Kei-Ai Los Angeles Healthcare Center

Based on observation, interview, and record review the facility failed to update and revise the range of motion (ROM - uses guided exercises to help joints move properly, reducing stiffness and increasing flexibility after injury, surgery, or illness) care plan for one out of one sampled resident (Resident 12). This deficient practice had the potential to prevent Resident 12 from receiving care to address their specific needs, which could lead to a decline in emotional and physical health. Findings: During a review of Resident 12's admission Record, the admission record indicated the facility admitted Resident 12 on 1/24/2022 with diagnoses that include bipolar disorder (mood swings that range from the lows of depression to elevated periods of emotional highs), acquired absence of right leg above the knee (leg removed surgically or lost due to an injury at a point above the knee joint), unspecified dementia (a progressive state of decline in mental abilities) and neuralgia and neuritis unspecified (nerve pain and irritation of unknown cause). During a review of Resident 12 Baseline…

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

Based on observation, interview, and record review, the facility failed to maintain the appropriate Low Air Loss Mattress (LALM - a pressure-relieving mattress used to prevent and treat pressure injuries, localized damage to the skin and/or the he non-hardened, flexible area beneath your skin usually over a bony area) settings for two of six sampled residents (Resident 42 and Resident 193). This failure had the potential to increase the risk of skin breakdown (damage to the skin and underlying tissue, ranging from red, irritated skin to deep, open wounds/bedsores) and development of pressure ulcers/injuries (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence) for Resident 42 and Resident 193.Findings: During a review of Resident 42's admission Record, the admission Record indicated the facility originally admitted Resident 42 on 8/3/2021 and readmitted Resident 42 on 4/11/2022 with diagnoses that included rheumatoid arthritis (a chronic progressive disease-causing inflammation in the joints and resulting in painful deformity and…

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

Based on observation, interview, and record review, the facility failed to ensure one of five sampled residents (Resident 79) identified as at risk for falls was free from risks of falling, by failing to ensure the resident's bed was placed in the lowest position. This deficient practice placed Resident 79 at increased risk for falls and complications related to fall injuries such as fractures, cuts, and internal bleeding.Findings: During a review of Resident 79's admission Record, the admission Record indicated the facility admitted Resident 79 on 6/28/2024 with diagnoses that included vascular dementia (a progressive state of decline in mental abilities), pain in right hip, pain in left hip, collapsed vertebra thoracolumbar region (one of the bones in the spine, located where the middle back meets the lower back, has broken and flattened, becoming shorter in height), malignant neoplasm of prostate (prostate cancer, a disease where cells in the walnut-sized male gland below the bladder grow uncontrollably and can spread), and pain in unspecified ankle and joints of unspecified…

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

Based on observations, interviews, and record reviews, the facility failed to provide necessary respiratory care services for one of one sampled residents (Resident 120), by failing to ensure Resident 120's oxygen nasal cannula tubing (a lightweight, flexible plastic tube with two small prongs that sit just inside your nostrils to deliver supplemental oxygen) was not resting on the floor while Resident 120 was using the oxygen nasal cannula. This failure had the potential for Resident 120 to experience respiratory infections (infections of parts of the body involved in breathing) associated with using an unsanitary (dirty, unhealthy, or unclean in a way that could endanger health) oxygen nasal cannula tubing.Findings: During a review of Resident 120's admission Record, the admission Record indicated the facility originally admitted Resident 120 on 8/2/2021 and readmitted Resident 120 on 3/7/2022 with diagnoses that included personal history of COVID-19 (a contagious respiratory illness caused by the SARS-CoV-2 virus), dementia (a progressive state of decline in mental abilities),…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the facility's medication error rate (the percentage of errors observed during medication administration) was less than five percent (%). Two medication errors out of a total of twenty-six opportunities contributed to an overall medication error rate of seven-point six nine percent (7.69 %), affecting one of four sampled residents (Resident 260) who was observed during medication administration (med pass). The facility failure to assess Resident 260's systolic blood pressure (SBP - the pressure in the arteries when the heart beats [bpm]) and/or heart rate (HR - the number of times the heart beats per minute) prior to administering Labetalol and Lisinopril (medications used to treat hypertension [HTN - high blood pressure]) to the resident as ordered. The failure placed Resident 260 at risk for bradycardia (HR that is too slow) and/or hypotension (low blood pressure [BP]), which could lead to other complications and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure proper storage, labeling, and/or disposal of medications, by failing to ensure an open box of Advair Diskus (a medication that contains both an anti-inflammatory medicine (fluticasone propionate) and a long-acting bronchodilator (salmeterol) with a shorten expiration date (the medicine will become less effective or unsafe sooner than the date originally printed on the bottle) once opened, had an open date (the date the medication was first opened) for one of four sampled residents (Resident 334), as per the manufacturer's label for Advair Diskus dated 6/2023. The deficient practice increased the risks associated with Resident 334 chronic obstructive pulmonary disease (COPD - a chronic lung disease causing difficulty in breathing) could have received expired or ineffective medications which could result in health complications, difficulty breathing, or hospitalization.During a review of Resident 334's admission record, the admission…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, interviews, and record reviews, the facility failed to maintain infection control measures necessary to prevent the spread of infections for two out of nine sampled residents (Resident 262 and Resident 292), by failing to: Ensure Licensed Vocational Nurse 3 (LVN 3) performed hand hygiene (cleaning your hands to remove dirt, viruses, and bacteria, primarily through washing with soap and water or using alcohol-based sanitizer) before administering medications and coming in direct contact (physically touching someone or interacting face-to-face, allowing for the potential for immediate transfer of germs) with Resident 262.Ensure Certified Nurse Assistant 2 (CNA 2) wore full personal protective equipment (PPE-mask, gown, eye protection, gloves) per facility policy and procedures (P&P) titled Enhanced Barrier Precautions (EBP) with an last reviewed date of 1/8/2026 before providing care and treatment to Resident 292, who required enhanced barrier precautions (an infection control intervention…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop and implement an appropriate discharge plan for one of the four sampled residents (Resident 1) who was transferred to General Acute Care Hospital (GACH) on 7/29/2025 for further psychiatric evaluation and was not permitted to return to the facility per their policy. This deficient practice resulted in Resident 1 to unnecessary remain in GACH four months after he was cleared for discharge.A review of Resident 1's admission record indicated the facility initially admitted the resident on 7/22/2025, with diagnosis that included encephalopathy (a broad term for any disease, damage, or dysfunction of the brain that changes its function or structure, often showing up as an altered mental state like confusion, memory loss, or personality changes, caused by issues like infection, toxins, trauma, or lack of oxygen), epilepsy (a chronic brain disorder characterized by two or more unprovoked, recurring seizures, caused by sudden, abnormal electrical…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 make prompt efforts to resolve grievance for one of four sampled residents (Resident 1). The facility failed to address Resident 1's complaints regarding inadequate assistance from staff and nursing care.This deficient practice violated the residents' right to have his grievances addressed promptly.During a review of the admission Record indicated the facility admitted Resident 1 on 7/18/25 with diagnoses including esophagitis (inflammation of the lining of the esophagus [muscular tube that connects the throat to the stomach], duodenal ulcer (sores on the lining of the stomach) and generalized muscle weakness.During a review of the Minimum Data Set (MDS, resident assessment tool) dated 10/22/25 indicated Resident 1 was cognitively intact. Resident 1 used the walker and wheelchair for mobility. Resident 1 was independent with eating, oral hygiene, upper body dressing, putting on/taking off footwear. Resident 1 needed clean-up assistance with toileting hygiene and substantial assistance (helper does more than half 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 obtain a physician's order before applying topical (a medication applied to the skin) ointment in accordance with professional standards of practice for one of five sampled residents (Resident 1). For Resident 1, the facility failed to obtain a physician order before applying zinc oxide (a protective skin cream that works by creating a physical barrier on top of the skin) topical ointment to Resident 1's Moisture Associated Skin Damage (MASD, moisture associated skin damage caused from prolonged exposure to moisture) in the buttock skin folds on 11/18/25 at 9:10 a.m. This deficient practice had potential to place Resident 1 at risk for receiving unnecessary medication and experiencing adverse effects.During a review of the admission Record indicated the facility originally admitted Resident 1 on 9/25/2001, and readmitted on [DATE], with diagnoses including dysphagia (difficulty swallowing), cerebral infarction (a stroke caused by a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure residents' medical records are complete and accurate for two of three sampled residents (Resident 1 and Resident 2). The facility failed to:1. Document in Resident 1's medical record that a nurse-to-nurse report was given on 9/8/25 when Resident 1 was discharged to Facility A on 9/8/25. 2. Document in Resident 2's medical record that a nurse to nurse report was given on 9/17/25 when Resident 2 was discharged to Facility B on 9/17/25. These deficient practices resulted in inaccurate and incomplete records for Resident 1 and Resident 2. 1.During a review of the admission Record indicated the facility admitted Resident 1 on 8/1/25 with diagnoses including cerebral infarction (a medical condition that occurs when the blood flow to the brain is disrupted), diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) and generalized muscle weakness.During a review of the Minimum Data Set (MDS, a resident…

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

Based on interview and record review the facility failed to ensure one of three sampled residents (Resident 1) was free from unnecessary restraints (a method or device that restricts a patient's freedom of movement or normal access to their body) by failing to: 1.Ensure Certified Nursing Assistant 2 (CNA2) did not wrap a linen sheet around Resident 1's legs and tied it to Resident 1's bedframe to restrict Resident 1's movement on 9/11/2025. This failure resulted in Resident 1's movement being restricted and had the potential for Resident 1 to develop an injury, impaired circulation (a condition where blood flow is reduced or blocked in certain areas of the body), skin breakdown (damage to the skin that can lead to open wounds and infections), and/or pain. Findings: During a review of Resident 1's admission Record, the admission Record indicated the facility admitted the resident on 7/25/2024 with diagnoses that included type 2 diabetes (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing), Alzheimer's disease (a disease characterized by a…

