La Brea Rehabilitation Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to ensure its medication error rate was less than five (5) percents (%). Three medication errors out of 33 total opportunities yielded a medication error rate of 9.09%, in 3 of 4 sampled residents (Resident 114, Resident 89, and Resident 45) observed during medication administration (med pass). This failure of med pass error rate exceeded the 5 % threshold had the potential of adverse effects that may or may not affect Resident 114, Resident 89, and Resident 45's health condition. (Cross Reference F757 and F761) Findings: a.During a medication administration (med pass) observation on 6/17/2025 9:06 AM, outside Resident 114's room, the Licensed Vocational Nurse1 (LVN 1) prepared a total of three medications: vitamin C mg (also known as ascorbic acid, is a water-soluble vitamin essential for various bodily functions, including immune system support, wound healing, and collagen formation) 500 milligrams (mg, unit to measure mass), aspirin (a…

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

Based on observation, interview, and record review, the facility failed to ensure the label on a bubble pack (a card that packages doses of medication within small, clear plastic bubbles or blisters) matched the physician's order for one of four sampled residents (Resident 114). This failure had the potential of medication error that may or may not affect resident's condition. (Cross Reference F759) Findings: During an observation and concurrent interview on 6/17/2025 at 12:30 PM at the Station A medication cart 3, the Licensed Vocational Nurse (LVN 1) found Resident 114's doxazosin (generic for Cardura, used to treat high blood pressure and prostate condition) 2 milligrams (mg, unit to measure mass) bubble pack in a drawer that stored evening medications. LVN 1 pointed to the label on the bubble pack and stated the label indicated take one tablet by mouth at bedtime. During a concurrent review of the medication administration record (MAR) of Resident 114's doxazosin, LVN 1 stated the scheduled time was at 9 AM. During a review of Resident 114's medication orders, the orders…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 sanity food storage practices in the kitchen for124 of 135 residents who received food from the facility and including residents who had food stored in the resident refrigerator when: 1. One opened container of cottage cheese was observed unlabeled in the refrigerator. A plastic bag that contained a staff member's (unidentified) lunch was observed in the refrigerator. 2. The temperature of TCS foods (Time/Temperature control for safety food) checked was above 41 degrees Fahrenheit (F). TCS foods are foods that can support bacterial growth than can result in food borne illness unless stored, prepared and served safely. The temperature of a previously cooked rice from 6/16/2025 stored in the walk-in refrigerator checked using the facility thermometer was 45.5 degrees Fahrenheit (F). There was one tray of previously cooked breakfast sausage stored on the same shelf and next to raw chicken and beef thawing. This had the potential to cross contaminate food and result in food borne illness in 124 out…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 an effective pest control program (is the practice of managing and regulating undesirable organisms, commonly known as pests, that pose threats to human health) for 136 residents who resided in the facility to destroy and prevent cockroaches in the facility This failure resulted in the presence of one live cockroach in the utility room (a room where medical supply is stored and the location of the resident refrigerator for outside food and the unit ice machine) and placed 136 residents at risk of serious disease that can be transmitted through various routes (direct contact or inhalation) and by contaminating human food with germs (small living things/cells, especially one which cause diseases) that pests pick up from drains, garbage dumps and outside grounds. Findings: During a concurrent observation of the facility's utility room and interview with the Nurse Supervisor (RN2) on 6/18/2025, at 9 AM, one small brown cockroach was observed traveling from under the counter and went under the resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide care in a manner that promoted or enhanced a resident's dignity for two of three sampled residents (Resident 6 and Resident 492) by failing to ensure to: 1. Provide Resident 6 with a privacy curtain (cloth barriers that surround a patient's bed) of adequate length. 2. Provide a cover for Resident 492's urinary catheter (a hollow tube inserted into the bladder to drain or collect urine) bag. These failures had the potential to cause emotional distress, affect the Resident 6's and Resident 492's self-esteem (how we value and perceive ourselves), and cause a loss of dignity (he quality or state of being worthy, honored, or respected) and decline in psychosocial (social factors and individual thought and behavior) wellbeing. Findings: 1. During a review of Resident 6's admission Record, the admission Record indicated the facility admitted the resident on 6/24/2024 with diagnoses that included encephalopathy (brain damage that causes…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 residents (Resident 126) would not be allowed to keep ear drops (Debrox drops, earwax removal kit) medication at the bedside without a physician's order. This failure had the potential to result in unsafe medication application and/or over medicating for Resident 126. Findings: During a review of Resident 126's admission Record, the admission Record indicated the facility admitted the resident on 3/1/2025 and readmitted on [DATE] with diagnoses that include lack of coordination, bed confinement, and history of falling. During a review of Resident 126's Care Plan Report, date initiated 3/3/2025, the Care Plan Report indicated the resident was at risk for adverse reaction (harmful reaction to a medicine) related to polypharmacy (is when you take several medications [five or more] each day). The Care Plan Report indicated the intervention was to ensure each physician had the full list of medications available,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 resident assessment tool) discharge (the formal release from a facility) assessment was accurately performed for one of seven sampled residents (Resident 138). This failure had the potential to result in the inadequate care of Resident 138 during her discharge from the facility. Findings: During a review of Resident 138's admission Record, the admission Record indicated the facility admitted the resident on 3/5/2025 with diagnoses that included chronic kidney disease (a condition in which the kidneys are damaged and cannot filter blood as well as they should), lack of coordination (inability to smoothly and accurately control body movements), difficulty in walking, a history of falling, and a displaced fracture of the greater trochanter of the left femur (a broken left upper thigh bone). During a review of Resident 138's MDS dated [DATE], the MDS indicated Resident 138 was discharged to a Short-Term General Hospital…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to develop an individualized person-centered care plan (a plan of care that summarizes a resident's health conditions, specific care and services facility staff need to provide a resident to promote healing and prevent a worsening of a condition, and current treatment) to meet the resident's needs for one of three sampled residents (Resident 44) by failing to create an appropriate care plan for Resident 44's tube feeding (a method of providing nutrition directly into the stomach or small intestine through a tube, when a person is unable to eat or drink enough to meet their nutritional needs). This failure had the potential for Resident 44 to receiving inadequate care. Findings: During a review of Resident 44's admission Record, the admission Record indicated the facility admitted the resident on 9/16/2024 and readmitted on [DATE] with diagnoses that include hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2. During a review of Resident 45's order for diclofenac sodium (a medication used to relieve pain and inflammation in certain joints) external gel 1 %, the order (dated 8/24/2024) indicated apply to both [hands] topically two times a day for pain management. During an observation on 6/18/25 at 8:49 AM, Licensed Vocational Nurse (LVN 3) applied the diclofenac gel to both of Resident 45's knees. During an interview on 6/18/2025 at 11:32 AM, the Director of Nursing (DON) stated Resident 45's diclofenac gel order was written for the application to the hands and the nurse should contact doctor if Resident 45 had pain in the knees. During an interview, and a concurrent review of Resident 45's medication administration record (MAR) of June 2025, on 6/18/2025 at 12 PM, the DON reviewed Resident 45's MAR for the diclofenac gel. The DON stated the hans in the order was misspelled and should be hands. The MAR indicated that at least four of 17 morning applications of diclofenac with the sites of applications noted as BLE…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 rotate the insulin (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication) injection (the act of putting a liquid, especially a drug, into a person's body using a needle ) administration sites for one of one sampled residents (Resident 109). This failure had the potential for Resident 109 to develop skin infection. Findings: During a review of Resident 109's admission Record, the admission Record indicated the facility admitted the resident on 1/3/2025 with diagnoses that included type 2 diabetes (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 109's Minimum Data Set (MDS, a resident assessment tool) dated 4/19/2025, the MDS indicated the resident had moderate cognitive impairment (some impairment in the ability to think, understand, and reason). The MDS indicated Resident 109 received insulin injections. During a review of Resident 109's Order Summary Report dated 6/18/2025, the 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 the correct enteral tube feeding (way to get nutrients into the body through a tube that's inserted into the stomach or small intestine, bypassing the mouth) rate of 65 milliliter (mL, a unit of measure) per hour for one of three sampled residents (Resident 21). This failure had the potential for Resident 21 to experience malnutrion (is a serious condition that happens when a person's diet does not contain the right amount of nutrients). Findings: During a review of Resident 21's admission Record, the admission Record indicated Resident 21 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included encephalopathy (a condition where the brain does not function properly), dysphagia (difficulty swallowing), seizures (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness), and gastrostomy (a surgical opening…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide an emergency kit (a special kit placed at the resident's bedside used in emergency situations such as bleeding from a dialysis fistula [surgically created connection between an artery and a vein, usually in the arm, that makes it easier to access your bloodstream for dialysis]) for two of five sampled residents (Resident 124 and Resident 491). This failure had the potential for Resident 124 and Resident 491 to experience uncontrollable bleeding. Findings: a. During a review of Resident 124's admission Record, the admission Record indicated Resident 124 was admitted on [DATE] with diagnoses that included diabetes mellitus type 2 (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), ESRD (End Stage Renal Disease-irreversible kidney failure, and dependence on renal dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 four sampled residents (Resident 45) did not receive medication without a physician order and/or without adequate indication of use. This failure had the potential for medication error and delay in proper treatment that may or may not affect Resident 45's condition negatively. (Cross Reference 759) Findings: During an observation on 6/18/2025 at 8:49 AM, Licensed Vocational Nurse 3 (LVN 3) applied the diclofenac sodium (a medication used to relieve pain and inflammation in certain joints) external gel 1 %, to Resident 45's both knees. (Refer to F-759) During an interview on 6/18/2025 at 10:38 AM, LVN 3 reviewed Resident 45's Medication Administration Record (MAR) and the physician's order for diclofenac and LVN3 stated the order was to apply to resident's both hands, however, Resident 45 wanted the gel to be applied to the knees. During an interview on 6/18/2025 at 3:40 PM, the Director of Nursing (DON) stated the applications of diclofenac gel to the Resident 45's knees were administered…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 two of 27 sampled residents (Resident 54 and Resident 39) were served food preferences listed on the lunch meal ticket (physician ordered diet with resident food preferences) when: 1.Resident 54 who had lactose intolerance (lactose a sugar found in dairy products such as milk) was served chocolate flavored ice cream, despite lactose being listed as an intolerance on the resident's lunch meal ticket/tray care. 2. Resident 39 was served pork despite cultural preferences for no pork or ham. These failures had the potential to result in decreased meal satisfaction, decrease caloric intake, Resident 54 and Resident 39 being upset and for Resident 54 to experience symptoms associated with lactose intolerance. Findings: 1. During a review of Resident 54's Dietary Quarterly Progress Notes dated 3/11/25 and 6/13/25 indicated Resident 54's current diet was regular NAS (no added salt) and CCHO (diet for people to control blood sugar levels). The Dietary Quarterly Progress Notes indicated Resident 54 did not like…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 During a review of Resident 101's admission Record, the admission Record indicated the facility admitted Resident 101 on 11/5/2024 with diagnoses that included seizures (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness), Parkinson ' s Disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), HIV (Human Immunodeficiency Virus Disease (a virus that attacks the body's immune system), weakness, and anxiety disorder (mental health conditions that cause fear, dread and other symptoms) During a review of Resident 101's History and Physical (H&P) dated 11/7/2024, the H&P indicated Resident 101 had lack of coordination and needed safety precautions. During a review of Resident 101's MDS dated [DATE], the MDS indicated Resident 101 sometimes understood others and sometimes had the ability to understand others. During a review of Resident 101's general progress note dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure accident and hazard free environment for one of three sampled residents (Resident 1). The facility failed to ensure: 1. Resident 1 ' s bed footboard was not broken and left on the floor for several hours. 2. Resident 1 ' s feet (at ankle level) were not dangling at the foot of the bed. 3. Staff did report and request maintenance for the broken footboard. This deficient practice had the potential for Resident 1 to sustain fall and injury. Findings: A review of Resident 1 ' s admission record indicated Resident 1 was initially admitted to the facility on [DATE] with a diagnosis of not limited to unspecified abnormalities of gait and mobility, encephalopathy (a disease damaged the functions of the brain), myocardial infarction (heart attack, happens when blood flow to the heart muscle is blocked). A review of Resident 1 ' s Minimum Data Set (MDS, a assessment tool) dated 3/9/2025 indicated, Resident 1 had a cognitive (mental action or…

