observation on 6/25/25 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 safely discharge on e of three sampled residents (Resident 1) when: 1. The facility discharged Resident 1 from the facility, without his knowledge, request, or consent, against medical advice (AMA), on 5/2/2025. This deficient practice placed the resident at risk for avoidable physical and psychosocial harm due to their discharge without confirmation of his whereabouts and/or safety. Findings: During a review of Resident 1 ' s Face Sheet (front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] and readmitted on [DATE]. Resident 1 ' s diagnoses included schizophrenia (a mental disorder characterized by disturbances in thought), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and diabetes mellitus (DM – a disorder characterized by difficulty in blood sugar control and poor wound…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 seven sampled Residents (Resident 3 and Resident 7) were provided a clean homelike environment by failing to ensure the residents bed linen were changed daily or when soiled. This deficient practice had the potential to spread of infection and placed the residents at risk for physical discomfort. Findings: During a review of Resident 3 ' s admission Record, the admission Record indicated Resident 3 was originally admitted to the facility on [DATE] and re admitted on [DATE]. Resident 3 ' s diagnoses included schizophrenia (a mental illness that can affect thoughts, mood and behavior), anxiety disorder (excessive worry, fear, and other physical and behavioral symptoms that interfere with daily life), unspecified psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality). During a review of Residents 3 ' s Minimum Data Set (MDS - a resident assessment tool) dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to report to the California Department of Public Health (CDPH), a fall that resulted in a hip fracture (broken bone) after it was reported to the facility by a general acute care hospital (GACH). This deficient practice had the potential to lead to severe complications, including prolonged pain, blood clots (semi-solid masses that form and could block blood flow), and potentially death. Findings: During a review of Resident 1's Face Sheet (front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE]. Resident 1's diagnoses included paraplegia (paralysis in the lower half of the body), muscle wasting and atrophy (loss of muscle and strength), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). During a review of Resident 1's History and Physical (H&P), dated [DATE], the H&P indicated 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 observation, interview, and record review, the facility did not provide a safe and homelike environment for four of four sampled residents (Residents 1, 2, 3, 4) when flies were present in resident rooms. This failure resulted in residents feeling unhygienic (dirty) and dehumanized (degrade). Findings: 1. During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] and readmitted on [DATE]. The admission Record indicated Resident 1 had a history of psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality), schizophrenia (a mental illness that is characterized by disturbances in thought), and anxiety disorder (a mental health condition that causes feelings of unease, worry, fear, and apprehension). During a review of Resident 1's History and Physical (H&P), dated 1/20/2025, the H&P indicated Resident 1 could make medical decisions. During a review of Resident 1's Minimum Data…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow its policy and procedure (P&P) titled Residents' Personal Property, when a grievance (complaint) was not filed, and an investigation not conducted, when one of four residents (Resident 3), reported belongings were missing. This failure resulted in a violation of Resident 3's rights and resulted in Resident 3 feeling sad. Findings: During a review of Resident 3's admission Record, the admission Record indicated Resident 3 was admitted to the facility on [DATE]. During a review of Resident 3's History and Physical (H&P), dated 10/23/2024, the H&P indicated Resident 3 had a history of major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest) and anxiety (a mental health condition that causes feelings of unease, worry, fear, and apprehension). The H&P indicated Resident 3 had the ability to make medical decisions. During a review of Resident 3's Minimum Data Set (MDS – a federally mandated 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 observation, interview, and record review, the facility failed to ensure, one of four sampled residents ' (Resident 3) call light was plugged in and placed within reach, as indicated in the facility ' s policy and procedure (P&P) titled, Answering Call Lights. This failure had the potential for the resident not to call staff for assistance and could delay care and assistance, potentially resulting in falls, pressure ulcers (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence), and neglect. Findings: During a review of Resident 3 ' s admission Record, the admission Record indicated Resident 3 was admitted to the facility on [DATE]. During a review of Resident 3 ' s History and Physical (H&P), dated 10/23/2024, the H&P indicated Resident 3 had a history of major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest) and anxiety (a mental health condition that causes feelings of unease, worry, fear, 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 ensure skin treatment orders were not missed on 2/2/2025, 2/13/2025, 2/15/2025, 2/16/2025, 2/17/2025, and 2/18/2025, to one of three residents (Resident 2). This failure had the potential to delay the healing of Resident 2's skin condition and placed the resident at risk for