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

Based on interview and record review, the facility failed to report an allegation of staff to resident abuse to the California Department of Public Health (CDPH) and the ombudsman (an advocate for residents of nursing homes, board and care centers, and assisted living facilities) within two hours from when one of three sampled residents (Resident 1) was found with a linen sheet wrapped around Resident 1's legs and tied to his bedframe. This failure had the potential to result in a delay of an onsite inspection by CDPH and had the potential for Resident 1 to experience ongoing abuse.Findings: During a review of Resident 1's admission Record, the admission Record indicated the facility admitted the resident on 7/25/2024 with diagnoses that included type 2 diabetes (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing), Alzheimer's disease (a disease characterized by a progressive decline in mental abilities), dementia (a progressive state of decline in mental abilities), dysphagia (difficulty swallowing), benign prostatic hyperplasia (a…

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

Based on observation, interview, and record review the facility failed to implement its policies and procedure (P&P) on infection control to prevent the spread of coronavirus disease 2019 (COVID19, a highly contagious infection affecting the respiratory system caused by a virus that can spread from person to person). The facility failed to:1. Ensure all personnel wear N95 masks (disposable face mask that covers the user's nose and mouth which offers protection from small solid or liquid droplets found in the air) during the COVID19 outbreak.2. Ensure the N95 was properly worn.3. Remove gloves promptly after contact with resident items. 4. Comply with the local health department guidelines to contain the spread of the COVID19 that included social distancing, staggered communal activities, separate laundry items of residents who were exposed to the COVID19 from the non-infected residents and keeping doors closed for residents who were exposed to the COVID19 These deficient practices resulted in protective measures not being used by the facility and had the potential to increase 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 update the residents regarding their discharge plan for one of two sampled residents (Resident 1). For Resident 1, the facility failed to notify and update Resident 1 regarding Resident 1's plan for discharge.This deficient practice resulted in Resident 1 stating that she wanted to go home and felt frustrated for not knowing what the discharge plan for her was. During a review of the admission Record indicated the facility admitted Resident 1 on 8/23/22 and re-admitted on [DATE] with diagnoses including anemia (a condition where the body does not have enough healthy red blood cells) and hypertension (HTN-high blood pressure).During a review of the Minimum Data Set (MDS, a resident assessment tool) dated 5/28/25 indicated Resident 1 was cognitively intact. Resident 1 needed substantial assistance (helper does more than half the effort) with toileting hygiene, shower/bathe self, lower body dressing, partial assistance (helper does less than 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 create an effective discharge plan for one of two sampled residents (Resident 1). For Resident 1, the facility failed to:1.Update Resident 1's discharge care plan. 2. Include Resident 1 in the discharge planning process.These deficient practice resulted in Resident 1 stating that there was a lack of communication regarding her discharge from the facility.During a review of the admission Record indicated the facility admitted Resident 1 on 8/23/22 and re-admitted on [DATE] with diagnoses including anemia (a condition where the body does not have enough healthy red blood cells) and hypertension (HTN-high blood pressure).During a review of the Minimum Data Set (MDS, a resident assessment tool) dated 5/28/25 indicated Resident 1 was cognitively intact. Resident 1 needed substantial assistance (helper does more than half the effort) with toileting hygiene, shower/bathe self, lower body dressing, partial assistance (helper does less than the effort) with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to notify and update the resident's responsible party (RP) for one of three sampled residents (Resident 1). For Resident 1, the facility failed to:1.Notify and update Resident 1's RP on 7/12/25 when Resident 1's transportation to take him home was delayed. 2.Review and respond accordingly to the voicemail left by Resident 1's RP. These deficient practices resulted in Resident 1 feeling anxious to go home and Resident 1's RP stated she was waiting and worried because Resident 1 had not arrived home. 1.During a review of the admission Record indicated the facility admitted Resident 1 on 6/14/25 with diagnoses including fracture (break in the bone) of the right femur (thigh bone), Parkinsons disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements) and muscle weakness. During a review of the Minimum Data Set (MDS, resident assessment tool) dated 6/18/25 indicated Resident 1 was cognitively intact.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to revise and update the care plan for one of four sampled residents (Resident 1). For Resident 1 the facility failed to update the care plan when Resident 1's Alprazolam (medication used to treat anxiety disorder) was discontinued on 4/10/25. This deficient practice resulted in inaccurate reflection of the actual care provided to Resident 1. Findings: During a review of the admission Record indicated the facility admitted Resident 1 on 3/6/25 and re-admitted on [DATE] with diagnoses including anxiety disorder, mood disorder and generalized muscle weakness. During a review of the Minimum Data Set (MDS, resident assessment tool) dated 4/12/25 indicated Resident 1 had moderately impaired cognitive skills. Resident 1 was dependent (helper does all the effort) with toileting hygiene, upper/lower body dressing, putting on/taking of footwear, personal hygiene, substantial assistance with oral hygiene and supervision with eating. During a review of the Physician…

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

Based on observation, interview and record review, the facility failed to follow their policy on infection control for cleaning and disinfection of re-usable devices. During observation on 6/24/25 at 10:13 a.m., five oxygen concentrators (type of medical device used for delivering oxygen to individuals with breathing-related disorders) that were not sanitized (reduces the number of germs on objects and surfaces to levels considered safe) were observed in the supply room. This deficient practice had the potential to contaminate the clean supplies of the unit used by other residents. Findings: During observation and concurrent interview on 6/24/25 at 10:13 a.m., licensed vocational nurse (LVN) 1 stated there are five oxygen concentrators kept in the supply room that were not covered with plastic. LVN 1 stated the five concentrators were used by the residents and are waiting to be picked up by the hospice company. LVN 1 stated if the concentrators were sanitized it would be covered with plastic. LVN 1 also stated the supply room is where they keep the clean supplies for the other…

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

Based on observation, interview and record review the facility failed to ensure the medications were not left unattended at the bedside table according to the professional standard of practice for medication administration for one of three sampled residents (Resident 1). On 6/6/25 at 9:52 a.m., a medication cup with pills was observed at the bedside table of Resident 1. The facility failed to remain with Resident 1 to ensure Resident 1 had taken all her medications and not leave medications at the bedside. This deficient practice had the potential for Resident 1 to not take all her medications and for other residents to consume the medication left at the bedside. Findings: During a review of the admission Record indicated the facility admitted Resident 1 on 7/31/23 with diagnoses including hypertension (high blood pressure), seizure (sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness) and generalized muscle weakness. During a review of Resident 1's Care Plan revised on 1/10/25 indicated Resident 1…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to implement the care plan for one of two sampled residents (Resident 1). For Resident 1, the facility failed to monitor Resident 1 ' s intake and output as indicated in the care plan. This deficient practice had the potential for the facility not to be able to meet the hydration and nutritional needs of Resident 1. Findings: During a review of the admission Record indicated the facility initially admitted Resident 1 on 3/7/24 and re-admitted on [DATE] with diagnoses including heart failure (the heart cannot pump enough blood and oxygen to support other organs in the body), chronic kidney disease (progressive damage and loss of kidney [organ that filters blood) function) and dementia (a progressive state of decline in mental abilities). During a review of Resident 1 ' s Care Plan initiated on 12/29/24, indicated Resident 1 had impaired renal (kidney) function related to chronic kidney disease. The Care Plan goal indicated Resident 1 will be free from signs…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 order was transcribed accurately for one of two sampled residents (Resident 1). For Resident 1, the facility failed to ensure the gastrostomy tube (GT, a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems) feeding start and stop times were accurately documented. The Physician Order dated 4/15/25 at 3 p.m. indicated to give Resident 1 GT feeding of Nutren (tube feeding formula) at 50 milliliters per hour (ml./hr., measure of flow rate) and water at 40 ml/hr. for 16 hours. However, the order indicated to start at 6 p.m. and stop at 6 a.m., (12 hours instead of 16 hours). This deficient practice resulted in inaccurate documentation of Resident 1 ' s medical record and had the potential for Resident 1 not given the adequate nutrition and fluid needed by Resident 1. Findings: During a review of the admission Record indicated the facility initially…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 resident call light system (a communication tool used in medical facilities to facilitate communication between residents and healthcare providers; by allowing residents to signal when they need assistance. The system typically includes call buttons or pull cords in resident rooms or bathrooms, often with visual indicators like dome lights outside the rooms to alert staff) remained functional on 5/3/2025 – 5/4/2025 for 71 out of 71 residents on the second floor of the facility. By failing to ensure staff reset bathroom call lights after being triggered. This deficient practice had the potential to result in injury or harm due to residents not being able to call for facility staff as needed for help and/or during an emergency. Findings: During a review of the facility ' s Incident Response Timeline and Action Plan (IAP) dated 5/3/2025, the IAP indicated the facility had a call light system malfunction (when a piece of equipment fails to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to implement the comprehensive care plan for one of six sampled residents (Resident 1). For Resident 1, the facility failed to apply floor mat at the right side of Resident 1 ' s bed as indicated in Resident 1 ' s care plan for falls. This deficient practice had the potential for Resident 1 to sustain an injury when Resident 1 falls. Findings: During a review of the admission Record indicated the facility admitted Resident 1 on 12/10/24 with diagnoses including dementia (a progressive state of decline in mental abilities), history of falling and unsteadiness on the feet. During a review of Resident 1 ' s Fall Risk Screen dated 12/10/24 at 5 p.m., indicated Resident 1 was at high risk for falling. During a review of Resident 1 ' s Care Plan initiated on 12/11/24 and revised on 2/6/25, indicated Resident 1 had high risk for falls and injury related to history of falling, impaired mobility, weakness and with concurrent medical conditions. The…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure staff maintain current basic life support (BLS, set of emergency procedures designed to sustain life in victims experiencing cardiac arrest [when the heart stops beating suddenly]) certification for one of five sampled healthcare workers (Certified Nursing Assistant 1 [CNA 1]). CNA 1 ' s BLS certificate expired on [DATE]. This deficient practice had the potential for CNA 1 not to recognize residents who may need immediate emergency intervention. Findings: During a concurrent interview and record review on [DATE] at 11:39 a.m., the BLS certificates for one registered nurse (RN) one licensed vocational nurse (LVN) and three CNAs were reviewed with the director of staff development (DSD). DSD stated the facility require BLS certification for licensed staff only and needs to be renewed every two years. DSD stated the CNAs were not required to have BLS certification. CNA 1 ' s BLS certificate expired on [DATE]. During a review of the facility'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 provide adequate supervision to prevent accidents for one of six sampled residents (Resident 1). For Resident 1 the facility failed to: 1.Ensure the sensor pad alarm (device that detects when weight is removed from the pad, triggering an audible or visual alarm) placement was monitored and functioning. 2. Ensure staff respond immediately when the sensor pad alarm triggers an audible alarm. These deficient practices resulted in Resident 1 having unwitnessed falls on 2/6/25, 2/7/25 and 2/9/25 and had the potential for Resident 1 to sustain major injury such as fracture (break in the bone). Findings: During a review of the admission Record indicated the facility admitted Resident 1 on 12/10/24 with diagnoses including dementia (a progressive state of decline in mental abilities), history of falling and unsteadiness on the feet. During a review of Resident 1 ' s Fall Risk Screen dated 12/10/24 at 5 p.m. indicated Resident 1 was at high risk for falling. During a review of Resident 1 ' s Care Plan initiated on 12/11/24 and…