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

Based on observation, interview, and record review, the facility failed to treat one of three sampled residents (Resident 1) with dignity and respect by failing to safeguard Resident 1 ' s personal belongings. This failure resulted in the loss of Resident 1 ' s shoes which caused his feelings of being upset. Findings: During a review of Resident 1 ' s admission Record, the admission Record indicated the facility admitted the resident on 2/18/2025, and readmitted the resident on 5/7/2025, with diagnoses including dementia (a progressive state of decline in mental abilities), depression (a common mental health condition characterized by persistent feelings of sadness, loss of interest and changes in thoughts, behavior, and physical well-being) and schizophrenia (a mental illness that is characterized by disturbances in thought). During a review of Resident 1 ' s Inventory of Personal Effects, dated 2/18/2025, the Inventory of Personal Effects indicated Resident 1 had one pair of shoes (unidentified description). During a review of Resident 1 ' s History and Physical (H&P) dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to timely document administered medications per facility policy to three of four sampled residents (Residents 6, 7 and 8). This deficient practice had the potential to result in unsafe, and improper medication administration per facility policy. Findings: a. A review of Resident 6's admission Record indicated Resident 6 was originally admitted to the facility on [DATE] and was re-admitted on [DATE] with diagnoses including pneumonia (PNA-infection that inflames air sacs in one or both lungs which may fill with fluid), congestive heart failure (CHF-a chronic condition in which the heart does not pump blood as well as it should) and gastrostomy (GT- a flexible tube surgically inserted through the abdomen into the stomach for feeding, fluid, and medication administration). A review of Resident 6's Minimum Data Set (MDS - a resident assessment tool), dated 1/26/2025, indicated Resident 6's cognitive (mental action or process of acquiring…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 staff failed to ensure physician (MD) notification was done for one of nine sampled residents (Resident 1's) change of condition (COC/CIC) by failing to notify MD when Resident 1 had multiple episodes of refusal of basic care. This deficient practice had the potential to result in possible delayed provision of necessary care and services to Resident 1. Cross Referenced F656 Findings: A review of Resident 1's admission Record indicated Resident 1 was originally admitted to the facility on [DATE], and was re-admitted on [DATE] with diagnoses including carcinoma (cancer cells) in the rectum (final section/ part of the lower gastrointestinal tract [GI tract-organ system of the body from the mouth to the anus [part of the GI tract where the stool or feces are being eliminated from the body], colostomy (opening of the large intestine [abdominal area] to the outside of the body for passing of stool and gas) and abnormalities of gait (ambulation) and mobility. A review…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility staff failed to develop and implement a comprehensive care plan that meet the care/services based on the resident ' s individual assessed needs for one of nine sampled residents (Resident 1) by failing to ensure Resident 1 ' s episodes of refusal of basic care were care planned. This deficient practice had the potential to result negative impact on Resident 1 ' s health and safety, as well as the quality of care and services received. Cross Referenced F580. Findings: A review of Resident 1 ' s admission Record indicated Resident 1 was originally admitted to the facility on [DATE], and was re-admitted on [DATE] with diagnoses including carcinoma (cancer cells) in the rectum (final section/ part of the lower gastrointestinal tract [GI tract-organ system of the body from the mouth to the anus [part of the GI tract where the stool or feces are being eliminated from the body], colostomy (opening of the large intestine [abdominal area] to the outside of the body for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide the necessary treatment and service to one of three sampled residents (Resident 4) consistent with the resident's needs and professional standard of care by failing to ensure low air loss (LAL) mattress was set up properly for Resident 4. This deficient practice can place Resident 4 at risk of poor wound healing of the current pressure ulcer (injury to skin and underlying tissue resulting from prolonged pressure on the skin) and possibly development of a new pressure injury. Findings: A review of Resident 4's admission Record indicated Resident 4, was admitted to the facility on [DATE] with diagnoses including paraplegia (paralysis of the legs and lower body), diabetes mellitus (DM-a chronic condition that affects the way the body processes blood sugar [glucose]) and osteomyelitis (bone infection). A review of Resident 4's Minimum Data Set (MDS-a resident assessment tool), dated 10/21/2024, indicated Resident 4 was moderately…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide necessary respiratory care services for one of two sampled residents (Resident 2) by failing to ensure the nasal cannula (NC -a connector attached to oxygen) tubing and humidifier (a device used to make supplemental oxygen moist) for oxygen (O2) therapy was changed per facility ' s policy. This deficient practice had the potential to cause complications associated with oxygen therapy. Findings: A review of the admission Record indicated Resident 10 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis including pneumonia (lung infection that inflames air sacs with fluid or pus), chronic obstructive pulmonary disease (COPD - a group of lung diseases that block airflow and make it difficult to breathe), and acute on chronic respiratory failure (condition in which your blood does not get enough oxygen or has too much carbon dioxide). A review of the Minimum Data Set (MDS – a resident assessment…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to effectively and timely manage/treat/assess the pain for two of three sampled residents (Resident 2 and Resident 3) . Resident 2 was experiencing severe pain of the left knee in the facility for two days Resident 3 was admitted to the facility for pain management (The process of providing medical care that alleviates or reduces pain). This deficient practice resulted in: Resident 2 was sent to a general acute care hospital (GACH) emergency room after the resident's family intervened and requested for the transfer to GACH. Resident 3 experiencing unnecessary pain affecting the resident's appetite and ability to sleep. Findings: 1. During a review of the admission record for Resident 2 indicated Resident 2 was admitted to the facility on [DATE] with diagnoses including Urinary Tract Infection (UTI- an infection in the bladder/urinary tract), dementia (a progressive state of decline in mental abilities), and hyperlipidemia (a condition where there are high…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure one of three sampled residents (Resident 2), who had severe left knee pain was appropriately assessed in a timely manner. This failure resulted in the delay of care for Resident 2 who had to suffer from pain and discomfort for two days. Findings: During a review of the admission record for Resident 2 indicated Resident 2 was admitted to the facility on [DATE] with diagnoses including Urinary Tract Infection (UTI- an infection in the bladder/urinary tract), dementia (a progressive state of decline in mental abilities), and hyperlipidemia (a condition where there are high levels of fats or lipids in the blood). During a review of Resident 2's skin assessment dated [DATE] indicated the skin was intact, with no abnormalities. During a review of Situation, Background, Assessment, Recommendation (SBAR-a communication tool used by healthcare workers when there is a change of condition among the residents) dated 10/31/2024 at 1:16 pm, 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 one for three sampled residents (Resident 1), Resident 1's Responsible Party (RP) was made aware of the reason Resident 1 was being discharged from the facility . This failure resulted in Resident 1's Responsible Party (RP) not being notified of the transfer and reasons why the Resident 1 was not to be readmitted to the facility. Findings: During a review of Resident 1's admission Record , dated 11/1/24 indicated, Resident 1 was admitted to the facility originally on 7/19/24 and had a readmission date of 10/15/24. The same record further indicated Resident 1 had diagnosis including paranoid schizophrenia (a mental illness that is characterized by disturbances in thought), cerebral palsy (a group of neurological disorders that affect a person's ability to move, maintain balance, and posture), bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), and anxiety disorder (a condition that causes excessive and persistent…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 two of three sampled residents (Resident 1 and Resident 2) were free from physical abuse (deliberately aggressive or violent behavior by one person toward another that results in bodily injury) from Resident 3. Resident 3 slapped Resident 2 in the arm and assaulted Resident 1 in the activity room where facility staff was present and there was no documented monitoring of Resident 3, per the Mood Problem care plan interventions. This deficient practice resulted in Resident 1 sustaining a bloody lip with jaw pain, and was transferred to the General Acute Care Hospital for evaluation. Findings: a.A review of Resident 3's admission record indicated the resident was admitted to the facility on [DATE] with a diagnoses including peripheral vascular disease (a condition that occurs when blood vessels narrow or become blocked, reducing blood flow to the limbs or other organ), and cellulitis (a bacterial infection that affects the skin and tissues beneath…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 comprehensive care plan interventions for two of three sampled residents (Resident 2 and Resident 3). Both residents were not monitored after an altercation with another resident, per the care plan interventions. This deficient practice had the potential to result in missed opportunity for any changes in the residents. Findings: a.A review of Resident 2's admission record indicated the resident was admitted to the facility on [DATE], with a diagnoses including hemiplegia (the partial or total loss of movement to one side of the body) following cerebral infarction (a serious condition that occurs when blood flow to the brain is blocked) and altered mental status. A review of Resident 2's MDS, dated [DATE], indicated Resident 2 showed no delirium issues and did not have feelings of depression or hopelessness, or little interest or pleasure in doing things. A review of Resident 2's SBAR, dated 10/29/24, indicated Resident 2 had an altercation…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 social services to one of three sample residents (Resident 1) by failing to follow up on an order for ophthalmology (eye care specialist) evaluation appointment. This deficient practice had the potential for delay in the delivery of care and services. Findings: A review of Resident 1 ' s admission record indicated, Resident 1 was originally admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses that included schizophrenia (a mental illness that causes disturbed or unusual thinking, loss of interest in life, and strong or inappropriate emotions), acute kidney failure(a rapid loss of the kidneys' ability to remove waste and help balance fluids and electrolytes in the body.), diabetes mellitus(a chronic metabolic disease that occurs when the body is unable to regulate blood glucose levels), and depression (a mental disorder characterized by loss of pleasure or interest in activities for long periods of time), 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.