complications. Findings: During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was admitted to the facility on [DATE] and readmitted on [DATE]. The admission Record indicated Resident 2 had a history of diabetic polyneuropathy (disease or dysfunction of multiple nerves, typically causing numbness or weakness in the hands and feet), morbid (severe) obesity (excessive body fat), cellulitis (a skin infection that causes swelling and redness), and a pressure ulcer (localized damage to the skin and/or underlying tissue usually over a bony prominence). During a review of Resident 2's History and Physical (H&P), dated 11/12/2024, the H&P 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 interview, and record review, the facility failed to develop an individualized plan of care for two of two residents (Resident 1 and Resident 2) after a both residents had a physical altercation on 12/22/2024. The deficient practice had the potential for unidentified interventions and placed Resident 1 and Resident 2 at risk for recurring physical altercations, injuries and hospitalization. Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 1's diagnoses included schizoaffective disorder (serious mental illness that affects how a person thinks, feels, and behaves) and migraine (recurring headache that can cause moderate to severe pain). During a review of Resident 1's History and Physical (H&P), dated 10/5/2024, H&P indicated Resident 1 had the capacity for medical decision making. During a review of Resident 1's Minimum Data Set ([MDS], a resident assessment tool),…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to administer one of six sampled resident's (Resident 1) medication as ordered by the physician. This deficient practice placed Resident 1 at risk for subtherapeutic drug levels (level too low to produce intended medical effect of the medication) and worsening of the resident's medical condition or symptoms. Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] and re-admitted on [DATE]. Resident 1's diagnoses included schizophrenia (a mental illness that is characterized by disturbances in thought), anxiety disorder (excessive fear of or apprehension about real or perceived threats, leading to altered behavior and often to physical symptoms such as increased heart rate or muscle tension) and suicidal ideations (thinking about or formulating plans for taking ones own life). During a review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool), dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interview, and record review, the facility failed to conduct a thorough assessment to one out of three residents (Resident 1), who had a bruise (an injury appearing as an area of discolored skin on the body caused by a blow or impact) on the hand and scratch on arm. This deficient practice caused the facility to not have proper plan of care in place for Resident 1. Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including metabolic encephalopathy (a problem in the brain caused by a chemical imbalance in the blood), atrial fibrillation (a heart condition that causes an irregular and often very rapid heart rhythm), and dementia (a decline in mental ability that interferes with daily life). During a review of Resident 1's History and Physical (H&P), dated 10/21/2024, the H&P indicated Resident 1 did not have the capacity for medical decision making…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record, the facility failed to: 1.Re-admit Resident 6 to the facility on [DATE] after the resident discovered the Assisted Living Facility (ALF) did not have an available bed for him. 2. Followed its policy and procedure (P/P) titled Transfer and Discharge, which indicated prior to discharging a resident, the facility will prepare the resident for a safe and orderly discharge and orient the receiving facility of the resident ' s daily patterns. This deficienct practice resulted in Resident 6 staying in a motel for five days, became sick, called 911, and was transferred to a general acute care hospital (GACH) for evaluation and treatment. During a review of resident 6 admission Record, indicated Resident 6 was admitted to the facility on [DATE] with diagnoses including depression (a common mental health condition characterized by a low mood or loss of pleasure or interest in activities for long periods of time), and diabetes ( [DM] a disorder characterized by difficulty in blood sugar…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 discharge summary for one of three sampled residents (Resident 6), who was discharged to an Assisted Living Facility ([ALF] a residential facility that provides housing and personal care for residents who need help with daily activities but don ' t require the level of care found in a nursing home), was completed with a reconciliation of the resident ' s pre/post discharge medications. This deficient practice had the potential to result in Resident 6 not receiving the needed medications upon discharge and could negatively affect the resident ' s physical well-being. Findings: During a review of Resident 6's admission Record, the admission Record indicated Resident 6 was admitted to the facility on [DATE] with diagnoses including depression (a common mental health condition characterized by a low mood or loss of pleasure or interest in activities for long periods of time), glaucoma (eye disease that damages the nerve), and diabetes ( [DM] 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 failed to: 1. Obtain a doctor order before transering one out of three sampled residents (Resident 2) to the General Acute Care Hospital (GACH). This had the potential to result in adverse outcome, medication error, and/or unnecessary medication or treatment. Findings: During a review of Resident 1 ' s admission Record (Face Sheet), the admission Record indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease (a lung disease causing restricted airflow and breathing problems), schizophrenia (a serious mental illness that affects how a person things, feels, and behaves), and myocardial infarction (blood flow to the heat muscle is blocked, causing the heart muscle to die from lack of oxygen). During a review of Resident 1 ' s History and Physical (H&P), dated 7/31/2024, the H&P indicated, Resident 1 did not have the capacity to understand and make decisions.