Longwood Manor Conv.hospital

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to: 1. Ensure one of seven sampled residents (Resident 67) smoking paraphernalia (an electronic cigarette device that heats a liquid containing nicotine) had been properly stored. 2. Ensure one of seven sampled residents (Resident 124) bed rails were properly padded. 3. Ensure one of seven sampled residents (Resident 95) lighter was stored in a safe location. These deficient practices had the potential to cause serious injuries. Findings: a. During a review of Resident 67's admission Record, the admission Record indicated Resident 67 was admitted to the facility on [DATE] and was readmitted on [DATE] Resident 67's diagnoses multiple sclerosis (a chronic, unpredictable disease of the central nervous system), chronic obstructive pulmonary disease ([COPD]-a chronic lung disease causing difficulty in breathing), and acute kidney failure (a sudden and significant decline in the kidney function). During a review of Resident 67's History and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to: 1. Ensure one of seven sampled residents (Resident 123) had a Complete Blood Count ([CBC]- a blood test that measures the number and type of cells in your blood), Comprehensive Metabolic Panel ([CMP]- a blood test that measures fourteen different substances in the blood) and Ammonia (a waste product found in blood) level completed per physician's order. 2. Ensure one of two sampled residents (Resident 156) had weekly pre-albumin (a lab test measures the level of prealbumin in the blood, a protein made by the liver) laboratory order drawn as ordered by the physician. These deficient practices had the potential for a delay in healthcare services and interventions for Residents 123 and 156 . Findings: a. During a review of Resident 123's admission Record, the admission Record indicated Resident 123 was initially admitted to the facility on [DATE], with a readmission on [DATE]. Resident 123's diagnoses included malnutrition (a condition caused by not…

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

Based on observation, interview and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen by failing to: 1. Ensure food item was labeled in dry food storage 2. Ensure the outside compartment of ice machine was clean These deficient practices had the potential to result in foodborne illness and cross contamination (transfer of harmful bacteria from one place to another). Findings: 1. During a concurrent observation and interview on 5/6/2025 at 8:40 a.m., with the Dietary Service Supervisor (DSS) in the dry storage room, an opened box of spaghetti whole wheat pasta was noted with no label with an open date. The DSS stated all food items in the dry storage are once opened in the box, should be labeled with the date it was opened and follow the standard food guidelines when to be consumed. The DSS stated the risk of not labeling with an open date of food items could result in residents consuming expired food. During a review of the facility's undated policy and procedure (P&P), titled Storage of Canned and Dry Goods,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to: 1. Ensure two of five sampled residents (Resident 152 and Resident 441) was offered the flu vaccine for the 2024-2025 flu season. This deficient practice had the potential for Resident 152 and Resident 441 at higher risk of acquiring and transmitting the flu to other residents in the facility. Findings: During an interview on 5/8/2025 at 8:56 a.m. with Infection Prevention Nurse (IPN) 1, IPN 1 stated all residents of the facility are offered the flu vaccine during the flu season. If the resident or their representative received the flu vaccine, it would be documented in the resident's chart that they received the flu vaccine, if they declined, there would also be documentation they declined the flu vaccine. IPN 1 stated she was unable to find documentation to show if Resident 152 and Resident 441 declined or received the flu vaccine for the 2024-2025 flu season. During a review of Resident 152's Face Sheet (front page of the chart that contains 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: 1. Ensure one out of seven sampled residents (Resident 49) had an accurate assessment for the use of four bed rails. This deficient pracfailure had the potential for Resident 49 to not have received necessary care and services. Findings: During a review of Resident 49's admission Record, the admission Record indicated Resident 49 was admitted to the facility on [DATE] and was readmitted on [DATE]. Resident 49's diagnoses metabolic encephalopathy (a condition characterized by altered brain function due to a systemic or metabolic disturbance), dementia (a progressive state of decline in mental abilities), and schizophrenia (a mental illness that is characterized by disturbances in thought). During a review of Resident 49's History and Physical (H&P), dated 4/15/2025, the H&P indicated Resident 49 did not have the capacity to understand and make decisions. During a review of Resident 49's Minimum Data Set ([MDS]- a resident assessment tool),…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record, the facility failed to ensure a Minimum Data Set ([MDS] - a resident assessment tool) assessment was completed accurately for one of 35 sampled residents (Resident 40) by failing to: 1. Ensure Resident 40's diagnosis of depression (a mood disorder that causes a persistent feeling of sadness and loss of interest) was encoded under MDS section I5800 (Active Diagnoses). This deficient practice resulted in incorrect data being transmitted to the Center for Medicare and Medicaid Services (CMS) and had the potential to negatively affect the plan of care and delivery of care and services for Resident 40. Findings: During a review of Resident 40's admission Record (front page of the chart that contains a summary of basic information about the resident), the admission Record indicated, Resident 40 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 40's diagnoses included depression, intracranial hemorrhage ([a type of stroke] - loss of blood flow to a part…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to complete and re-submit the Preadmission Screening and Resident Review ([PASARR - a tool to determine if the person had, or was suspected of having a mental illness, intellectual disability, or related condition) Level one (I) screening and refer one of one sampled resident (Resident 175) who had a diagnoses of bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), and major depressive disorder ([MDD] - a mood disorder that causes a persistent feelings of sadness and loss of interest) to the appropriate state-designated authority for PASARR Level two (II) evaluation and determination. This deficient practice had the potential to result in Resident 175 to not receive the appropriate medical treatments for mental illness diagnoses. Findings: During a review of Resident 175's admission Record (front page of the chart that contains a summary of basic…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to: 1. Ensure one out of seven sampled residents (Resident 106) had a revised care plan (a structure written document that outlines the care a nurse will provide to a patient based on their specific needs and goals) for the low air loss ([LAL] -a specialized medical mattress designed to prevent and treat pressure ulcers by reducing pressure and moisture buildup on the skin) mattress. This deficient practice of not having revised care plan for the use of the LAL mattress placed Resident 106 at risk for not being provided with the appropriate, consistent, and individualized care. Findings: During a review of Resident 106's admission Record, the admission Record indicated Resident 106 was admitted to the facility on [DATE] and was readmitted on [DATE]. Resident 106's diagnoses metabolic encephalopathy (a condition characterized by altered brain function due to a systemic or metabolic disturbance), hemiplegia (total paralysis of the arm, leg, 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: 1. Ensure one of seven sampled residents (Resident 56) received a weekly weight per physician's order. This deficient practice resulted in inadequate monitoring of Resident 56's weight loss. Findings: During a review of Resident 56's admission Record, the admission Record indicated Resident 56 was initially admitted to the facility on [DATE], with a readmission on [DATE]. Resident 56's diagnoses included malnutrition (a condition caused by not getting enough calories or the right amount of key nutrients), diabetes mellitus ((DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), and congestive heart failure (CHF-a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling). During a review of Resident 56's History and Physical (H&P), dated 2/20/2025, the H&P indicated Resident 56 had the capacity to understand and make decisions. During a review of Resident 56'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 interview and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice, by failing to: 1. Provide compression stockings (elastic garments that squeeze the legs to improve blood flow, circulation, and to reduce swelling) per physician's order for one of one sampled resident (Resident 170) who had an edema (swelling caused by an accumulation of excess fluid in the body's tissues) of bilateral (both) lower extremities. This deficient practice had the potential to result in a delay in reducing the swelling of bilateral lower extremities of Resident 170 that would result in medical complication requiring hospitalization. Findings: During a review of Resident 170's admission Record (front page of the chart that contains a summary of basic information about the resident), the admission Record indicated, Resident 170 was admitted to the facility on [DATE]. Resident 175's diagnoses included cellulitis (a skin infection 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: 1. Ensure resident with long thick elongated (nail plate grows longer than the nail bed) toenails received podiatry (profession dealing with specialized care of the feet) care services for one of one sampled resident (Resident 170). This deficient practice had the potential to result in discomfort and decline in physical mobility of Resident 170. Findings: During a review of Resident 170's admission Record (front page of the chart that contains a summary of basic information about the resident), the admission Record indicated, Resident 170 was admitted to the facility on [DATE]. Resident 175's diagnoses included cellulitis (a skin infection that causes swelling and redness) of