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

Based on interview and record review, the facility failed to provide laboratory services to one of six sampled residents (Resident 2). For Resident 2, the facility failed to follow physician order to do blood tests that included complete blood count (CBC, blood test that measure the number and types of cells in the blood) and comprehensive metabolic panel (CMP, blood test that measures 14 components of the blood that would assess including liver and kidney function) every Friday. Resident 2 had blood tests done on 6/28/24 (Friday) but failed to repeat the blood test the following Friday on 7/5/24. This deficient practice had the potential for the facility to fail to determine if Resident 2 ' s kidney function was worsening. Findings: During a review of the admission Record indicated the facility admitted Resident 2 on 6/25/24 with diagnoses including osteomyelitis of the vertebra (bone infection in the spine) and chronic kidney disease stage five (the kidneys (body organ) are severely damaged and have stopped doing its job of filtering waste from the blood). During a review of the…

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

Based on interview and record review, the facility failed to obtain the discharge order from the primary physician in accordance with professional standard of practice for one of three sampled residents (Resident 1). For Resident 1 the facility failed to: 1.Obtain discharge order from Resident 1 ' s primary physician before discharging Resident 1 on 1/23/25. The facility entered a telephone order from the primary physician on 1/22/25 that Resident 1 was for discharge home on 1/23/25. However, the primary physician did not give the discharge order. 2.Ensure accurate entry in Resident 1 ' s Progress Note on 1/21/25 at 9:01 pm that an order was obtained to discharge Resident 1 home on 1/23/25. The entry did not indicate which physician gave the discharge order. These deficient practices resulted in inaccurate record for Resident 1 and falsification of physician orders. Findings: During a review of the admission Order indicated the facility admitted Resident 1 on 12/26/24 with diagnoses including after care following surgery, unsteadiness on feet and generalized muscle weakness. 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 obtain informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding risks, benefits and alternatives offered) for one of five sampled residents (Resident 1). For Resident 1, the facility failed to obtain informed consent before starting Resident 1 on the following psychotropic medications (drugs that affect the mind, emotions and behavior) on 12/19/24. 1. Trazadone 12.5 milligrams (mg., metric unit of measurement, used for medication dosage and/or amount) orally at bedtime for depression. 2. Wellbutrin extended release (XL) 150 mg. orally one tablet daily for depression. 3. Duloxetine 30 mg. orally two capsules two times a day for depression. 4. Brexpiprazole one mg. one tablet orally at bedtime for psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality). This deficient practice resulted in Resident 1 not given the right to know the risks…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 toileting (maintain perineal hygiene after voiding or bowel movement) and personal hygiene for one of five sampled residents (Resident 1). For Resident 1, who was frequently incontinent (involuntary loss of control) of bowel and bladder and refused personal and toileting hygiene multiple times after each episode of incontinence, the facility failed to: 1. Involve Resident 1 ' s responsible party (RP) to discuss the plan of care regarding Resident 1 ' s refusal of personal and toileting hygiene after each episode of incontinence. 2. Notify the physician regarding Resident 1 ' s refusal of hygiene care. These deficient practices resulted in Resident 1 with unpleasant smell, poor hygiene and had the potential for Resident 1 to develop infection and pressure ulcer (wounds that occur from prolonged pressure the skin). Findings: During a review of the admission Record indicated Resident 1 was initially admitted to the facility on [DATE] and was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY d. A review of Resident 60's admission record indicated Resident 60 was admitted to the facility on [DATE], with diagnoses including dementia (a chronic condition that causes a gradual decline in cognitive abilities, such as thinking, remembering, and reasoning), peripheral vascular disease (PVD - a slow progressive narrowing of the blood flow to the arms and legs), and urinary incontinence (involuntary leakage of urine from the bladder). A review of Resident 60's History and Physical (H&P) report completed on 11/5/2024, indicated Resident 60 was alert, confused, and responded to simple questions. The H&P indicated Resident 60 did not have the capacity to understand and make decisions. A review of Resident 60's MDS dated [DATE], indicated Resident 60 usually understood others and was usually able to express ideas and wants. The MDS indicated Resident 60 used a wheelchair, and was dependent for toileting, showering, and upper/lower body dressing. The MDS indicated Resident 60 was always incontinent. A review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to assess and directly notify the primary physician of a significant change in condition (major decline or improvement in a resident's status that will not resolve itself without intervention) for one of nine sampled residents (Resident 130) with limited range of motion [ROM, full movement potential of a joint (where two bones meet)] and mobility (ability to move) on 12/20/2024 regarding Resident 130's inability to walk with the Restorative Nursing Aide ([RNA] certified nursing aide program that helps residents to maintain their function and joint mobility). These failures resulted in the discontinuation of RNA for walking using hand-held assistance (physical assist by holding onto a person's hand) or front-wheeled walker ([FWW] an assistive device with two front wheels used for stability when walking) without directly discussing Resident 130's care with the physician, which had the potential to contribute to the development 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 interview and record review the facility failed to ensure one of one resident (Resident 38) had an accurate assessment documented in the resident's medical record to support the administration of the psychotropic medications (drugs that affect the brain and nervous system to treat mental illness). This deficient practice caused an increased risk for Resident 38 to receive unnecessary medications. Findings: A review of Resident 38's admission record indicated the resident was admitted to the facility on [DATE] with diagnoses including dementia (a progressive state of decline in mental abilities), alcohol dependency, and opioid dependency (a class of drugs that derive from, or mimic, natural substances found in the opium poppy plant. A review of Resident 38's Minimum Data Set (MDS-a federally mandated resident assessment tool) dated 11/16/24, indicated the resident was alert and oriented with good recall. The MDS indicated Resident 38 had little interest or pleasure in doing things and felt down,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 A review of Resident 44's admission Record indicated the facility admitted the resident on 3/03/2021 with diagnoses including schizophrenia (a mental illness that is characterized by disturbances in thought) and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). A review of Resident 44's Minimum Data Set (MDS - a resident assessment tool) dated 3/07/2024, indicated while in the facility it was somewhat important to participate in religious services or practices and do her favorite activities. A review of Resident 44's Activity Assessment Form dated 3/08/2024, indicated the resident's preferences included turning on television or music, Christian service 1x week, and bingo games at bedside. The assessment indicated the residents desired outcome from involvement within the activity program was pleasure and comfort. A review of Resident 44's MDS dated [DATE], indicated the resident had severe cognitive impairment (problems with a person's ability to think,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY c. A review of Resident 44's admission Record indicated the facility admitted the resident on 3/03/2021 with diagnoses including schizophrenia (a mental illness that is characterized by disturbances in thought) and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). A review of Resident 44's Minimum Data Set (MDS - a resident assessment tool) dated 3/07/2024, indicated while in the facility it was somewhat important to participate in religious services or practices and do her favorite activities. A review of Resident 44's Activity Assessment Form dated 3/08/2024, indicated the resident's preferences included turning on television or music, Christian service 1x week, and bingo games at bedside. The assessment indicated the residents desired outcome from involvement within the activity program was pleasure and comfort. A review of Resident 44's Activity Monthly Time Sheet dated 10/2024, indicated the resident watched television 29 days, had…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide services to five of nine residents (Resident 37, 127, 44, 36, and 128) with limited range of motion ([ROM] full movement potential of a joint [where two bones meet]) and mobility (ability to move) by failing to: 1. Provide Resident 37 with active range of motion ([AROM] performance of ROM of a joint without any assistance or effort of another person) to both arms, five times per week, in accordance with the physician's order, dated 12/26/2024. 2. Provide Resident 37 with sit-to-stand transfers using a front-wheeled walker ([FWW] an assistive device with two front wheels used for stability when walking), five times per week, in accordance with the physician's order, dated 12/26/2024. 3. Provide Resident 127 with passive range of motion ([PROM] movement of joint through the ROM from an external force with no effort from the person) to both legs, five times per week, from 11/2024 to 12/2024 in accordance with the physician's order,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide therapy services, including Occupational Therapy ([OT] profession aimed to increase or maintain a person's capability of participating in everyday life activities [occupations]) and Physical Therapy ([PT] profession aimed in the restoration, maintenance, and promotion of optimal physical function) to one of nine sampled residents (Resident 96) with range of motion ([ROM] full movement potential of a joint [where two bones meet]) and mobility (ability to move) concerns in accordance with Resident 96's physician signed care plans for OT and PT. This failure resulted in Resident 96 not receiving OT and PT interventions from 10/9/2024 to 10/29/2024 to improve activities of daily living ([ADLs] tasks related to personal care including bathing, dressing, hygiene, eating, and mobility) and potentially contributed to Resident 96's further ROM limitations in both knees. Findings: During a review of Resident 96's admission Record, 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 did not ensure four of nine sampled residents (Resident 96, 130, 44, and 37) with limited range of motion ([ROM] full movement potential of a joint [where two bones meet]) and mobility (ability to move) had complete clinical records. 1. Resident 96's clinical records did not include the Physical Therapy ([PT] profession aimed in the restoration, maintenance, and promotion of optimal physical function) and Occupational Therapy ([OT] profession aimed to increase or maintain a person's capability of participating in everyday life activities [occupations]) Discharge Summaries on 6/14/2024. 2. Resident 96's clinical records did not include the Occupational Therapy Discharge Summary on 11/2/2024 and PT Discharge Summary on 11/4/2024. 3. Resident 130's clinical record did not include the OT Discharge Summary on 10/14/2024 and PT Discharge Summary on 10/15/2024. 4. Resident 44's clinical record did not include the OT Discharge Summary on 9/12/2024 and PT Discharge…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 respect the resident's right to dignity and respect for one sampled resident (Resident 82), by failing to utilize the facility's translation services to communicate with non-English speaking Resident 82. This deficient practice had the potential to negatively affect Resident 82's psychosocial wellbeing. Findings: A review of Resident 82's admission record indicated Resident 82 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including congestive heart failure (CHF-a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), toxic encephalopathy (a reversible brain dysfunction syndrome), and depression (a constant feeling of sadness and loss of interest). A review of Resident 82's History and Physical dated 1/19/2024, indicated Resident 82 could make needs known but could not make medical decisions. A review of Resident 82's quarterly Minimum Data Set (MDS - a 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 one sampled resident (Resident 173's) care plan for alteration in comfort was updated quarterly. This deficient practice had the potential to slow or stop Resident 173's progress toward achieving the highest practicable level of functioning. Findings: A review of the admission record indicated Resident 173 was admitted to the facility on [DATE], with diagnoses including diabetes, dysphagia (difficulty swallowing), gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems), and spinal stenosis (a narrowing of the spinal canal in the lower part of your back). A review of Resident 173's History and Physical (H&P) report completed on 5/2/2024, indicated Resident 173 did not have the capacity to understand and make decisions. A review of the Resident 173's Minimum Data Set (MDS - a resident assessment tool) dated 11/6/2024, 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 observation, interview, and record review, the facility failed to ensure one of two sampled residents (Resident 238) identified as at risk for seizures was free from accidents by failing to ensure a physician's ordered bilateral (both sides) padded side rails were placed on Resident 238's bed. This deficient practice placed Resident 238 at increased risk for falls injuries during a seizure (a disorder in which nerve cell activity in the brain is disturbed, causing seizures/convulsions). Findings: A review of Resident 238's admission Record indicated the resident was originally admitted to the facility on [DATE] with diagnosis including epilepsy and hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (condition that causes weakness or an inability to move on one side of the body) following cerebral infarction (occurs as a result of disrupted blood flow to the brain) affecting left non-dominant side and aphasia (a disorder that makes it difficult to speak).…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, interviews, and record reviews, the facility failed to ensure one of eight sampled residents (Resident 96) had physician orders to receive oxygen therapy via nasal cannula as needed for shortness of breath. This deficient practice had the potential to cause complications associated with oxygen therapy. Findings: A review of Resident 96's admission record indicated Resident 96 was originally admitted to the facility on [DATE] and readmitted [DATE] with diagnoses that include emphysema (chronic lung condition), cachexia (general stated of ill health involving great weight loss and muscle loss, and chronic kidney disease (Long lasting disease of kidneys leading to kidney failure). A review of Resident 96's initial Minimum Data Set (MDS-a comprehensive assessment and screening tool) dated 11/11/24, indicated Resident 96's cognition (level for daily decision making) was not intact. The MDS indicated the resident required extensive assistance from staff in transfers, bed mobility, and dressing.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure: 1. Two of five staff (Licensed Vocational Nurses [LVN 6] and 1 Registered Nurse [RN 3]) had a completed annual performance evaluation. 2. One of five staff (Registered Nurse [RN 4]) had a completed annual competency evaluation. 3. One of five staff (Certified Nursing Assistant [CNA 7]) had an active certified nursing assistant certification. This deficient practice had the potential for all 294 residents to not receive appropriate services. Findings: During a review of LVN 6's employee file, LVN 6's employee file indicated a hire date of [DATE]. The employee file indicated LVN 6's competency evaluation was last completed on [DATE]. No performance evaluation was noted on file. During a review of RN 3's employee file, RN 3's employee file indicated a hire date of [DATE]. No performance evaluation was noted on file. During a review of RN 4's employee file, RN 4's employee file indicated a hire date of [DATE]. No annual competency evaluation was…