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 shower grab bar (metal bar used as safety devices designed to enable a person to maintain balance or lessen fatigue) in Shower 1, used by 34 of 66 residents , was properly screwed (secured) on the wall. This failure had the potential to cause accidents and injuries. Findings: During a concurrent observation and interview on 7/22/2024 at 12:23 p.m. with Maintenance Supervisor (MS), four (4) screws (a device to secure thins on the wall) on each side of the grab bar were loose. The MS stated he (MS) did not know how long it had been loose. The MS stated he checked the grab bar last week. The MS stated the facility do not have a method to track things they check every week. The MS stated it (loose grab bar) was not brought to his attention that the grab bar was loose. During a concurrent observation and interview on 7/22/2024 at 12:35 p.m. with Maintenance Assistant (MA). The MA stated if the grab bar was loose and unstable, it placed the residents at risk for falling. During an interview on 7/23/2024…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to notify, one of three residents ' (Resident 2) family representative and physician after a change in condition (unusual condition) was identified. This failure had the potential for delay in treatment necessary to maintain resident ' s highest practicable mental, physical, and psychosocial well-being. Findings: During a review of Residents 2 ' s Face Sheet, the face sheet indicated Resident 2 was admitted to the facility on [DATE], with diagnoses that included pain in left and right knee and schizophrenia (a mental disorder characterized by disruptions in thought processes, perceptions, emotional responsiveness, and social interactions). During a review of Resident 2's Minimum Data Set ([MDS], a standardized assessment and care screening tool) dated 5/10/2024, the MDS indicated Resident 2 had the ability to understand and be understood by others. The MDS indicated Resident 2 required substantial/maximal assistance (helper does more than half the effort)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to modify one of three sampled residents' (Resident 2), care plan who had multiple falls, as indicated in the facility's policy and procedure (P&P) titled, Fall Prevention Program, which indicated the facility should implement all precautions to protect the resident and identify approaches to reduce the risk of falls. This failure resulted to a total of five falls (8/29/2023, 3/29/2024, 5/4/2024, 6/30/2024 and 7/19/2024) and placed Resident 2 at risk for further falls and severe injuries which could lead to hospitalization and death. Findings: During a review of Residents 2 ' s Face Sheet, the face sheet indicated Resident 2 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 2 ' s diagnoses included pain in left and right kneeand schizophrenia (a mental disorder characterized by disruptions in thought processes, perceptions, emotional responsiveness, and social interactions). During a review of Resident 2 ' s Fall Risk…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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. Follow physician orders for six out of 18 sampled residents (Residents 7, 9, 37, 39, 42, and 42). These failures had the potential to compromise the residents care and services which could cause medical complications. Findings: a. A review of Resident 42's Face Sheet, indicated Resident 42 was admitted to the facility on [DATE] with diagnoses included chronic obstructive pulmonary disease ([COPD] group of lung diseases that make it difficult to breathe, dementia (a decline in memory, language, problem solving and other thinking skills that affect one's ability to perform everyday activities), and history of fall. A review of Resident 42's History and Physical (H&P), dated 6/3/2024, the H&P indicated Resident 1 did not have the capacity to understand and make decisions. A review of Resident 42's Minimum Data Set ([MDS] a standardized assessment and care screening tool), dated 5/29/2024, the MDS indicated Resident 42 required maximum…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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. Ensure abuse reporting, orientation, and competency assessment post-test (a measurable pattern of knowledge, skills, and abilities) were completed upon hire for four out of five randomly selected staff. This deficient practice had the potential for the facility to not be able to assess nursing skills necessary to assure resident safety. Findings: During a concurrent interview and record review on 6/27/2024 at 10:31 a.m., with the Director of Staff Development (DSD), five random employees file were checked. The DSD stated Certified Nurse Assistant 3 (CNA 3), Certified Nurse Assistant 4 (CNA 4), Infection Preventionist Nurse (IP), and the Director of Nursing (DON) did not have their abuse competency tests and orientation packets completed. The DSD stated competency assessment skills check must be done upon hire. The DSD stated licensed nursing staff cannot work on the floor without completing and passed all required competency assessment skills. The DSD stated competency tests should have been completed for the 4 out 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.