left and right lower limb (body part), hypertension ([HTN] - high blood pressure), and generalized muscle weakness. During a review of Resident 170's History and Physical (H&P), dated 1/29/2025, the H&P indicated, Resident 170 had the capacity to understand 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: 1. Ensure one of four sampled residents (Resident 175) was provided with a scheduled toileting plan (a technique that involves using a set schedule to go to the bathroom) or bladder training (type of training that will help a person manage urinary incontinence), per bowel and bladder assessment. This deficient practice had the potential for decline in bladder function for Resident 175. Findings: During a review of Resident 175's admission Record (front page of the chart that contains a summary of basic information about the resident), the admission Record indicated, Resident 175 was admitted to the facility on [DATE]. Resident 175's diagnoses included bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), major depressive disorder ([MDD] - a mood disorder that causes a persistent feelings of sadness and loss of interest) and generalized muscle weakness.…

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

The facility failed to: 1. Ensure one of four sampled residents (Resident 62) oxygen (O2) tubing was labeled with date last changed. This failure resulted in Resident 62 not having a clean and patent tubing and placed at risk for developing a respiratory infection. Findings: During an observation on 5/6/2025 and 5/7/2025 at 11:30 a.m., Resident 62 was observed receiving continuous oxygen at 4 L/minute (amount of oxygen delivered) with no date label on the O2 tubing. The O2 tubing was cloudy and contained clear thick fluid in the tubing around the nasal area. During a concurrent interview and record review on 5/7/2025 at 11: 45 a.m. with Licensed Vocational Nurse (LVN) 4, LVN 4 stated oxygen tubing needs to be changed daily as a routine. LVN 4 stated nursing staff are supposed to label the O2 tubing. During a review of Resident 62's admission Record (Face sheet), the admission Record indicated the facility admitted Resident 62 on 1/29/2025 with diagnoses including chronic obstructive pulmonary disease (COPD - a chronic lung disease causing difficulty in breathing). During 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, record review the facility failed to: 1. Ensure one out of seven sampled residents (Resident 49) appropriate alternatives were used prior to installing all four bed rails. This deficient practice of having all four bed rails up had the potential for Resident 49 to feel entrapped. Findings: During a review of Resident 49's admission Record, the admission Record indicated Resident 49 was admitted to the facility on [DATE] and was readmitted on [DATE]. Resident 49's diagnoses metabolic encephalopathy (a condition characterized by altered brain function due to a systemic or metabolic disturbance), dementia (a progressive state of decline in mental abilities), and schizophrenia (a mental illness that is characterized by disturbances in thought). During a review of Resident 49's History and Physical (H&P), dated 4/15/2025, the H&P indicated Resident 49 did not have the capacity to understand and make decisions. During a review of Resident 49's Minimum Data Set ([MDS]- a resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to: 1. Ensure one of one sampled resident (Resident 170) was evaluated by a physician at least once every 30 days for the first 90 days following admission and document his visit in resident's clinical records. This deficient practice had the potential for Resident 170's current medical condition not timely assessed by a physician that can lead to delay in necessary care and treatment. Findings: During a review of Resident 170's admission Record (front page of the chart that contains a summary of basic information about the resident), the admission Record indicated, Resident 170 was admitted to the facility on [DATE]. Resident 175's diagnoses included cellulitis (a skin infection that causes swelling and redness) of left and right lower limb (body part), hypertension ([HTN] - high blood pressure), and generalized muscle weakness. During a review of Resident 170's History and Physical (H&P), dated 1/29/2025, the H&P indicated, Resident 170 had the capacity…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to: 1. Ensure the correct prescribed eyedrops were in the Sub-Acute Medication Cart according to physician orders for Resident 84. This deficient practice had the potential to result in medication errors. Findings: During a review of Resident 84's face sheet (front page of the chart that contains a summary of basic information about the resident), the face sheet indicated Resident 84 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included respiratory failure (a condition where the lungs cannot adequately exchange oxygen and carbon dioxide in the blood), aphasia (difficulty speaking), dysphagia (difficulty swallowing), and brain damage. During a review of Resident 84's Minimum Data Set (MDS- a federally mandated resident assessment tool), the MDS indicated Resident 84's cognitive (thinking) skills were severely impaired. The MDS indicated Resident 84 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to: 1. Act