Based on interview and record review, the facility failed to develop a complete baseline care plan for one of five sampled residents (Resident 3) within 48 hours of resident's admission. This deficient practice had the potential for delayed administration of necessary care and services. Findings: A review of Resident 3's admission Record (Face Sheet) indicated the facility admitted the resident on 7/18/2024, with diagnoses including encephalopathy (a change in your brain function due to injury or disease) and type two diabetes mellitus (a long-term condition in which the body has trouble controlling blood sugar and using it for energy). A review of Resident 3's Minimum Data Set (MDS - a standardized assessment and care screening tool) dated 7/25/2024, indicated the resident's cognitive skills for daily decision making (ability to think, remember, and make decisions) was severely impaired (never/rarely made decisions). The MDS indicated Resident 3 required partial/moderate assistance for oral hygiene, toileting hygiene, upper and lower body dressing, showering/bathing, and personal…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide the necessary treatment and services for two of five sampled residents (Resident 3 and Resident 5) consistent with the residents' needs and professional standards of practice, by failing to: -Ensure Resident 3 received wound treatment for right posterior hip unstageable (full-thickness skin and tissue loss in which actual depth of the ulcer is completely obscured by slough-yellow, tan, green or brown and/or eschar-tan, brown, or black, in the wound bed) pressure injury (localized injury to the skin and or underlying tissue usually over a bony prominence as a result of pressure or pressure in combination with shear-layers are laterally shifted in relation to each other, and or friction-surfaces sliding against each other). -Ensure Resident 5 received wound treatment for coccyx (tailbone) Stage IV pressure injury (full thickness skin loss extended to muscle, tendon, or bone). These deficient practices had the potential for Resident 3 and Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement a comprehensive care plan that met the care/services based on the resident's individual assessed needs for three of five sampled residents (Resident 1, Resident 2, and Resident 4) by failing to ensure that a comprehensive (CP) was implemented for refusals of vaccinations (a medical treatment that helps body's immune system to recognize and fight disease). This deficient practice had the potential to result negative impact on residents ' health and safety, as well as the quality of care and services received. Findings: 1. During a review of Resident 1 ' s admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including acute kidney failure (a condition in which the kidneys suddenly can't filter waste from the blood) and hypertension (HTN - elevated blood pressure). During a review of Resident 1 ' s Minimum Data Set (MDS - a standardized assessment and screening tool), dated 5/24/2024, indicated Resident 1's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to: a. Ensure the physician ' s order for transmission-based precaution are implemented for three of five sampled residents (Resident 4, Resident 5, and Resident 6) who tested positive for coronavirus (COVID-19 - an infectious disease that can cause respiratory illness in humans). b. Ensure the Dietary Staff 1 (DS 1) wear fit-tested for National Institute for Occupational Safety and Health (NIOSH - federal agency responsible for conducting research and making recommendations for the prevention of work-related injury and illness) approved N95 or higher-level respiratory protection (mask that protect used by filtering out contaminants in the air) in the facility. These deficient practices had the potential to transmit infectious diseases and increase the risk of infection to the residents, staff, and visitors. Findings: 1a. A review of Resident 4 ' s admission Record indicated Resident 4 was admitted to the facility on [DATE] and readmitted on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of five sampled residents, (Resident 1) ' s clinical record was updated per facility ' s policy and procedure by failing to ensure resident's clinical records were updated regarding Physician Orders for Life-Sustaining Treatment (POLST - is a form designed to improve patient care by creating a portable medical order form that records patients' treatment wishes so that emergency personnel know what treatments the patient wants in the event of a medical emergency). This deficient practice violated resident ' s and/or representatives ' right to be fully informed of the option to formulate advance directive and POLST and had the potential to cause conflict with resident's wishes regarding health care. Findings: During a review of Resident 1 ' s admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including acute kidney failure (a condition in which the kidneys suddenly can't filter waste from the blood) and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement its policy and procedure (P&P) of incident reporting for unusual occurrence for one of one sampled resident (Resident 1) by failing to report an unusual occurrence to the State Survey Agency and send a written report within 24 hours of Resident 1 ' s death. This deficient practice resulted in a delay of an onsite inspection by the Department of Public Health and had potential to place other residents during an COVID-19 (an infectious disease that can cause respiratory illness in humans) outbreak. Findings: During a review of Resident 1 ' s admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including acute kidney failure (a condition in which the kidneys suddenly can't filter waste from the blood) and hypertension (HTN - elevated blood pressure). During a review of Resident 1 ' s Minimum Data Set (MDS - a standardized assessment and screening tool), dated [DATE], indicated Resident 1's cognitive skill…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 Controlled Drug Record (CDR- accountability record of medications that are considered to have a strong potential for abuse) coincided with the Medication Administration Records (MAR) for four of five sampled residents (Resident 7, 9, 11 and 13). This deficient practice had the potential to result in medication errors and/or drug diversion (illegal distribution or abuse of prescription drugs). Findings: A review of Resident 7 ' s admission Record indicated the facility originally admitted the resident on 5/9/2024 and readmitted on [DATE] with diagnoses including cardiomyopathy (a disease of the heart muscle that makes it harder for the heart to pump blood to the rest of the body), anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety or fear that are strong enough to interfere with one ' s daily activities), and type two diabetes mellitus (DM-a chronic condition that affects the way the body…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, facility failed to ensure one of five sampled residents (Resident 8) was free from significant medication error by failing to ensure the Ativan (lorazepam – used to relieve anxiety) 0.5 milligram (mg-unit of measurement) one tablet by mouth every 12 hours as needed for anxiety was not administered after 14 days ([DATE]) when the order expired. This deficient practice has the potential to result in Resident 8 in unintended complications related to the management of medication. Findings: A review of Resident 8 ' s admission Record indicated the facility admitted the resident on [DATE] with diagnoses including major depressive disorder (a mental health condition that causes a persistently low or depressed mood and a loss of interest in activities that once brought joy), anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety or fear that are strong enough to interfere with one ' s daily activities), and Alzheimer ' s disease (a…

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

Based on observation, interview and record review, the facility failed to ensure the actual hours worked by licensed and unlicensed nursing staffing directly responsible for resident care per shift were accurate for two of two sampled days (8/1/2024 and 8/2/2024). This deficient practice resulted in incorrect actual hours staffing information and had the potential to cause inadequate staffing. Findings: During an observation of the facility on 8/1/2024 at 10:44 a.m., Direct Care Services Hours Per Patient Day (DHPPD) were observed posted on a wall indicating actual PPD hours of 3.58 in the DHPPD posting. The DHPPD included the information of total staff and starting census for 7 a.m. to 3 p.m. shift, 3 p.m. to 11 p.m. shift and 11 p.m. to 7 a.m. shift. During an observation of the facility on 8/2/2024 at 10:43 a.m., observed Direct Care Services Hours Per Patient Day (DHPPD) posted on the wall with an actual PPD hours of 3.61 indicated in the DHPPD posting. The DHPPD included the information of total staff and starting total census for 7 a.m. to 3 p.m. shift, 3 p.m. to 11 p.m. shift…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 two out of 12 sampled residents (Resident 1 and 15) had Advance Directives (written statement of a person's wishes regarding medical treatment made to ensure those wishes are carried out should the person be unable to communicate them to a doctor) or Advanced Directives Acknowledgement forms (a signed acknowledgment indicating the resident and/or resident representative were provided with information regarding creating an Advanced Directive) documented in the residents' active medical record. This deficient practice had the potential for Residents 90 and Resident 96 to be denied the right to request or refuse medical care and treatment or have those options honored in the event of an emergency. Findings: A review of Resident 1's admission Record indicated the facility initially admitted Resident 1 on 11/27/2023 and readmitted on [DATE] with diagnoses that included metabolic encephalopathy (problem in the brain caused by chemical imbalance 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 observation, interview, and record review the facility failed to store and label food in accordance with professional standards and the facility's policy and procedure (P&P) titled Labeling and Dating of Foods reviewed 9/202 by failing to label food with the open date (date indicating packaging opened; used to determine amount of time food can be safely consumed). This deficient practice placed all 127 facility residents at risk for foodborne illnesses. Findings: During a concurrent observation and interview of the facility kitchen on 5/20/2024 at 8:40 AM, the following were observed: 1. A box containing 13 potatoes with no label or date in the dry storage section of the kitchen. 2. One opened and two unopened packages of frozen breaded fish with no label or open date in freezer 1. 3. One opened bottle of creamer with no label or open date in refrigerator The Dietary Supervisor (DS) confirmed the box of potatoes, frozen breaded fish, and creamer were all unlabeled and undated. The DS stated food had to be dated and labeled with a received by, use by, and open date. The DS…

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

Based on observation, interview, and record review, the facility failed to honor the rights of one of 32 (Resident 58) sampled residents shower preferences. This deficient practice resulted in Resident 58 feeling dirty and uncomfortable. Findings: A review of Resident 58's admission Record indicated the facility admitted Resident 58 on 6/7/2020 and readmitted the resident on 4/19/2023 with diagnoses that included acute kidney failure (condition in which one's kidney's suddenly stop working), diabetes (high blood sugar), and heart failure (condition in which the heart muscle is unable to pump enough blood to meet the body's needs for blood and oxygen). A review of Resident 58's History and physical, dated 4/21/2023 indicated Resident 58 had the capacity to understand and make decisions. A review of Resident 58's quarterly Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 3/18/2024, indicated Resident 58 was cognitively intact (ability to acquire and understand knowledge). The MDS indicated Resident 58 was dependent upon staff for bathing, and shower.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 mandatory information on the Nursing Facility (SNF) must issue this notice to a resident when it believes that Medicare may not cover their care or stay. The SNF must provide the notice to the resident before providing the non-covered care.) appeal process in a timely manner for one of three randomly selected residents (Resident 7). This deficient practice denied Resident 2 the right to accept or decline non covered specific skilled services or file an appeal. This placed Resident 7 at risk for an unexpected financial burden/crisis. Findings: A review of Resident 7's admission Record indicated the facility re-admitted the resident on 4/22/2024 with diagnoses that included dysphagia (difficulty swallowing), hypoxia (low levels of oxygen in the body tissues), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest and can interfere with your daily activities of living), schizophrenia (a serious mental health condition that affects how people think, feel and behave), dementia…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to provide a bed hold notification (written notice of holding or reserving a resident's bed while the resident is absent from the facility for therapeutic leave or hospitalization) at the time of transfer to the hospital for one of two sampled residents (Resident 133). This deficient practice denied Resident 133 and/or the Responsible Party (RP) the right to be informed of their right to have the facility hold and reserve Resident 133's bed while absent from the facility. Findings: A review of Resident 133's admission Record (Face Sheet) indicated the facility originally admitted the resident on 2/9/2021, and readmitted on [DATE], with diagnoses that included type two (2) diabetes mellitus (a chronic condition that affects the way the body processes blood sugar [glucose]), and heart failure (a condition in which the heart muscle cannot pump enough blood to meet the body's needs for blood and oxygen). A review of Resident 133's Minimum Data Set (MDS- a…