Based on observation, interview, and record review, the facility failed to: 1. Ensure safe and sanitary food preparation practices were being conducted while preparing to serve food in the kitchen. These deficient practices had the potential to result in foodborne illnesses in the highly susceptible resident population. Findings: a. During an observation on 6/26/2024 at 12:00 p.m., in the kitchen area during tray line, DA 1 did not wear a hairnet while serving food. During an interview with the Dietary Manager (DM) on 6/26/2024 at 12:45 p.m., the DM stated DA 1 did not wear a hairnet because he had no hair. During an interview with the Registered Dietitian (RD) on 6/26/2024 at 12:50 p.m., the RD stated the standard of practice and facility policy for kitchen staff who did not have hair was not to use any protective hair covering. A review of the facility's policy and procedure (P&P) titled, Dress Code, dated 2023, the P&P did not disclose if kitchen staff has no hair you don't have to wear hairnet. A review of the California Health and Safety Code, section 113969-Hair Restraints (b)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to: 1. Inform the physician when one of one sampled residents (Resident 42) continuously refused blood to be drawn for lab test. This deficient practice had the potential to result in a delay of necessary medical care and interventions. Findings: A review of Resident 42's Face Sheet, indicated Resident 42 was admitted to the facility on [DATE] with diagnoses included chronic obstructive pulmonary disease ([COPD] group of lung diseases that make it difficult to breathe, dementia (a decline in memory, language, problem solving and other thinking skills that affect one's ability to perform everyday activities), and history of fall. A review of Resident 42's History and Physical (H&P), dated 6/3/2024, the H&P indicated Resident 1 did not have the capacity to understand and make decisions. A review of Resident 42's Minimum Data Set ([MDS] a standardized assessment and care screening tool), dated 5/29/2024, the MDS indicated Resident 42 required maximum…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 Resident 15 had a fall mat beside her bed for safety purposes. This deficient practice put Resident 15 at risk for injury in the event of a fall. a. A review of Resident 15's admission Record (Face Sheet) indicated Resident 15 was admitted to the facility on [DATE]. Resident 15's diagnoses included knee pain, muscle wasting, anxiety (excessive worry), and dementia (loss of ability to reason and remember). A review of Resident 15's Minimum Data Set ([MDS] a standardized assessment and care screening tool) dated 5/10/2024, indicated Resident 15 needed substantial assistance transferring from bed to chair. A review of Resident 15's Physician Orders, dated June 2024, indicated Resident 15 was to have a fall mat on the right side of the bed. A review of Resident 15's Fall Risk assessment dated [DATE], indicated Resident 15 was at high risk for fall. Resident 15's fall score was 13 (greater than 10 is high risk). 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to: 1. Ensure respiratory care was consistent with professional standards of practice when there was no physician order to administer oxygen for one of six sampled residents (Resident 16). This deficient practice had the potential to result in unsafe use of oxygen equipment. Findings: A review of Resident 16's admission record indicated Resident 16 was initially admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included osteoporosis (a condition in which bones become weak and brittle), muscle atrophy (the decrease in size and wasting of muscle tissue), anxiety (intense, excessive, and persistent worry and fear about everyday situations), and insomnia (problems with falling and staying asleep). A review of Resident 16's Minimum Data Set (MDS- an assessment and care screening tool) assessment, dated 4/10/2024, indicated Resident 16 was cognitively intact. Resident 16 also required maximal assistance on staff…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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. Obtain physician orders for pain for one of 6 sampled residents (Resident 40). This deficient practice had the potential to negatively affect the residents physical comfort and psychosocial well-being. Findings: A review of Resident 40's admission record, indicated Resident 40 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included asthma (a chronic disease in which the bronchial air ways in the lungs become narrowed and swollen, making it difficult to breathe), suicidal ideation (thinking about or planning suicide), muscle atrophy (the decrease in size and wasting of muscle tissue) and nicotine dependence (an addiction to tobacco products caused by the drug nicotine). A review of Resident 40's Minimum Data Set (MDS- an assessment and care screening tool) assessment, dated 5/29/2024, indicated Resident 40 was severely cognitively impaired. Resident 40 also required partial assistance on staff…

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