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

Based on interview and record review, the facility failed to ensure one of six Certified Nursing Assistants (CNA 5) had a completed annual performance evaluation as per facility policy and procedures titled Performance Evaluations, revised June 2010. This deficient practice had the potential for all 294 residents to not receive appropriate services. Findings: During a review of CNA 5's employee file, it indicated that their date of hire was 7/26/2022. No performance evaluation was noted in CNA 5's employee file. During a concurrent interview and record review of CNA 5's employee file on 1/9/2025 at 8:17 AM with the Director of Staff Developer (DSD), CNA 5's employee file was reviewed. The DSD confirmed CNA 5 did not have a completed annual performance evaluation. The DSD stated it was important staff had an annual performance evaluation, so the staff knew how there were performing and issues like attendance and call offs were addressed with the employee. During an interview on 1/9/2025 at 2:12 PM with the Director of Nursing (DON), the DON stated certified nursing assistants were to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to: 1. Administer medication as per physician's orders for two of three sampled residents (Resident 256 and Resident 205). By failing to: a. Ensure Resident 256's Lidocaine External Patch (a medication applied topically to relieve pain) 4 percent (% - a unit of measurement for strength), apply to left knee topically one time a day for pain management and remove per schedule, order date 11/24/2024, and Lidocaine External Patch 4%, apply to right knee topically one time a day for R knee pain and remove per schedule, order date 10/27/2024 were removed on 1/6/2025 and new patches applied as per physician's orders. b. Resident 256's psyllium husk powder (a fiber laxative used to relieve constipation) give 1 scoop by mouth one time a day for gastrointestinal (GI) regularity mix with 8 ounces (oz - a unit of measurement for volume) of water or juice was administered in 8 ounces of water or water as per physician's orders dated 10/24/24. c. Ensure…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain a medication error rate of less than 5% (percent) during medication pass for two of three sampled residents (Residents 256 and 205) by failing to administer Resident 256's psyllium husk (a fiber laxative used to relieve constipation), and Resident 205's aspirin (a medication used to prevent heart attack [flow of blood and oxygen is blocked] and stroke [loss of blood flow to a part of the brain]) in accordance with physician's orders. These failures of medication administration error rate of 6.06% exceeded the five (5) percent threshold. Findings: a. During a review of Resident 256's admission Record (a document containing demographic and diagnostic information), dated 1/8/2025, the facility admitted Resident 256 on 10/9/2024 with diagnosis including (but not limited to) generalized muscle weakness. During a review of Resident 256's History and Physical dated 10/10/2024, the document indicated Resident 256 had 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.

Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 256) was free from significant medication errors by failing to administer Resident 256's lidocaine patch (a medication applied topically to relieve pain) in accordance with physician's orders. This failure of not administering Resident 256's medication in accordance with the physician orders or professional standards of practice had the potential to result in hospitalization due to adverse effects such as abnormal breathing, abnormal heartbeat, numbness, and tingling. Findings: During a review of Resident 256's admission Record (a document containing demographic and diagnostic information), dated 01/08/2025, the facility admitted Resident 256 on 10/09/2024 with diagnosis including (but not limited to) generalized muscle weakness. During a review of Resident 256's History and Physical dated 10/10/2024, the document indicated Resident 256 had the capacity to understand and make decisions. During a review of Resident 256'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.

Based on observation, interview, and record review, the facility failed to: 1. Ensure storage, labeling, and/or removal of expired, undated and/or discontinued medications including insulin (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication), Calcitonin (a medication administered into the nostrils to treat osteoporosis [a bone disease with low bone mineral density]) salmon (synthetic origin) nasal spray, Zytiga (generic name - abiraterone acetate, a medication used to treat cancer [a disease caused by uncontrolled division of abnormal cells in a part of the body]) and Stiolto Respimat (generic name - a combination of two medications containing tiotropium bromide and olodaterol used to treat chronic obstructive pulmonary disease [COPD - a chronic lung disease causing difficulty in breathing]), in accordance with manufacturer requirements and facility's policy and procedure (P&P) titled, Discontinued Medications undated and Storage of Medications undated, affecting four residents (Residents 111, 184, 218, 481) in three…

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

Based on observation, interview and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen, by failing to: 1.Discard expired food and/or drinks. a. One medium sized container of cottage cheese with dates 12/30-1/4/25 exceeding storage period for cottage cheese was stored in the reach in refrigerator. b. Five expired single serve cartons of milk with dates 1/5/25 were stored in the reach in refrigerator. 2. Label food taken from freezer with dates the foods were thawed. a. Nutritional Supplement labeled store frozen with manufacturers instruction to use within 14 days of thawing, were not monitored for the date they were thawed to ensure expired shakes were discarded after this time frame. b. One tray with 30 single serve cartons of mixed vanilla and chocolate flavored nutrition supplement were stored in the reach in refrigerator with no thaw date. c. Individual juice cartons with manufacturers instruction indicating if frozen, thaw, refrigerate and use within 10 days, were not monitored for the date they were thawed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 trash stored in the dumpster areas was maintained in sanitary manner. One of five garbage dumpster was overfilled with trash bags and uncovered. The floor area around the trash dumpsters was not clean, there was disposable gloves, paper, and food. This deficient practice had the potential for harborage and feeding of pests. Findings: During a concurrent observation and interview with DS and Facility Maintenance Manager (FMM) on 1/6/2025 at 2:00PM, one large dumpster outside of the food storage area was not covered. The dumpster was overfilled with trash bags and not covered. There was trash on the floor including disposable gloves and melted ice cream. During a concurrent interview with DS, DS stated the dumpster lids should be covered and there should not be trash on the floor. DS stated everyone uses the trash bins and it's not only dietary staff. During the same observation, FMM stated housekeeping cleans the area per shift and this must have happened after lunch shift. FMM stated trash bins…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement infection control practices for 3 of 6 residents (Resident 96, 228, and 74) with infection control concerns by failing to ensure staff and visitors wore eye protection, including a face shield or eye goggles, while providing care to the residents, who were under observation for exposure to Coronavirus Disease 2019 (COVID-19, a highly contagious viral disease that can cause respiratory illness), in accordance to the signage posted upon entering the room and Federal guidance. This failure had the potential to spread COVID-19 throughout the facility. Findings: a. During a review of Resident 96's admission Record, the facility admitted Resident 96 on 3/7/2024 and readmitted on [DATE]. The admission Record indicated Resident 96's diagnoses including a history of falling and adult failure to thrive (a decline caused by chronic diseases and functional impairments which can cause weight loss, decreased appetite, poor nutrition, and…