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

Based on interview and record review, the facility failed to develop a comprehensive care plan (a document outlining a detailed approach to care customized to an individual resident's need) for Apixaban (Eliquis, an anticoagulant medication [medication that help prevent blood clots]) 5 milligrams (mg) by mouth twice a day for anticoagulant (medication used to treat and prevent blood clots) one of four sampled residents (Resident 7). This deficient practice had the potential for Resident 7 to not be provided personalized care and experience negative effects from the anticoagulant medication such as bruising, internal bleeding, and uncontrolled bleeding. Findings: A review of Resident 7's admission Record indicated the facility re-admitted the resident on 4/22/2024 with diagnoses that included dysphagia (difficulty swallowing), hypoxia (low levels of oxygen in the body tissues), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest and can interfere with your daily activities of living), schizophrenia (a serious mental health condition that…

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

Based on observation, interview, and record review, the nursing staff failed to revise the tube feeding (also known as enteral nutrition, is a way to provide nutrition, fluids, and medicines through a feeding tube placed into the stomach or small intestine) care plan to meet the individual needs for one of two sampled residents (Resident 76). This deficient practice had the potential to prevent Resident 76 from receiving care to address specific needs, which could lead to a decline in emotional and physical health. Findings: A review of Resident 76's admission Record indicated the facility originally admitted the resident on 1/27/2021 and readmitted the resident on 1/15/2024 with diagnoses that included dysphagia (difficulty swallowing), stroke affecting the left side and type 2 diabetes mellitus (a disease in which your body does not produce enough insulin needed to control sugar levels in the blood). A review of Resident 76's tube feeding care plan, initiated 5/23/2023, indicated Resident 76 required tube feeding related to diagnoses of dysphagia and diabetes. The care plan…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to schedule the urology (medical conditions of the urinary tract) and gastroenterology (all the organs in the digestive system, including the GI tract (esophagus, stomach, and intestines) and biliary organs (your liver, bile ducts, pancreas and gallbladder) consults as ordered by the physician on 5/10/2024, for one of four sampled residents (Resident 99) in a timely manner. As a result, as of 5/22/2024 Resident 99's appointments had still not been scheduled. This deficient practice placed the resident at risk for worsening of symptoms, infections, organ failure, and death. Findings: A review of Resident 99's admission record indicated Resident 99 was admitted to the facility on [DATE] with diagnoses that included neuromuscular dysfunction of the bladder and benign prostatic hyperplasia (BPH - condition that occurs when the prostate gland enlarges, potentially slowing or blocking the urine stream) and diverticulitis (small bulging sacs or pouches that form…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 skin and pressure ulcer (injuries to the skin and underlying tissue, primarily caused by prolonged pressure on the skin) care consistent with professional standards of practice and per the physician's orders for one of three sampled residents (Resident 131) at risk for developing pressure ulcers by failing to ensure the resident's Low Air Loss Mattress (LALM - a pressure-relieving mattress used to prevent and treat pressure injuries) was set at the appropriate level. This deficient practice placed Resident 131 at risk for developing new pressure injuries and complications resulting from untreated or improperly treated pressure injuries which could result in systemic infections that could lead to death. Findings: A review of Resident 131's admission Record indicated the facility admitted the resident on 2/29/2024 with diagnoses that included encephalopathy (a change in your brain function due to injury or disease) atrial flutter (a condition in which the heart's upper chambers (atria) beat too quickly),…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 37) received colostomy (an opening in the abdominal wall that's made during surgery, and it is used to move waste out of the body) care in accordance with the resident's comprehensive person-centered care plan (a set of instructions for providing individualized care to a resident for an identified area of concern) by failing to provide colostomy care during every shift and as needed, and monitor skin irritation as per the plan of care. This deficient practice had the potential for Resident 37 to suffer from infection, skin breakdown, and pain. Findings: A review of Resident 37's admission Record (Face Sheet) indicated the facility originally admitted Resident 37 on 4/17/2017, and readmitted on [DATE], with diagnoses including colostomy, and lack of coordination. A review of Resident 37`s Care Plan dated 8/1/2023, indicated Resident 37 had colostomy bag. The care plan goal for the resident was to be free from…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide one to one (1:1) feeding assistance as indicated in the care plan one of three residents (Resident 62) when: Restorative Nursing Assistant (RNA) 1 and (RNA) 2 (staff who provides care to help to restore and maintain function) did not provide 1:1 feeding assistance to Resident 62 during lunch on 5/21/24 and 5/22/2024. These deficient practices had the potential for Resident 62 and other 1:1 feeder at the facility to experience poor oral intake and be at risk for weight loss. Findings: During a review of Resident 62's admission Record indicated the resident was admitted to the facility on [DATE], with diagnoses including cachexia (involuntary weight loss and muscle loss), adult failure to thrive, and dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities). During a review Resident 62's Minimum Data Set (MDS, a comprehensive assessment and care screening tool), dated 4/17/2024,…