Based on observation, interview and record review, the facility failed to: 1. Ensure an opened personal beverage (soda) of the licensed staff was not stored in the medication cart at Station 1. This failure resulted in a lack of oversight for checking medications stored in medication cart. Findings: During an observation and interview, on 6/27/2024 at 11:30 a.m., of medication cart at Station 1 with Licensed Vocational Nurse 2 (LVN 2), LVN 2 was observed removing an opened personal beverage from the cart during inspection. LVN 2 stated licensed staff personal beverages or food items were not allowed to be stored in the medication cart at any time. During an interview, on 6/27/2024 at 1:46 p.m., with the Director of Nursing (DON), the DON stated personal items and food was not allowed near or in the medication cart. The DON stated the risk of having personal beverages in the cart could result in spills, unsanitary areas, and medication cross contamination. A review of the facility's policy and procedures, titled Medication Labeling and Storage, dated 2/2023, indicated The nursing…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to: 1. Follow its policy and procedure for hospice care (a comprehensive set of services identified and coordinated by an interdisciplinary group ([IDT] team members from different disciplines who come together to discuss resident care) to provide for the physical, psychosocial, spiritual, and emotional needs of a terminally ill patient as delineated in a specific patient plan of care) by failing to ensure hospice representative participates with facility IDT care conference for one of one sampled resident (Resident 42). This deficient practice had the potential to result in a delay or lack of coordination of care and services for residents. Findings: A review of Resident 42's Face Sheet, indicated Resident 42 was admitted to the facility on [DATE] with diagnoses included chronic obstructive pulmonary disease ([COPD] group of lung diseases that make it difficult to breathe, dementia (a decline in memory, language, problem solving and other thinking skills…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to: 1. Complete the McGeer Criteria ( minimum set of signs and symptoms which, when met, indicate that a resident likely has an infection and that an antibiotic might be needed) Surveillance Data Collection Form for one of one sampled resident (Resident 173). This deficient practice had the potential to result in the improper use of antibiotics (a drug used to treat infections caused by bacteria). Findings: A review of Resident 173's Face Sheet, indicated Resident 173 was admitted to the facility on [DATE] with diagnoses included Urinary Tract Infection ([UTI) urine infection), hypertension (elevated blood pressure), and chronic indwelling urinary catheter (a device that drains urine from your urinary bladder into a collection bag outside of your body when you can't urinate on your own). A review of Resident 173's Physician Orders dated 6/25/2024, indicated Resident 173 had a Physician Order for Ceftriaxone (antibiotic) 1 gram ([gm] unit of measurement)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 identify resident's needs, and ensure the needed care and services during showers and personal hygiene were provided in accordance with professional standards of practice, and the comprehensive person-centered care plan, for one of three residents (Resident 1). This deficient practice resulted in lice (tiny insects that crawl on the scalp eating human blood) grown in Resident 1's head/ hair that can affect resident's highest practicable physical, mental, and psychosocial well-being. Findings A review of Resident 1's admission record indicated Resident 1 was admitted to the facility on [DATE], and re-admitted on [DATE], with a diagnosis that included schizophrenia (a mental disorder affecting the person's ability to think, fell and behave), protein calorie malnutrition (insufficient intake of protein), and candidiasis (fungal infection) of skin and nails. A review of Resident 1's history and physician (H&P) dated 10/25/2023, indicated resident had 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 implement one of three sampled residents (Resident 1's) care plan by not monitoring his hypersexual behavior (urges or behaviors that can not be controlled). This deficient practice had the potential to place residents at risk for unwarranted sexual advances. Findings: During a review of the face sheet, Resident 1 was admitted to the facility on [DATE] with diagnoses that included paranoid schizophrenia (a chronic and severe mental disorder that affects how a person thinks, feels, and behaves), bipolar disorder (a mental disorder marked by alternating periods of great happiness and great sadness), and hypersexual behaviors. During a review of Resident 1's care plan ([CP]- a form that summarizes a resident's health conditions, care needs and current treatment) dated 3/7/2024, the CP indicated Resident 1 needs behavioral management and monitoring every shift beginning on 3/8/24. During a review of Resident 1's physician orders, dated 3/7/ 2024 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 interview and record review the facility failed to complete Physician Orders for Life-Sustaining Treatments (POLST-care directives during life threatening situations) an approach to improve end of life care by encouraging providers to speak with patients and create specific medical orders to be honored by health care workers during medical