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

Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment, by failing to provide one of five sample resident (Resident 38) a stable toilet seat with side rails. The deficient practice had the potential for Resident 38 to fall and sustain an injury. Findings: During an interview on 1/6/25 at 11:32 AM, Resident 38 reported having fallen in the bathroom on earlier that morning (1/6/25). Resident 38 stated she did not grab hold of the toilet seat side rails because they were loose. One is looser than the other. During an observation in Resident 38's bathroom on 1/6/25 at 11:36 AM, the toilet seat side rails were attached by grey screws to the back of the toilet. The side rails raised up and down allowing a resident to grab hold to get up. The side rails moved freely but in the down position the railings did not adhere to the floor and were wobbly back and forth. During an interview on 1/7/25 at 7:30 AM, in Resident 38 room, Resident 38 stated she felt confident getting up. Resident 38 stated she was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed provide adequate supervision when using mechanical lift for one of three sampled residents (Resident 1). For Resident 1, the facility failed to provide two persons assist while using the easy stand (mechanical device used to lift individuals directly from the wheelchair, bed, or other seated surface into standing position) to transfer Resident 1 from the bathroom to Resident 1 ' s bed on 12/31/24. This deficient practice had the potential for Resident 1 to fall or sustain injury while using the easy stand. Findings: During a review of the admission Record indicated the facility admitted Resident 1 on 8/28/20 and re-admitted on [DATE] with diagnoses including morbid obesity and diabetes mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of the Minimum Data Set (MDS, a resident assessment tool) dated 12/20/24 indicated Resident 1 had moderately impaired cognitively 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 observation, interview and record review, the facility failed to ensure stored food items have expiry dates. During observation in the food storage area on 12/31/24, several canned vegetables and food items did not have expiry dates. This deficient practice had the potential to serve expired food to all residents of the facility. Findings: During observation and concurrent interview on 12/31/24 at 8:34 a.m. the following food items have no expiry dates: 1.Custard mix 2.Devil food cake mix 3.[NAME] mix 4.Maraschino cherry 5. Blueberry filling - two cans 6.Cut sweet potato - 12 cans 7. Pinto beans – 18 cans During concurrent interview the food service director and the kitchen lead stated they were unable to find expiry dates written on the cans or the packages of the above food items. During an interview on 12/31/24 at 10:42 a.m., the registered dietitian (RD) stated the food items should have expiry dates. RD stated, the expiry date should be on the food product. RD further stated the facility should…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to protect the resident's right to be free from abuse (deliberate, aggressive, or violent behavior with the intention to cause harm) for one of three sampled residents (Resident 1), who had a diagnosis of unspecified severe dementia with psychotic disturbance (the loss of the ability to think, remember, and reason to levels that affect daily life and activities, as well as psychotic disturbances like hallucinations, delusions, paranoia, or suspiciousness). The facility did not monitor or care plan Resident 2's behavior of yelling and angry outbursts. As a result, on 10/23/2024 at around 4:40 PM, Resident 2 had a physical altercation with Resident 1 over his preferred chair which resulted in Resident 1 sustaining a skin tear on the left thumb. Findings: A review of Resident 1's admission Record indicated the resident was originally admitted to the facility on [DATE] with diagnoses including unspecified severe dementia with psychotic disturbance (the loss…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 timely orders for the necessary treatment and care needs for one of three residents (Resident 1), who sustained a skin tear on her left thumb. This deficient practice had the potential for Resident 1's skin tear to worsen and develop infection. Findings: A review of Resident 1's admission Record indicated the resident was originally admitted to the facility on [DATE] with diagnoses including unspecified dementia, with psychotic disturbance (the loss of the ability to think, remember, and reason to levels that affect daily life and activities), schizophrenia (a mental illness that is characterized by disturbances in thought), and depression (mental health condition that involves a persistent low mood, loss of interest in activities, and difficulty with daily life). A review of Resident 1's History and Physical (H&P) dated 1/25/2024, indicated the resident did not have capacity to understand and make decisions. A review of Resident 1's Change 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 inform the family or resident representative of an alleged abuse allegation for one of three sampled residents (Resident 1). The facility also failed to document in the resident medical record, events, incidents or accidents involving the resident, per the facility policy. This deficient practice caused an increased risk in abuse or potential abuse for Resident 1. Findings: A review of Resident 1's admission record indicated the resident was admitted to the facility on [DATE], with diagnoses including encephalopathy (a change in your body or your brain affects how well you think), dementia (a progressive state of decline in mental abilities), and epilepsy (a disorder in which nerve cell activity in the brain is disturbed). A review of Resident 1's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 9/10/24, indicated the resident needed some help with self-care, assistance with indoor mobility (walking), and required some help…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 residents (Resident 1), alleged abuse allegation was reported to local authorities and State Agency in a timely manner. This failure resulted in the breach of the facility's abuse policy. Findings: A review of the facility document received to the Department dated 10/7/24, indicated Staff 1 observed Certified Nursing Assistant (CNA) 3 slapped the arm and wrist of Resident 1. A review of Resident 1's admission record, dated 10/16/24, indicated Resident 1 was admitted to the facility on [DATE], with diagnoses including encephalopathy (a change in your body or your brain affects how well you think), dementia (a progressive state of decline in mental abilities), and epilepsy (a disorder in which nerve cell activity in the brain is disturbed). A review of Resident 1's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 9/10/24, indicated the resident required help with self-care, assistance with indoor…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure residents received dignity and respect in full recognition of their individuality for one of two sampled residents (Resident 1). Resident 1, who had a language barrier, was not able to fully communicate her needs and staff did not use the facility translation services to assist the non-English speaking resident. This deficient practice had the potential to negatively affect Resident 1's psychosocial wellbeing. Findings: A review of the admission record (face sheet) indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including cellulitis (bacterial skin infection that affects the skin's deeper layers, affected skin is swollen and inflamed) of right lower limb leg, urinary tract infection, and anxiety. A review of the History and Physical report completed on 8/12/2024 indicated Resident 1 had the capacity to understand and make decisions. A review of the care plan dated 8/14/2024 indicated Resident 1 had a language barrier…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 two sampled residents (Resident 1), who had dysphgia (difficulty swallowing), received treatment and care in accordance with professional standards of practice to meet the resident's physical, mental, and psychosocial needs. Resident 1 had a change in condition (COC) and received a medication for nausea and vomiting, but there was no documentation regarding the COC and no documentation to indicate if the medication was effective. This deficient practices had the potential for Resident 1 to receive a delay in the treatment and services to treat her nausea and vomiting. Findings: A review of the admission record (face sheet) indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including cellulitis (bacterial skin infection that affects the skin's deeper layers, affected skin is swollen and inflamed) of right lower leg, urinary tract infection(UTI- an infection in the bladder / urinary tract), and anxiety. A review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the nursing staff had the specific skills sets necessary to care for Resident 1, who had symptoms of nausea and vomiting and vomitted on 9/27/2024. This deficient practice had the potential for Resident 1 to receive a delay in the treatment and services to treat nausea and vomiting. Findings: A review of the admission record (face sheet) indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including cellulitis (bacterial skin infection) of right lower leg, urinary tract infection, and anxiety. A review of Resident 1's Minimum Data Set (MDS- federally mandated resident assessment tool) dated 8/15/2024 indicated the resident had moderate cognitive impairment and needed minimal to moderate assistance with all activities of daily living (ADL's). A review of the care plan dated on 8/25/2024 indicated that Resident 1 was at risk for alteration in comfort related to nausea. The goal for Resident 1 was to be free 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 update and/or revise a behavioral care plan for bipolar disorder (a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration) for one of two sampled residents (Resident 1), who had behavioral patterns manifested by angry outbursts and verbal abuse. This deficient practice had the potential to negatively affect the provision of care and services for Resident 1. Findings: A review of Resident 1's admission Record (Face Sheet) indicated the facility admitted the resident on 10/18/2023, with diagnoses including bipolar disorder. A review of Resident 1's behavioral care plan for bipolar disorder initiated 10/23/2023 and last revised on 10/23/2023, did not indicate to provide and maintain consistent caregivers. A review of the Minimum Data Set (MDS - a standardized assessment and care screening tool) dated 7/26/2024, indicated Resident 1's cognitive skills (ability to think, remember, and make decisions) was not impaired. The MDS indicated Resident 1 displayed…

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

Based on interview and record review, the facility failed to ensure one of two sampled residents (Resident 1), who had diagnosis of schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves), was provided with the necessary behavioral health care services as indicated in the comprehensive assessment. The facility failed to: -Monitor Resident 1 for schizophrenic behavior. -Develop and implement a person-centered care plan for Resident 1's schizophrenia diagnosis. -Develop individualized interventions related to the Resident 1's schizophrenia diagnosis. -Identify Resident 1's individual responses to stressors and utilize person-centered interventions to support Resident 1. This deficient practice caused an increased risk in the mental and psycho-social well being of Resident 1. Findings: A review of Resident 1's history and physical (H&P) dated 10/4/2023 from the General Acute Care Hospital (GACH) indicated Resident 1 had a diagnosis of acute schizophrenia. A review of Resident 1's admission Record (Face Sheet) indicated the facility admitted the…