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

Based on observation, interview, and record review, the facility failed to follow their infection prevention and control procedure by not displaying the proper isolation-based precaution sign and posting the specific type of isolation outside the door for one of one sampled resident (Resident 106). This failure resulted in posting incorrect isolation precaution instructions, incorrect personal protective equipment (PPE, equipment worn to minimize exposure to hazards that cause serious illnesses) outside the resident's door and had the potential for staff donning incorrect PPE and contracting and spreading infections to other residents. Findings: During a review of Resident 106's admission Record, dated 5/22/2024 indicated, the resident was admitted to the facility with diagnoses including but not limited to acute kidney failure (when the kidneys suddenly become unable to filter waste products from the blood, anemia (low red blood cells), cardiac arrhythmia (irregular heart rate) and cellulitis (bacterial infection of the skin) of right and left lower limb. During a review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure one of one sampled resident (Resident 4) received care and services when providing parenteral fluids (intravenous [IV-a small, flexible tube placed into a small vein for intravenous therapy such as medication fluids] infusion of various solutions to maintain hydration, restore and/ or maintain fluid volume, reestablish lost electrolytes [substance that help regulate chemical balance in the body] or maintain nutrition) consistent with professional standards of practice by failing to ensure Resident 4 ' s Peripheral Inserted Central Catheter (PICC line- a type of a Central Venous Catheter [CVC-a catheter placed into a large vein]) was flushed with 10 milliliter (mL - unit of measurement) 0.9 percent (%) sodium chloride (NS-normal saline) prior to administering an antibiotic medication per facility policy. This deficient practice had the potential to result in Resident 4 ' s PICC line catheter site to develop complication such as…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 document medication administration immediately after dose were administered for three of five sampled residents (Residents 1, 2, and 3). This deficient practice had the potential to result in medication administration error and risk for unsafe, improper medication administration use for Residents 1, 2, and 3. Findings: 1. A review of Resident 1's admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and was re-admitted on [DATE] with diagnoses including cholecystitis (inflammation of gallbladder [a small organ under the liver]) and neuropathy (weakness, numbness, and pain from nerve damage usually in the hands and feet). A review of Resident 1's Minimum Data Set (MDS - a standardized comprehensive assessment and care screening tool), dated 3/24/2024, indicated Resident 1's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision-making was intact and required…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to ensure the residents have the right to be free from sexual abuse for one of seven sampled residents (Resident 3). This deficient practice resulted in residents being subject to neglect and sexual abuse. Cross Reference F609 and F610. Findings: A review of Resident 2 ' s admission Record indicated Resident 2 was admitted on [DATE] with diagnoses including encephalopathy (a chemical imbalance in the blood affecting the brain), human immunodeficiency virus (HIV - a virus that attacks cells that help the body fight infection, making a person more vulnerable to other infections and diseases, It is spread by contact with certain bodily fluids of a person with HIV, most commonly during unprotected sex [sex without a condom or HIV medicine to prevent or treat HIV], or through sharing injection drug equipment), schizophrenia (a disorder that affects a person ' s ability to think, feel, and behave clearly) and cellulitis of right lower limb (bacterial skin…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement their policy regarding reporting of residents ' allegation of sexual abuse and to submit a conclusion report of investigation within five days or in accordance with state or federal law for two of seven sampled residents (Resident 2 and Resident 3). This resulted in a delay of an onsite inspection by the Department of Public Health to ensure the residents' allegation of abuse was investigated which can also lead to a delay in prevention of further sexual abuse for Resident 2 and Resident 3. Findings: A review of Resident 2 ' s admission Record indicated Resident 2 was admitted on [DATE] with diagnoses including encephalopathy (a chemical imbalance in the blood affecting the brain), human immunodeficiency virus (HIV - a virus that attacks cells that help the body fight infection, making a person more vulnerable to other infections and diseases, It is spread by contact with certain bodily fluids of a person with HIV, most commonly 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 implement its abuse prevention policy by failing to report an allegation of sexual abuse within 2 hours or in accordance with state or federal law for two of seven sampled residents (Resident 2 and Resident 3). This resulted in a delay of an onsite inspection by the Department of Public Health to ensure the residents' allegation of abuse was investigated which can also lead to a delay in prevention of further sexual abuse for Resident 2 and Resident 3. Cross Reference F609. Findings: A review of Resident 2 ' s admission Record indicated the resident was admitted on [DATE] with diagnoses including encephalopathy (a chemical imbalance in the blood affecting the brain), human immunodeficiency virus (HIV - a virus that attacks cells that help the body fight infection, making a person more vulnerable to other infections and diseases, It is spread by contact with certain bodily fluids of a person with HIV, most commonly during unprotected sex [sex without 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 that one of six sampled residents, (Resident 1) received treatment and care accordance with professional standards of practice to meet the resident's physical, mental, and psychosocial needs by failing to ensure the physician ' s order was carried out. This deficient practice resulted to failure in the delivery of necessary care and services and resulted in Resident 1 ' s hospitalization. Findings: A review of Resident 1's admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis including aftercare following joint replacement surgery (a procedure in which a surgeon removes a damaged joint and replaces it with a new, artificial part), abnormalities of gait and mobility, and hypertensive heart disease (problems with heart that can develop if a person have high blood pressure and not treated for years). A review of Resident 1's 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide pharmaceutical services including procedures that assure the accurate acquiring and administering of all drugs and biologicals to meet the needs of each resident for one of six sampled residents (Resident 2) by failing to ensure that Resident 2 ' s medications were not left unattended at the bedside. This deficient practice had the potential to result in Resident 2 in unintended complications related to the management of medications. Findings: A review of Resident 2 ' s admission Record indicated the resident was admitted on [DATE] with diagnoses including encephalopathy (a chemical imbalance in the blood affecting the brain), human immunodeficiency virus (HIV - a virus that attacks cells that help the body fight infection, making a person more vulnerable to other infections and diseases, It is spread by contact with certain bodily fluids of a person with HIV, most commonly during unprotected sex [sex without a condom or HIV…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 four of six sampled Certified Nursing Assistant staff (CNA 1, CNA 2, CNA 4, and CNA 5) had a performance review every 12 months to provide in-service training based on the outcome of their performance review. This failure resulted in CNA 1, 2, 4 and 5 being denied a yearly performance review as required by the federal regulation. Findings: During a concurrent interview and record review on 4/2/23 at 3:55 pm with Director of Staff Development (DSD) the personnel files of CNA 1, 2, 4, and 5 were reviewed. The files indicated no evidence of a performance review to have been done in the last 12 months for the CNAs employed at the facility. The DSD confirmed the performance reviews were not done and stated they should be done to know where we need further education and if we are up to par, to know where we are lacking so we can improve. A review of facility's Job Descriptions and Performance evaluation, dated 9/2023, indicated, I. The primary purpose of job descriptions is to provide uniform standards for the…