crisis for five out of six Residents (Residents 11, 49, 8 ,60, and 47). This deficient practice had the potential to delay emergency treatment or the potential to force emergency, life-sustaining procedures against the resident's personal preferences. Findings: a. During a review of Resident's 11 admission Record (Face Sheet), the Face Sheet indicated Resident 11 was admitted to the facility on [DATE]. Resident 11's diagnoses included schizophrenia (a mental condition marked by withdrawal from reality, illogical thinking, delusions, and hallucinations behavior), bipolar (mental illness that causes unusual shifts in a person's mood, energy, activity levels, and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview the facility failed to ensure the call lights were within reach for two out five Residents (Resident 6 and 49). This deficient practice placed Resident 6 and 49 at risk for not receiving prompt care when needing assistance. Findings: a. During a review of Resident's 6 admission Record (Face Sheet), the Face Sheet indicated Resident 6 was initially admitted to the facility on [DATE] and was readmitted on [DATE]. Resident 6's diagnoses included schizophrenia (a mental condition marked by withdrawal from reality, illogical thinking, delusions, and hallucinations behavior), anxiety (the feeling of fear that occurs when faced with threatening or stressful situations), and gastro-esophageal reflux disease (a condition when the stomach contents move up into the esophagus [the canal that connects the throat and the stomach]). During a review of Resident 6's History and Physical (H&P), dated 9/20/2023, the H&P indicated, Resident 6 cannot make decisions but can make needs known.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of three sampled resident (Resident 62) were appropriately notified regarding changes in their Medicare coverage through provision of Notice of Medicare Non-Coverage (NOMNC) form. This deficient practice had the potential to result in the responsible parties not being able to exercise their right to file an appeal. Findings: During a review of Resident 62's Face Sheet, the Face Sheet indicated Resident 62 was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease (a progressive disease that destroys memory and other important mental functions), schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly), and insomnia (persistent problems falling and staying asleep). During a review of Resident 62's History and Physical (H&P), dated 5/18/2023, the H&P indicated, Resident 62 had the capacity for medical decision making. During an interview on 1/10/2024 at 9:40 a.m., with Business…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 quarterly Minimum Data Set ([MDS] resident assessment and care screening tool) for one of one sampled resident (Resident 7) were completed and submitted within the required timeframe. This deficient practice could potentially affect the care services of Resident 7. Findings: During a review of Resident 7's Face Sheet, the Face Sheet indicated Resident 7 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease (a group of lung disease that blocks the airflow and make it difficult to breathe), anemia (a common blood disorder that occurs when the body has fewer red blood cells than normal), and schizoaffective disorder (a mental illness that can affect your thoughts, mood and behavior. During a review of Resident 7's History and Physical (H&P), dated 2/28/2023, the H&P indicated, Resident 7 cannot make own decisions but can make needs known. During a review of Resident 7's last quarterly MDS…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide accurate information in the Minimum Data Set ([MDS] resident assessment and care screening tool) for one of one sampled resident (Resident 2). This deficient practice had the potential to result inaccurate care and services for the Resident 2 due to inappropriate MDS care screening and assessment tool practices. Findings: During a review of Resident 2's Face Sheet, the Face Sheet indicated the facility originally admitted Resident 2 on 1/4/2015 and was readmitted on [DATE] with diagnoses including dysphagia (difficulty of swallowing), Gastrostomy tube placement (a tube inserted through the belly that brings nutrition directly to the stomach), and chronic obstructive pulmonary disease (a group of lung disease that block airflow and make it difficult to breathe). During a review of Resident 2's History and Physical (H&P), dated 12/7/2023, the H&P indicated, Resident 2 had fluctuating capacity to understand and make decisions. During…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure one out of five Residents (Resident49) had a revised care plan. This deficient practice of not revising the care plan for Resident 49 had the potential of not receiving appropriate interventions. Findings: During a review of Resident's 49 admission Record (Face Sheet), the Face Sheet indicated Resident 49 was admitted to the facility on [DATE]. Resident 49's diagnoses included schizophrenia (a mental condition marked by withdrawal from reality, illogical thinking, delusions, and hallucinations behavior), dementia (difficulty with reasoning, judgement, and memory), and metabolic encephalopathy (an altercation in consciousness caused due to brain dysfunction). During a review of