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

Based on observation, interview, and record review, the facility failed to develop and implement care plan for one of three sampled residents (Resident 1). For Resident 1, the facility failed to: 1. Develop a care plan addressing Resident 1 ' s behavior of removing his clothes and incontinence briefs. Resident 1 remained undressed. 2. Develop and implement interventions to maintain Resident 1 ' s privacy and dignity. These deficient practices had the potential to affect Resident 1 ' s psychosocial well-being. Findings: During a review of the admission Record indicated the facility admitted Resident 1 on 8/8/24 with diagnoses including metabolic encephalopathy (chemical imbalance in the blood that can cause problem in the brain) and anxiety disorder. During a review of the Minimum Data Set (MDS, standardized care and health screening tool) dated 8/14/24 indicated Resident 1 had moderately impaired cognitive skills. Resident 1 was dependent (helper does all the effort) with shower/bathe, upper/lower body dressing, putting on/taking off footwear maximal assistance (helper does more…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 inform the resident representative when there was a change in billing for one of one sampled resident (Resident 1). For Resident 1, who does not have the capacity to understand and make decisions, the facility failed to notify Resident 1 ' s family member (FM) regarding the change in billing for Resident 1 on 7/9/24. The facility instead presented the Notice of Last Covered Date (advance notice of non-coverage) to Resident 1 and obtained his signature on 7/9/24. This deficient practice resulted in Resident 1 and Resident 1 ' s family member (FM) not given their right to be notified of the last covered date and had the potential for Resident 1 to not to meet the deadline for appeal. Findings: During a review of the admission Record indicated the facility admitted Resident 1 on 4/17/24 and re-admitted on [DATE] with diagnoses including dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure discharge planning was in place for one of one sampled resident (Resident 1). For Resident 1 who was for discharge on [DATE], the facility failed to: 1. Ensure discharge plan was in place when Resident 1 was admitted and as Resident 1 ' s needs changed. 2. Ensure the interdisciplinary team (IDT, group of professionals working together toward a common goal for the resident) evaluate Resident 1 ' s discharge plan prior to discharge. 3. Include Resident 1 ' s family member (FM) in determining the discharge plan and goals. These deficient practices had the potential for Resident 1 to have unsafe discharge and Resident 1 ' s FM stated being worried and scared about Resident 1 ' s discharge. Findings: During a review of the admission Record indicated the facility admitted Resident 1 on 4/17/24 and re-admitted on [DATE] with diagnoses including dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure the medical record are accurate and complete for one of one sampled resident (Resident 1). For Resident 1, the facility failed to: 1. Accurately reflect in Resident 1 ' s medical record Resident 1 ' s family member (FM) request to transfer Resident 1 to another facility on 7/15/24. 2. Ensure the Resident 1 ' s medical record reflects the notification of Resident 1 ' s FM of Resident 1 ' s last covered date of services on 7/9/24. These deficient practices resulted in incomplete and inaccurate record for Resident 1. Findings: During a review of the admission Record indicated the facility admitted Resident 1 on 4/17/24 and re-admitted on [DATE] with diagnoses including dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life) generalized muscle weakness and reduced mobility. During a review of Resident 1 ' s History and Physical (H&P) dated 7/3/24 indicated Resident 1 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.

Based on interview and record review the facility failed to provide sufficient certified nursing assistants (CNA) during the night shift (11 p.m. to 7 a.m.) on 7/11/24 and morning shift (7 a.m. to 3 p.m.) on 7/12/24. On 7/11/24 during the night shift CNAs had to take care of 17 to 18 residents and on 7/12/24 during the day shift CNAs had to take care of nine residents. The CNAs stated they felt rushed and unable to give quality care to the residents that they were assigned to take care of. This deficient practice had the potential for the facility not to meet the physical and psychosocial needs of each resident. Findings: During an interview on 7/12/24 at 6:43 a.m., CNA 1 stated he had 18 residents to take care of during the night shift on 7/11/24. CNA 1 stated he felt rushed when giving residents care because he had too many residents to take care of. During an interview on 7/12/24 at 6:48 a.m., CNA 2 stated she had 17 patients during the night shift on 7/11/24. CNA 2 stated she feels rushed when attending to each resident because .there are too many. CNA 2 stated I have to spend…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 state survey agency (SA) a fall with major injury for one of two sampled residents (Resident 1). For Resident 1, the facility failed to notify the SA when Resident 1 had an unwitnessed fall on 6/14/24 and was sent to the general acute hospital (GACH 1) for evaluation. GACH 1 informed the facility that Resident 1 did not have a fracture and sent Resident 1 back to the facility on 6/14/24. However, on 6/15/24, Resident 1 ' s left arm was found swollen, with discoloration and painful to touch. Xray of the left arm dated 6/15/24 indicated Resident 1 had fracture of the left elbow. This deficient practice resulted in delay of investigation if there was an occurrence of neglect or abuse for Resident 1. Findings: During a review of the admission Record indicated the facility admitted Resident 1 on 1/18/23 and re-admitted on [DATE] with diagnoses including dementia (loss of memory, language, problem solving and other thinking abilities that are…

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

Based on interview and record review the facility failed to provide the seven-day bed hold (holding or reserving a resident ' s bed while the resident is absent from the facility for therapeutic leave or hospitalization) for one of four sampled residents (Resident 1). Resident 1 was sent to the general acute hospital (GACH 1) on 5/28/24. The facility re-admitted another resident (Resident 2) to Resident 1 ' s bed on 5/29/24 while Resident 1 ' s bed was still under the seven-day bed hold period. This deficient practice resulted in Resident 1 not given her right to go back to the same bed she had within the seven-day bed-hold period and as indicated in Resident 1 ' s Bed Hold Notification Informed Consent. Findings: During a review of the admission Record indicated the facility admitted Resident 1 on 4/7/24 with diagnoses including pneumonia (infection that affects the lungs [breathing organ] and muscle weakness. During a review of the Bed Hold Notification Informed Consent dated 4/7/24 indicated Resident 1 was informed that she had the right to request the facility to hold my bed for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to implement their admission policy for one of five sampled residents (Resident 1). For Resident 1 who was cognitively intact (ability to think, remember, being aware of the surroundings and using judgment) the facility admitted Resident 1 to the facility's special care unit for residents with Alzheimer's Disease (a brain disorder that slowly destroys memory, thinking skills and eventually the ability to carry out the simplest tasks) and dementia (impaired ability to remember, think or make decisions that interferes with doing everyday activities). This deficient practice resulted in Resident 1 stating that her roommate (Resident 2) did not want Resident 1 in the room and Resident 1 stated she was scared of Resident 2. Findings: 1.During a review of the admission Record indicated the facility admitted Resident 1 on 4/4/24 with diagnoses including diabetes mellitus (a disease in which the body does not control the amount of glucose (a type of sugar) in the…

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

Based on interview and record review the facility failed to ensure the case manager (CM, healthcare professionals that specializes in coordinating and managing healthcare services) hired by the facility had the proper licensure and certification as indicated in their policy for one of two sampled employees (CM 1). The facility hired case manager (CM 1) who did not have a nursing degree from an accredited college or university, or a graduate of an approved licensed vocational nurse (LVN) program. This deficient practice had the potential to affect the care of residents in the facility. Findings: During an interview on 4/17/24 at 12:46 pm, the employee file of CM 1 was reviewed with the director of staff development (DSD). During concurrent interview, DSD stated CM 1 was hired by the administrator on 3/14/24. DSD stated the facility Policy indicated that CM 1 should be an RN or LVN. DSD stated it is important for the CM 1 to have a nursing degree or certification to be able to do the assessments and have basic nursing skills to justify treatment and possible consult requirements for…

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

Based on interview and record review the facility failed to maintain complete record for one of five sampled residents (Resident 3). For Resident 3, the facility failed to ensure the medication administration record (MAR) was signed as soon as the medication were given to Resident 3 on 4/9/24. This deficient practice resulted in inaccurate documentation and record for Resident 3. Findings: During a review of the admission Record indicated the facility admitted Resident 3 on 6/15/21 with diagnoses including diabetes mellitus (a disease in which the body does not control the amount of glucose (a type of sugar) in the blood) and anxiety disorder. During a review of the Minimum Data Set (standardized care and health screening tool) dated 12/21/23 indicated Resident 3 was cognitively intact. Resident 3 was dependent with upper and lower body dressing, putting on/taking off footwear, maximal assistance (helper does more than half the effort) with toileting hygiene, moderate assistance (helper does less than half the effort) with personal hygiene, supervision with eating and set up with…

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

Based on observation, interview, and record review, the facility failed to report to the local California Department of Public Health (CDPH) within two hours of the suspected Certified Nursing Assistant (CNA) 1 to resident physical abuse that occurred on 3/21/2024 for one of three sampled residents (Resident 1). This deficient practice resulted in a delay of an onsite inspection by the California Department of Public Health (CDPH) to ensure circumstance were investigated. This also had the potential to place Resident 1 at further risk for abuse. Findings: A review of Resident 1's admission record indicated the facility readmitted Resident 1 on 10/23/2023 with diagnoses including type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar [glucose]), chronic kidney disease (CKD - longstanding disease of the kidneys' failure to filter waste from the blood and excrete into the urine), and major depressive disorder (mood disorder that causes a persistent feeling of sadness and loss of interest). A review of the Minimum Data Set (MDS- a comprehensive…