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

Based on interview and record review, the facility failed to ensure one of six sampled Certified Nursing Assistant staff (CNA 6) had an active license when employed at the facility. This failure resulted in CNA 6 not meeting the requirements of the federal regulation for nurse aide registry (certification) verification. Findings: A review CNA 6 ' s employee file indicated CNA 6 ' s hire date as 1/12/23 and termination date as 6/9/23. During a concurrent interview and record review on 4/4/24 at 3:55 pm with Director of Staff Development (DSD) CNA 6 ' s L & C (Licensing & Certification) Verification Detail Page, undated, from CNA 6 ' s personnel file was reviewed. The L& C Verification Detail Page, indicated CNA 6 ' s license status was active, employable with expiration date of 3/19/25. The DSD verified the information and expiration date. During a concurrent interview and record review on 4/4/24 at 3:55 pm with Director of Staff Development (DSD) CNA 6 ' s L & C (Licensing & Certification) Verification Detail Page, dated 3/28/24, from the California Department of Public Health…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 procedures on infection control to prevent the spread of coronavirus disease 2019 (COVID-19, a highly contagious infection affecting the respiratory system caused by a virus that can spread from person to person) by failing to: 1. Ensure all staff were tested for the COVID-19 before the start of each shift as recommended by the local health department. 2. Ensure certified nursing assistant (CNA 1) wore protective gown and gloves when providing care and when in close contact with the resident who was potentially exposed to COVID-19. 3. Ensure the cleaning cart were sanitized and used exclusively for the rooms that house the COVID-19 positive residents. These deficient practices had the potential for COVID-19 and other transmissible diseases to spread to residents and staff. Findings: 1.During a review of the Site Visit Recommendation dated 1/4/24 indicated the local health department provided the facility with several recommendations to stop the spread of COVID-19 in the facility 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 observation and interview, the facility failed to provide a clean, free of odor, safe and home like environment for two of four sampled residents (Residents 1 and 4). This deficient practice resulted in Resident 1 feeling dizzy from the strong distinct odors and had also the potential of placing other residents at risk of cross contamination, spread of disease-causing organism, and accident/incidents. Findings: A review of the admission Record (FS) for Resident 1 indicated that Resident 1 originally admitted on [DATE], and was re-admitted on [DATE] with diagnoses including heart failure (a condition that develops when your heart doesn't pump enough blood for your body's needs), essential hypertension (occurs when you have abnormally high blood pressure that's not the result of a medical condition), and morbid (severe) obesity (abnormal or excessive fat accumulation that presents a risk to health). A review of Resident 1 ' s Minimum Data Set (MDS- a standardized 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to develop and implement an individualized person-centered plan of care with measurable objectives, timeframe, and interventions to meet the residents' needs for two of the four sampled residents (Resident 1 and 4) by failing to ensure Residents 1 and 4 Activities of Daily Living (ADL -which included showers and incontinence care [assistance with bladder and/or bowel function which includes supporting a person to maintain continence and manage incontinence]) care refusals were care planned and addressed during Interdisciplinary team meetings. These deficient practices resulted in Resident 1 and 4 ' s room to cause a strong odor that spread to the nursing station. The nurses shut the door which made Resident 1 feel dizzy from smelling the odor that he had to leave the room at 2 a.m. Findings: A review of the admission Record (FS) indicated the Resident 1 originally admitted on [DATE], and was re-admitted on [DATE] with diagnoses including…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that licensed nurses had the specific competencies and skill sets necessary to adequately assess stage Pressure Ulcers (PU-are skin and soft tissue injuries that form as a result of constant or prolonged pressure exerted on the skin) for two of three sampled residents (Residents 2 and 3). This deficient practice had the potential to result in improperly treating the wound which may lead to the wound getting worse for Resiednts 2 and 3. Findings: A review of Resident 2 's admission Record (FS) indicated Resident 2 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including diabetes mellitus 2 (a condition that happens because of a problem in the way the body regulates and uses sugar as a fuel), dysphagia (swallowing difficulties where some people have problems swallowing certain foods or liquids, while others can't swallow at all), and dementia (a general term for the impaired ability 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 re admit one of three sampled resident (Resident 1) after hospitalization on 11/9/2023 at a General Acute Care Hospital (GACH) as indicated in the facility's policy and procedure (P&P) titled Bed-holds and Returns. As a result, Resident 1 remained in GACH 1 since 11/16/2023 and had the potential to cause psychosocial harm. Findings: A review of Resident 1 ' s admission Record indicated resident was originally admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses including urinary tract infection (UTI- an infection in any part of the urinary system, including the kidney, bladder or urethra), epilepsy (a disorder in which nerve cell activity in the brain is disturbed causing seizures) and major depressive disorder (a mental disorder that have a persistent feeling of loss of pleasure or interest in life). A review of Resident 1 ' s History and Physical, dated 10/29/2023, physician indicated, resident does not have the capacity to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to accommodate residents' needs were met by failing to ensure: 1. That the call light (A device used by a patient to signal his or her need for assistance from professional staff) for one of four sampled residents (Resident 3) was within reach per facility protocol. 2. Resident 1's who was incontinent (inability of the body to control the evacuative functions of urination or defecation) care was provided incontinence care in a timely manner. This failure resulted in Resident 3 feeling isolated and unable to call for assistance whenever she needed help. Findings: During an initial tour on an unannounced visit to the facility on [DATE] at 5:10 p.m., Resident 3 was observed lying down with her right arm which she was unable to move herself was positioned on a pillow. She stated that staff always take her call light away and most of the times finds it hard to call for assistance and leaves her feeling isolated. The call light was observed to be…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure one out of 5 Residents (Resident 4) was free from significant medication error by failing to administer the morning dose of Risperdal (a medication that works in the brain to treat schizophrenia. It is also known as a second-generation antipsychotic (SGA) or atypical antipsychotic), Aricept (used to treat dementia (memory loss and mental changes) associated with mild, moderate, or severe Alzheimer's disease), potassium chloride (a mineral supplement used to treat or prevent low amounts of potassium in the blood. A normal level of potassium in the blood is important), and Namenda (used to treat dementia associated with Alzheimer's disease [most common type of dementia. It is a progressive disease beginning with mild memory loss and possibly leading to loss of the ability to carry on a conversation and respond to the environment]). This deficient practice had a potential to place Resident 1 at risk for worsening symptoms of dementia,…