Resident 49's History and Physical (H&P), dated 11/13/2023, the H&P indicated, Resident 49 does not have the capacity to understand and make decisions. Resident 49's Minimum Data Set ([MDS] a comprehensive assessment and care-screening tool), dated 12/20/2023, the MDS…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice, for one of one sampled resident (Resident 19) by failing to notify physician of left foot edema (swelling caused by too much fluid trapped in the body's tissues) and to provide and implement interventions. This deficient practice had the potential to result in a delay in reducing the swelling of the affected extremity and assessing for possible complications. Findings: During a review of Resident 19's Face Sheet, the Face Sheet indicated the facility originally admitted Resident 19 on 6/3/2016 and was readmitted on [DATE] with diagnoses including chronic obstructive pulmonary disease (a group of lung disease that block airflow and make it difficult to breathe), depression (a mood disorder that causes persistent feelings of sadness, emptiness, and loss of joy), and hypertensive heart disease (heart problems that occur because of high blood…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to have a sitter monitoring one out of six Residents (Resident 49) 24 hours a day due to impulsive outburst (without warning) behaviors and falls. This deficient practice of not having continuous supervision ([one to one sitter] staff that are immediately at hand to prevent a fall or redirect a patient from engaging in a harmful act) placed Resident 49 at for avoidable injuries. Findings: During a review of Resident's 49 admission Record (Face Sheet), the Face Sheet indicated Resident 49 was admitted to the facility on [DATE]. Resident 49's diagnoses included schizophrenia (a mental condition marked by withdrawal from reality, illogical thinking, delusions, and hallucinations behavior), dementia (difficulty with reasoning, judgement, and memory), and metabolic encephalopathy (an altercation in consciousness caused due to brain dysfunction). During a review of Resident 49's History and Physical (H&P), dated 11/13/2023, the H&P 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 interview and record review, the facility failed to ensure a competency assessment skill (a measurable pattern of knowledge, skills, abilities, behaviors, and other characteristics in performing that an individual need to perform work roles or occupational functions successfully) checks were performed annually for two of five randomly selected staff. This deficient practice had the potential for the facility not be able to assess the skills necessary to provide nursing services to assure resident safety and to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident will not be performed within the acceptable standards of practice. Findings: During a concurrent interview and record review on 1/11/2024 at 3:08 p.m., with the Director of Staff Development 1 (DSD1), five random employee files were checked and reviewed. Minimum Data Set nurse 1 (MDS nurse 1) and Licensed Vocational Nurse 1 (LVN 1) did not have yearly competency assessment skills done. DSD 1 stated it was the responsibility of the Director of Nursing 1 (DON 1) 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 establish a comprehensive and person-centered plan of care, for one of three sampled residents (Resident 1) to address the resident's history of refusing to take his psychotropic medications (treatment for managing psychosis) to manage his aggressive behavior towards staff and residents. This deficient practice resulted in Resident 1 not receiving the level of care needed to ensure his needs were met. This deficient practice also resulted in Resident 1 lashing out and hurting another resident. Findings: A review of Resident 1's admission record (Face sheet), the face sheet indicated Resident 1 was admitted on [DATE], with a diagnosis of schizophrenia (a mental disorder affecting the persons ability to think, fell and behave), Alzheimer's (a disorder that affects memory and other mental functions), and diabetes (high blood sugar). The face sheet indicated Resident 1 was self responsible. A review of Resident 1's minimum data set ([MDS] a standardized…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide supervision in the patio for 2 out of 2 sampled residents (Resident 1, and Resident 2) during a pending smoking break. This deficient practice resulted in a resident-to-resident altercation between Resident 1 and Resident 2 where Resident 1 sustained scratches on the left arm and Resident 2 sustained an abrasion (cut) below the lip. Findings: A review of Resident 1's admission record (Face sheet), the face sheet indicated Resident 1 was admitted on [DATE], with a diagnosis of schizophrenia (a mental disorder affecting the persons ability to think, fell and behave), Alzheimer's (a disorder that affects memory and other mental functions), and diabetes (high blood sugar). The face sheet indicated Resident 1 was self responsible. A review of Resident 1's minimum data set ([MDS] a standardized care assessment and care screening tool), dated 7/22/2023, the MDS indicated Resident 1's cognitive skills (thought process) was moderately impaired and could…

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