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

Based on observation, interview, and record review, the facility failed to ensure residents were free from accidents for one of four sampled residents (Resident 1) by failing to ensure bed was in low position and floor mat was placed next to he bed for Resident 1. This deficient practice placed Resident 1 at increased risk for falls and complications related to fall injuries. Findings: A review of Resident 1's admission record indicated the facility readmitted Resident 1 on 10/23/2023 with diagnoses including type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar [glucose]), chronic kidney disease (CKD - longstanding disease of the kidneys' failure to filter waste from the blood and excrete into the urine), and major depressive disorder (mood disorder that causes a persistent feeling of sadness and loss of interest). A review of Resident 1's High Risk for Fall Care Plan initiated 10/24/2023 was related to limitation of mobility, status post right below and knee amputation (surgical removal of a limb or body part), indicated the intervention…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 licensed vocational nurses (LVN) have the specific competency and skills set necessary to care for residents' needs, as identified through residents' assessments and plan of care, for one of two LVNs (LVN 1) reviewed for annual competency skills check. This deficient practice had the potential to place residents at risk for not receiving necessary care and services and the potential for injury. Findings: During a concurrent interview and record review on 3/27/2024 at 3 PM, with Director of Staff Development (DSD), the annual competency for LVN 1 was reviewed. The DSD stated LVN 1 did not have an annual competency for 2023 and all licensed staff were required upon hire and annually to have a completed evaluation and competency. She stated the potential outcome of failing to conduct evaluation of skills competency for licensed staff was the resident may not receive the necessary care and services and place residents at harm. During an interview on 3/27/2024 at 3:30 PM, LVN 1 stated she was required to have an annual…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 perform annual staff competencies for four of five sampled staff (Certified Nursing Assistant [CNA] 4, CNA 5, CNA 6, and CNA 7. This deficient practice had the potential to result in residents to not receive the appropriate level of care needed affecting quality of care and potentially leading to resident harm. Findings: A review the employee files on 12/14/2023 at 3:12 PM for CNA 4, CNA 5, CNA 6, and CNA 7 indicated the following: -CNA 4 was hired on 8/10/2021. There was no competency for the year 2023 available for review in CNA 4's employee file. -CNA 5 was hired on 10/1/2022. There was no competency for the year 2023 available for review in CNA 5's employee file. -CNA 6 was hired on 12/3/2019. There was no competency for the year 2023 available for review in CNA 6's employee file. -CNA 7 was hired on 2/6/2016. There was no competency for the year 2023 available for review in CNA 7's employee file. During a concurrent interview and record review, on 12/14/2023 at 4 PM, the employee files for CNA 4 through 7 were…

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

Based on interview and record review, the facility failed to perform annual performance evaluations for four of five sampled staff (Certified Nursing Assistant [CNA] 4, CNA 5, CNA 6, and CNA 7. This deficient practice had the potential for residents to not receive the appropriate level of care needed affecting quality of care and potentially leading to resident harm. Findings: A review of the employee files on 12/14/2023 at 3:12 PM for CNA 4, CNA 5, CNA 6, and CNA 7 were reviewed and indicated the following: -CNA 4 was hired on 8/10/2021. There was no performance evaluation for the year 2023 available for review in CNA 4's employee file. -CNA 5 was hired on 10/1/2022. There was no performance evaluation for the year 2023 available for review in CNA 5's employee file. -CNA 6 was hired on 12/3/2019. CNA 6's employee file indicated there was a performance evaluation dated 10/26/2021. There was no performance evaluation for the year 2023 available for review. -CNA 7 was hired on 2/6/2016. CNA 7's employee file indicated there was a performance evaluation dated 7/27/2020; there was no…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 food was prepared by methods that conserved flavor and served at appetizing temperatures for 259 out of 275 residents who received food from the kitchen and for one resident (Resident 170) who complained the food was cold. This deficient practice had the potential to result in meal dissatisfaction, decrease food intake and placed residents at risk for unplanned weight loss. Findings: A review of Resident 170's admission record indicated the facility admitted the resident on 8/15/2023 with diagnoses including hemiplegia (paralysis on one-side of the body) and hemiparesis (weakness on one side of the body), muscle weakness, congestive heart failure (a long-term condition in which the heart cannot pump blood well enough to meet the body's needs), atrial fibrillation (irregular heart rhythm), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest and can interfere with daily activities). A review of Resident 170'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.

Based on observation, interview and record review, the facility failed to ensure safe and sanitary food storage practices in the kitchen by failing to: -Ensure the 30 chocolate flavored nutritional supplements and 22 vanilla flavored supplements stored in the reach in refrigerator with no thaw date and labeled Store frozen with the manufactures instruction to use within 14 day of thawing, were monitored for the date they were thawed to ensure expired shakes were discarded after this time frame. This deficient practice had the potential to result in food borne illness in 80 residents who are on nutrition supplements at the facility. -Ensure the storage period of one large package of Ready to Eat sliced ham deli meat received on 12/2/2023 did not exceed the storage period for deli meat stored in the walk-in refrigerator. -Ensure food brought to residents from outside of the facility, was stored in the resident's food refrigerator, and was monitored for an expiration date. One sandwich was stored in the refrigerator that was expired and apple and cranberry juice for residents had no…

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

Based on observation, interview and record review, the facility failed to ensure one of two sampled residents (Resident 232) was not allowed to keep medications at the bedside without a physician's order and without assesing the resident's ability to self-administer medications. This deficient practice had a potential to result in the resident to self-medicate himself and for other residents to take unprescribed medication. Findings: A review of the admission record indicated the facility admitted Resident 232 on 8/8/2023, with diagnoses including dementia (loss of memory, thinking and reasoning), chronic bronchitis (long term inflammation of the lungs) and benign prostatic hyperplasia (BPH- a condition that occurs when the prostate gland enlarges, potentially slowing or blocking the urine stream). A review of Resident 232's Care Plan related to altered thought process, initiated on 8/26/2023, indicated Resident 232 had periods of short and long-term memory problem and periods of forgetfulness. A further review of the care plan indicated interventions that included to explain all…

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

Based on interview and record review, the facility failed to ensure one sampled resident (Resident 146) had an adaptive call light. This deficient practice placed the resident at risk of not receiving the necessary care and services. Findings: A review of Resident 146's admission record indicated the facility admitted Resident 146 on 8/4/2020 and readmitted him on 10/4/2021 with diagnoses including disorder of the autonomic nervous system (a condition that disrupts automatic body processes such as blood pressure and heart rate), muscle weakness, and a history of falling. A review of Resident 146's Care Plan, created on 10/5/2021 and revised on 3/6/2023, indicated that because Resident 146 was at moderate risk for falls and injury related to limitation of mobility, all things needed by the resident should be within reach, including the call light. A review of Resident 146's History & Physical, dated 10/19/2023, indicated Resident 146 had the capacity to understand and make decisions. A review of Resident 146's Minimum Data Set (MDS - an assessment and care screening tool) dated…

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

Based on interview and record review, the facility failed to provide one of three sampled residents (Resident 169) the Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNFABN - provides information to the beneficiary so that s/he can decide whether or not to get the care that may not be paid for by Medicare and assume financial responsibility) and Notice of Medicare Non-Coverage (NOMNC - notification of termination of covered care) forms. For Resident 169, who did not have the capacity to understand or make decisions, the facility failed to mail the beneficiary forms by certified mail with return receipt to Resident 169's responsible party. This deficient practice had the potential to result in Resident 169's responsible party not receiving the information needed to decide if she would like to continue receiving or refuse specific skilled services for Resident 169 and have those options honored. Findings: A review of the admission record indicated the facility admitted Resident 169 on 5/31/2023 with diagnoses including schizophrenia (a serious mental disorder in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to ensure the Minimum Data Set (MDS - a standardized assessment and care screening tool) was transmitted timely to the Centers for Medicare and Medicaid Services (CMS) system for two out of two sampled residents (Residents 219 and 224). This deficient practice had the potential to result in delayed services for the residents. Findings: a. A review of Resident 219's admission record (Face Sheet) indicated the facility admitted Resident 219 on 7/1/2023, with diagnoses including muscle weakness, and repeated falls. A review of Resident 219's MDS dated [DATE], indicated the resident had moderately impaired cognition (decisions poor, cues/supervision required) and required extensive assistance with one-person physical assist for bed mobility, transfers, dressing, eating, toilet use, and personal hygiene. A review of Resident 219's MDS assessments since admission on [DATE] at 11 AM, indicated that transmission of MDS assessment dated [DATE], was accepted.…

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

Based on interview and record review, the facility failed to develop a comprehensive person-centered care plan for the administration of antibiotics for one sampled resident (Resident 225). This deficient practice placed the resident at risk of not receiving the necessary care and services. Findings: A review of Resident 225's admission record indicated the facility admitted Resident 225 on 7/17/2023 and readmitted him on 10/21/2023 with diagnoses including gastrostomy (surgically made opening into the stomach from the abdominal wall for the introduction of food) malfunction, peripheral vascular disease (a systemic disorder that involves the narrowing of peripheral blood vessels [vessels situated away from the heart of the brain]), and dysphasia (swallowing difficulties). A review of Resident 225's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 10/25/2023, indicated Resident 225 had severely impaired cognition (the ability to make self-understood and understand other) and required maximum assistance from the staff for dressing, shower, transferring…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, facility failed to label the tube feeding with the date, time, and initials for one of six sampled residents (Resident 110). This deficient practice had the potential for the residents to develop tube feeding associated complications such as infection or diarrhea, and lead to serious illness, hospitalization, and death. Findings: A review of the admission record indicated the facility initially admitted Resident 110 on 9/2/2023 with diagnoses including gastrostomy (a surgical procedure used to insert a tube, often referred to as a G-tube, through the abdomen and into the stomach for feeding) and dysphagia (difficulty swallowing). A review of Resident 110's Minimum Data Set (MDS, a standardized assessment and care screening tool) dated 9/10/2023 indicated the resident had moderately impaired cognition (decisions poor; cues/supervision required), was totally dependent and required one-person physical assistance with toilet use. The MDS indicated Resident 110 required extensive assistance and one-person physical assistance for bed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow the facility's Oxygen Administration policy and procedure for two of two sampled residents (Resident 210 and Resident 248). These deficient practices had the potential to cause complications associated with oxygen therapy. Findings: a. A review of Resident 248's admission record indicated the facility admitted the resident on 9/27/2023, with diagnoses including a displaced spiral fracture of the shaft of the humerus of the right arm (the parts of the bone in upper arm at the break no longer line up correctly), and a fracture of unspecified carpal bone (fracture of one of the bones of the wrist), multiple fractures of ribs (crack in the rib). A review of Resident 248's history and physical, dated 9/29/2023, indicated the resident had the capacity to understand and to make decisions. A review of Resident 248's Minimum Data Set (MDS - an standardized assessment and care screening tool), dated 10/11/2023, indicated the resident had…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 reviews, the facility failed to implement an effective pain management plan for one of three sampled residents (Resident 132 ). This deficient practice had the potential to negatively affect the resident's psychosocial wellbeing and quality of life. Findings: A review of the admission record (Face Sheet) indicated the facility admitted Resident 132 on 9/6/2023 with diagnoses including low back pain, and repeated falls. A review of Resident 132's Physician's Orders dated 9/6/2023, indicated to apply non-pharmacological interventions (do not involve drugs) for pain to include the following: 1. Repositioning 2. Back rub 3. Relaxation 4. Give fluids 5 Redirection 6. Music 7. Activity 8. Adjusting room temperature 9. Quiet environment 10. Toilet 11. Breathing exercises 12. Distraction A review of Resident 132's Physician's Orders further indicated to use supplementary documentation and select corresponding numbers to indicate non-drug interventions as needed. A review of the Physician's Orders for Resident 132 dated 9/9/2023, indicated Resident 132 had an…