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

Based on interview and record review, the facility failed to ensure a resident's discharge summary was completed and was provided to the resident prior to discharge from the facility for one of 25 sample residents (Resident 1). This deficient practice had the potential to result in an unsafe discharge. Findings: A review of Resident 1 ' s admission Record indicated the facility admitted the resident, on 5/9/2023 with diagnoses including dementia, secondary bone cancer (when a cancer that started somewhere else in the body has spread to the bones), gait and mobility abnormalities and muscle weakness. The admission record listed both Resident 1 and Family Member 1 (FM 1) as the Responsible Party. A review of the Interdisciplinary Team (IDT) Conference Notes, dated 5/10/2023, indicated Resident 1 received Physical and Occupational therapy and the goals were to return the resident to her prior level of functioning, assess functional ability, and enhance fall recovery abilities. The IDT Conference Notes indicated Resident 1 was living at home alone prior to hospitalization 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 Based on observation, interview, and record review, the facility failed to answer the call light promptly per facility policy for four of 25 sampled residents (Residents 6, 8, 10 and 101). This deficient practice resulted in a delay for staff to answer the call light and had the potential to not address the needs for Residents 6, 8, 10 and 101 timely. Findings: 1. A review of Resident 6's admission Record, indicated the facility admitted Resident 6 on 8/27/2019, with diagnoses that included chronic obstructive pulmonary disease (COPD- a group of diseases that cause airflow blockage and breathing-related problem), heart failure (when the heart muscle does not pump blood as well as it should and fluid builds up in the lungs, causing shortness of breath), and transient cerebral ischemic attack (a brief episode during parts of the brain do not receive enough blood). A review of Resident 6's Minimum Data Set (MDS, a standardized assessment and care screening and tool) dated 9/3/2021, indicated Resident 6 had intact…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to provide a clean, free of odor, and home like environment for three of 25 sampled residents (Resident 25, 49 and 56). These deficient practices had the potential for cross contamination, spread of disease-causing organism, and negatively impact the quality of life for Residents 25, 49 and 56. Findings: 1. A review of Resident 25's admission Record, indicated the facility originally admitted Resident 25 on 6/7/2012, and readmitted the resident on 6/4/2021, with diagnoses that included, but were not limited to, dysphagia (occurs when there is a problem with the neural control or the structures involved in any part of the swallowing process), and thrombocytopenia (a condition in which you have a low blood platelet count (Platelets [thrombocytes] are colorless blood cells that help blood clot). A review of Resident 25's Minimum Data Set (MDS - a standardized assessment and care screening tool) dated 9/17/2021, indicated Resident 25 had severe cognition…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure an low air loss mattress (LAL-a mattress designed to prevent and treat pressure wounds) settings were consistent with weight and physician's order for five of 25 sampled residents (Residents 45, 49, 60, 66 and 100) who had severe cognitive (mental action or process of acquiring knowledge and understanding) impairment, and dependent on staff for activities of daily living (ADL, bed mobility, locomotion, surface transfer, eating, grooming, persional hygiene, toileting and or dressing) These deficient practice increased the risk for poor and or delayed pressure ulcer (also called pressure ulcers and decubitus ulcers -are injuries to skin and underlying tissue resulting from prolonged pressure on the skin) wound healing, and increased the risk to develop pressure ulcers /wounds for (Residents 45, 49, 60, 66 and 100). Findings: 1. A review of Resident 45's admission Record, indicated the facility originally admitted Resident 45 on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2. A record review of the admission record indicated Resident 58 was re-admitted to the facility on [DATE]. Resident 58 diagnoses included but were not limited to hemorrhage (bleeding) of the rectum (the terminal part of the intestine from the sigmoid colon to the anus), dementia (loss of cognitive functioning-thinking, remembering, and reasoning), gastrostomy tube (GT- a flexible tube surgically inserted through the abdomen into the stomach for feeding, fluid, and medication administration) and glaucoma (eye condition that can cause blindness). A record review of the Resident 58's MDS, dated [DATE], indicated Resident 58 had severe impairment in cognitive skills for daily decision making. The MDS also indicated Resident 58 was totally dependent on staff for help in bed mobility, dressing, eating, toilet use, personal hygiene, and bathing. A record review of Resident 58's fall risk assessment, dated 11/3/2021, indicated Resident 58 was a high risk for fall. A record review of Resident 58's care plan titled…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 3. During a concurrent observation and interview on 12/7/2021 at 7:53 a.m., unlabeled opened dietary supplements were found in the drawer of Station A medication cart (Cart 2). Licensed Vocational Nurse 5 (LVN 5) stated that all opened medication bottles should have labels with date and initials when it was opened so staff could know when to dispose (get rid of) medications for safety and effectiveness. 4. During a concurrent observation and interview on 12/7/2021 at 7:55 a.m., unlabeled opened foil pack of DuoNeb were found in the drawer of Cart 2. LVN 5 stated that when opening DuoNeb, foil pack should be labeled with date and should be discarded within a week per manufacturer's policy. A review of manufacturer's product labeling, undated, indicated DuoNeb should be used within a week. 5. During a concurrent observation and interview on 12/07/21 at 11:15 a.m., three (3) bottles of Magnesium Citrate with an expiration date of 11/2021 were found in the in-house storage room. Registered Nurse 2 (RN 2) stated 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 observation, interview and record review, the facility failed to ensure safe and sanitary food distribution and hand hygiene practice when: 1. One staff working in the dish machine area did not wash hands and change gloves when removing the clean and sanitized dishes from the dish machine. 2. Two certified nursing assistants (CNAs) did not perform hand hygiene during delivery of food and drink to Resident 41 and Resident 102. These failures had the potential to cross contaminate (transfer of harmful bacteria from one place to another) dishes and cause food borne illness in 95 out of 109 residents who received food from the facility's kitchen, exposing residents to infectious microorganisms (bacteria, virus, or fungus). Findings: 1. During an observation in kitchen on 12/6/21 at 7:55 a.m., Dishwasher (DW) was working alone in the dish machine area. DW was rinsing soiled dishes with gloves on. After rinsing soiled dishes, DW loaded dirty dishes in the dish machine. DW proceeded to wash, then to wipe 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 conduct Coronavirus - 19 (COVID-19 or COVID, a virus that causes respiratory illness that can spread from person to person) testing practices consistent with the current standard of practice and state guidelines as evidenced by failing to: 1) Label Resident 80's COVID-19 test specimen collection tube (culturette package) with Resident 80's identification. 2) Monitor the percentage of their residents and health care providers (HCPs, facility staff) that are fully vaccinated on a daily basis. These deficient practices had the potential resulting in transmission and spread of COVID-19 within the facility. Findings: 1) A review of admission record, dated 12/8/2021, indicated Resident 80 was admitted to the facility on [DATE]. Resident 80's diagnoses included epilepsy (a group of related disorders characterized by a tendency for recurrent seizures) and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and…

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

Based on observation, interview and record review, the facility failed to ensure staff did not stand over one of 10 sampled Residents (Resident 91) while assisting Resident 91 to eat at lunch time. This deficient practice violated the right to be treated with dignity and respect, and had the potential for psychosocial harm for Resident 91. Findings: A review of Resident 91's admission Record, indicated the facility admitted Resident 91 on 8/6/2019, with diagnoses that included, but not limited to diabetes mellitus (DM-a chronic condition that affects the way the body processes blood sugar [glucose]), abnormalities of gait and mobility, lack of coordination and dementia (loss of cognitive functioning-thinking, remembering, and reasoning). A review of Resident 91's Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated 11/13/2021, indicated Resident 91 had severe impaired cognition (mental action or process of acquiring knowledge and understanding) for daily decision-making and required extensive assistance from staff for activities of daily living (ADL-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.

Based on interview and record review, the facility failed to reimburse one of one sampled resident (Resident 47) for a missing mouthguard (is a protective device for the mouth that covers the teeth and gums to prevent and reduce injury to the teeth, arches, lips, and gums). This deficient practice the potential to compromise the dental health for Resident 47. Findings: A review of Resident 47's admission Record, indicated the facility admitted Resident 47 on 7/3/2019, with diagnoses that included rheumatoid arthritis (when the body's infection defense system is attacking its own tissue, internal organs, and joints that can cause bone destruction and deformity), cervical (neck bone) disc disorder (a condition when one or more cushioning discs in the cervical spine starts to break down due to wear and tear causing neck and arm pain), and fibromyalgia (a condition that causes pain all over the body, sleep problems and emotional distress). A review of Resident 47's Minimum Data Set (MDS, a standardized assessment and care screening tool) dated 10/7/2021, indicated Resident 47 had intact…

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

Based on interview and record review, the facility failed to update the Minimum Data Set (MDS - a comprehensive standardized assessment and screening tool) within 14 days for significant change in status for one of 25 sampled residents (Resident 60). This deficient practice had the potential to affect the provision of necessary care and services for Resident 60. Findings: A review of Resident 60's admission Record, indicated the facility originally admitted Resident 60 was originally on 5/16/2019, and readmitted the resident on 5/28/2020, with diagnoses that included, but were not limited to, Type II Diabetes (DM-a disorder which the body does not produce enough or respond normally to insulin causing blood sugar levels to be abnormally high), and Coronavirus disease 2019 (COVID-19, a contagious severe respiratory illness). A review of Resident 60's Minimum Data Sheet (MDS- a standardized assessment and care-screening tool) dated 10/9/2021, indicated Resident 45 had severe cognition (ability to make decisions for daily living) impairment, and was dependent on staff for activities 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 interview and record review, the facility failed to ensure the assessment entries on the Minimum Data Set (MDS - a comprehensive standardized assessment and screening tool) accurately reflected the resident's hospice status for one of 25 sampled residents (Resident 60). This deficient practice resulted in incorrect data transmitted to Centers for Medicare and Medicaid Services (CMS- a federal agency that administers the nation's major healthcare programs including Medicare, Medicaid) regarding resident's hospice status. Findings: A review of Resident 60's admission Record, indicated the facility originally admitted Resident 60 was originally on 5/16/2019, and readmitted the resident on 5/28/2020, with diagnoses that included, but were not limited to, Type II Diabetes (DM-a disorder which the body does not produce enough or respond normally to insulin causing blood sugar levels to be abnormally high), and Coronavirus disease 2019 (COVID-19, a contagious and severe respiratory illness). A review of Resident 60's Minimum Data Sheet (MDS- a standardized assessment 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 implement care plans on safety and peripherally (away from the center of the body) inserted central catheter (PICC- is a thin, flexible tube that is inserted into a vein in the upper arm and guided (threaded) into a large vein above the right side of the heart to administer intravenous [IV-inside a vein] fluids, blood transfusions, chemotherapy [medication to treat cancer], and other drugs) line care for two of 25 sampled residents (Resident 58 and 67). A review of facility's policy and procedures (P&P) titled Care Planning- Interdisciplinary Team, revised 1/2017, indicated that it is the policy of the facility that the interdisciplinary team is responsible for the development of an individualized resident centered comprehensive care plan for each resident. A review of facility's P&P titled admission Policy, revised 1/2017, indicated that the care plan will be developed to address minimum healthcare information required to properly care…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 monitor and document Peripherally Inserted Central Catheter (PICC-a thin, soft tube that is inserted into a vein in the arm, leg or neck for long-term intravenous [IV] antibiotics, nutrition, medications, and blood draws) site for one of two sampled residents (Resident 67). This deficient practice had a potential for Resident 67's PICC line site not being properly monitored for possible infection. Findings: A review of Resident 67's admission Record indicated the resident was re-admitted to the facility on [DATE]. Resident 67'3 diagnoses included, but were not limited to hypokalemia (low potassium [important mineral that the body needs, to work properly] level in the blood, ischemic heart disease (also called coronary heart disease [CHD-heart problems caused by a narrowed heart arteries which can cause less blood and oxygen circulation to the heart]), and diabetes mellitus (DM-a chronic condition that affects the way the body processes…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 communicate the consultant pharmacist's recommendation, in the Medication Regimen Review (MRR), to the attending physician for one of five sampled residents (Resident 96). This deficient practice had the potential for unnecessary medication use, resulting in an adverse drug reaction to affect the health and wellbeing of Resident 96. Findings: A review of the admission record indicated Resident 96 was admitted to the facility on [DATE]. Resident 96's diagnoses included cellulitis (a serious bacterial skin infection), Type I Diabetes (a chronic condition that affects the way the body processes blood sugar), venous insufficiency (failure of the veins to adequately circulate blood), anemia (a condition marked by a deficiency of red blood cells or hemoglobin in the blood), gout (a form of arthritis characterized by severe pain, redness, and tenderness in joints), hypertension (a condition in which the force of the blood against artery walls is too high). A…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to observe infection control measures for two of six sampled residents (Resident 31 and Resident 46) by failing to ensure: 1. The Hoyer lift (a mechanical lift that allows a person to be lifted and transferred with minimum physical effort) was cleaned after its use on Resident 31. 2. Licensed Vocational Nurse 7 (LVN 7) wore a Non-oil 95% mask (N95 - a respiratory protective device designed to achieve a very close facial fit and very efficient filtration of airborne particles) and eye protection (goggles or face shields) during oral suctioning (use of a rigid plastic suction catheter to remove pharyngeal secretions through the mouth) of Resident 46. These deficient practices had the potential to spread infection in the facility and place residents at risk for infection. Findings: 1. A review of Resident 31's admission Record indicated the resident was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 31'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.