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

Based on interview and record review, the facility failed to follow its Social Assessment, policy and procedure for one of three sampled residents (Resident 48). This deficient practice had the potential for the resident not to attain the highest practicable physical, mental, and psychosocial well-being and delay in the delivery of care and services. Findings: A review of Resident 48's admission record (Face Sheet) indicated the facility originally admitted Resident 48 on 1/13/2023, and readmitted Resident 48 on 5/18/2023, with diagnoses including diabetes mellitus (a disease that result in too much sugar in the blood), and end stage renal disease (a condition when the kidneys permanently fail to work). A review of the Social Service Notes dated 1/17/2023 at 6:36 PM, indicated social service visited Resident 48 to assess her well-being upon admission. A review of the Social Service Evaluation upon admission, indicated the resident's evaluation was performed on 2/6/2023. A review of Resident 48's history and physical dated 7/9/2023, indicated the resident had 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.

Based on interview and record review, the facility failed to follow their Antipsychotic Medication Use, policy and procedure for one of six sampled residents (Resident 123), as evidenced by failing to indicate a stop date and/or duration for how long the resident was to receive an as needed psychotropic medication (medication that affects the mind, emotions, and behavior). This deficient practice had the potential to result in administering unnecessary psychotropic drugs for Resident 123 that could lead to side effect and adverse consequence such as a decline in quality of life and functional capacity. Findings: A review of Resident 123's admission record (Face Sheet) indicated, the facility originally admitted Resident 123 on 12/12/2021, and readmitted the resident on 8/10/2023, with diagnoses including encounter for palliative care (specialized medical care that focuses on providing relief from pain and other symptoms of a serious illness), and anxiety disorder (a condition in which you have anxiety that does not go away and can get worse over time). A review of the Order Summary…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 staff followed fortified diet (increase caloric intake) guidelines during lunch preparation and tray line observation for one of 35 sampled residents by failing to: -Ensure a fortified diet was prepared and served to Resident 178, who had requested food only from the Japanese menu and was on a fortified diet. This deficient practice had the potential to result in decreased caloric intake and lead to undesirable weight loss. Findings: During a tray line observation for lunch service on 12/11/2023 at 11:30 AM, Resident 178 was on a fortified diet but requesting Japanese soup from the alternative menu. Dietary Aide (DA) 1 did not communicate the fortified diet orders written on the meal tickets during the lunch service. During a concurrent interview, [NAME] 1 stated residents who were on a fortified diet received a fortified mashed potato for the lunch and dinner meal and fortified cereal for the breakfast meal. [NAME] 1 stated the fortified mashed potato adds extra calories for residents on a fortified…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 staff adhered to the facility's infection control policy and procedures by ensuring facility staff conducted hand hygiene prior to entering and after exiting a resident's room. This deficient practice had the potential to result in the spread of infection and placed facility residents and staff at risk to become infected and seriously ill, leading to hospitalization and/or death. Findings: During an observation on 12/11/2023 at 1:49 PM, Licensed Vocational Nurse (LVN) 6 was observed entering Room (A) without performing hand hygiene. LVN 6 was observed assisting the resident in Room (A) set up their lunch tray and moving their bedside table. LVN 6 was then observed exiting the resident's room without performing hand hygiene. During an interview on 12/11/2023 at 1:53 PM, LVN 6 stated and acknowledged he did not perform hand hygiene prior to entering and exiting Room (A). LVN 6 indicated he was just helping the resident in Room (A) set up their lunch tray. LVN 6 stated he was Supposed to perform hand…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to maintain an infection prevention and control program designed to help prevent the development and transmission of Tuberculosis (TB- is a serious illness which may be fatal that mainly attacks the lungs but can affect almost any part of the body. It is caused by a bacterium called Mycobacterium tuberculosis which is spread through the air from one person to another if the infected person coughs, speaks, laughs, sings, or sneezes) by failing to: 1. Ensure that one of seven sampled residents (Residents 4) was screened for TB (Mantoux tuberculin skin test [TS]) and an Interferon Gamma Release Assay [IGRA] blood test) upon admission. The facility was aware Resident 4 had tested positive for TB positive while at a general acute care hospital (GACH) 2. Ensure that 34 of 34 direct care staff that worked with Resident 4 during the time when he was considered infectious (the infected person may spread the disease) for TB were screened for TB and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain temperatures of resident four (room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], and room [ROOM NUMBER]) out of six sampled rooms between 71 and 81 degrees Fahrenheit (F, scale of temperature). This deficient practice has the potential for the residents to experience hypothermia (a potentially dangerous drop in body temperature, usually caused by prolonged exposure to cold temperatures). Findings: During a concurrent observation and interview on 12/15/2023, at 2:54 p.m., in room [ROOM NUMBER], with the Administrator and the EVS Manager (EVSM), it was observed that the temperature measured at 68.2 degrees F on the wall over Bed A using the facility ' s infrared thermometer gun (a tool that measures temperature without touching the object). The temperature of the air blowing out from the vent was measured at 54 degrees F. The EVSM stated that the thermostat (device that automatically regulates temperature, or 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that the Fall Risk Assessment was completed within the required timeframe for one of 4 sampled residents (Resident 1) from 5/22/2021 to 10/2/2022. This deficient practice had the potential to negatively affect the provision of necessary care for Resident 1. Findings: A review of Resident 1's admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses including hypertension (high blood pressure), diabetes mellitus (high blood sugar), muscle weakness, and history of fall. A review of the History and Physical Examination dated 8/14/2023 indicated Resident 1 can make her needs known but cannot make medical decisions. A review of the Minimum Data Set (MDS - a standardized assessment and screening tool), dated 8/30/2023, indicated Resident 1's cognitive skills (ability to understand and make decisions) were severely impaired. The MDS indicated Resident 1 required one-person physical assistance for showering, dressing,…

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

Based on observation, interview, and record review, the facility failed to follow infection control practices as evidenced by: a. Licensed Vocational Nurse (LVN) 1 was observed wearing a N95 respirator mask (a respiratory protective device designed to achieve a very close facial fit and very efficient filtration of airborne particles) that was not fit tested (a test protocol conducted to verify that a respirator is both comfortable and provides the wearer with the expected protection). b. LVN 2, LVN 3, the Registered Dietitian (RD), and Environmental Services (EVS) 2 were not N95 respirator mask fit tested (a total of four staff). c. EVS 1 and EVS 2 failed to remove the N95 respirator mask after exiting a droplet isolation room and donned (put on) a new mask prior to entering a non-isolation room. EVS 2 failed to sanitize goggles after exiting a droplet isolation room. These deficient practices had the potential to expose residents, staff, and the community to infection including the Coronavirus (COVID-19, a virus that spreads from person to person causing respiratory illness).…

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

Based on interview and record review, the facility failed to ensure the Infection Preventionist Nurse (IP) completed the annual required specialized training related to infection control. The IP did not have the specific required training for two years (2021 and 2022). This deficient practice caused an increased risk to the facility's ability to prevent and manage the spread of infection, including Coronavirus (COVID-19, a virus that spreads from person to person causing respiratory illness). Findings: A review of the IP's certificate titled, Infection Preventionist, dated 5/28/2020, indicated the IP had received 16 hours of training on the role of the infection prevention and control nurse. On 8/14/2023 at 11:40 AM, a review of the IP's training certificate was conducted. The IP verified she received 16 hours of infection preventionist training on 5/28/2020. During a concurrent interview the IP stated she did not do the continuing education required every year for 2023. The IP stated, I was supposed to do it, but it hasn't been done. The IP stated every year 10 hours of continuing…

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

Based on observation, interview, and record review, the facility failed to provide one of two sampled residents (Resident 1) with the call light within reach. This deficient practice had the potential to prevent Resident 1 from using the call light to alert staff for assistance. Findings: A review of Resident 1's admission Record indicated the facility admitted the resident on 1/21/2023 with diagnoses including diabetes mellitus Type II (a chronic condition that affects the way the body processes blood sugar [glucose]), quadriplegia (paralysis of all four limbs), and encounter for attention to gastrostomy (an opening into the stomach from the abdominal wall, made surgically for the introduction of food). A review of Resident 1 ' s care plan for self-care deficit, initiated 3/22/2023, indicated to keep frequently use personal items and things needed within resident ' s reach. A review of Resident 1's Minimum Data Set (MDS- a standardized assessment and care screening tool) dated 7/15/2023 indicated the resident was cognitively severely impaired (never/rarely made decisions) 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.