on the pharmacist consultant's (a professional responsible for reviewing each resident's medication profile monthly to identify and report changes) recommendations timely, for one of five sampled residents (Resident 39). This deficient practice placed Resident 39 at risk for unnecessary medication administration. Findings: During a review of Resident 39's admission Record (front page of the chart that contains a summary of basic information about the resident), the admission Record indicated, Resident 39 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 39's diagnoses included psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality), bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), and Diabetes Mellitus ([DM] - a disorder characterized by…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to: 1. Ensure insulin pens were discarded for Resident 21. 2. Ensure a valproic acid (to treat seizures) bottle had a legible label for Resident 64. Findings: a. During a review of Resident 21's face sheet (front page of the chart that contains a summary of basic information about the resident), the face sheet indicated Resident 21 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included hemiplegia and hemiparesis (complete paralysis and weakness on one side of the body), type 2 diabetes (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), and epilepsy (seizures). During a review of Resident 21's Minimum Data Set (MDS- a federally mandated resident assessment tool), the MDS indicated Resident 21's cognitive (thinking) skills were moderately impaired. The MDS…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to: 1. Ensure licensed staff performed hand hygiene for one out of seven sampled residents (Resident 34) during a dressing change. This deficient practice had the potential to spread infections throughout the facility, which is transferred through direct contact from contaminated hands. Findings: During a review of Resident 34's admission Record, the admission Record indicated Resident 34 was admitted to the facility on [DATE] and was readmitted on [DATE]. Resident 34's diagnoses chronic respiratory failure ([COPD]- a chronic lung disease causing difficulty in breathing), transient ischemic attack ([TIA]- an interruption of blood flow to the brain), and diabetes mellitus ([DM]- a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 34's History and Physical (H&P), dated 10/3/2024, the H&P indicated Resident 34 did not have capacity to understand and make decisions During a review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) were free from verbal abuse by Certified Nursing Assistant (CNA) 1. This deficient practice had the potential for Resident 1 to feel upset and that his needs were not being met. Findings: a. During a review of Resident 1's admission Record ([Face Sheet] front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 1's diagnoses included partial amputation of the right foot (involves surgically removing part of the foot), functional quadriplegia (inability to move due a physical disability), and diabetes mellitus ([DM] - a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 1's History and Physical (H&P), dated 7/19/2024, the H&P indicated, Resident 1 had the capacity to understand and make…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to: 1). Provide a written notice of discharge to one of three sampled residents (Resident 1). 2). Provide a copy of the notice of discharge to the Office of the State Long-Term Care Ombudsman (Patient Advocate), for one of three sampled residents (Resident 1). These failures resulted in the resident not knowing the facility where he was going and unaware of his appeal rights. This failure also resulted in the Ombudsman not aware of the resident ' s discharge to another facility. Findings: During a review of Resident 1 ' s admission Record, the admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and was readmitted on [DATE]. Resident 1 ' s diagnoses included morbid (severe) obesity and schizophrenia (chronic mental illness that affects how people think, feel, and behave) During a review of Resident 1 ' s History and Physical (H&P), dated 12/11/2024, the H&P indicated Resident 1 had the capacity to understand and make…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement its policy and procedure (P&P) titled, Personal Property, which indicated the facility would inventory and pack the personal property of a resident , place in a secure location to prevent its loss, during a resident's absence of undetermined length, for one of three sampled residents (Resident 1). This failure had the potential for the residents' belongings missing if not properly inventoried. Findings: During a review of Resident 1 ' s admission Record, dated July 24, 2024, the admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis of Type 2 Diabetes Mellitus (a long-term condition in which the body has trouble controlling blood sugar and using it for energy) and Bipolar Disorder (a mental illness that causes unusual shifts in a person ' s mood, energy, activity levels, and concentration). During a review of Resident 1 ' s Minimum Data Set (Minimum Data Set [MDS] a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY b. A review of Resident 71's admission Record (Face Sheet), dated 4/17/2024, the Face Sheet indicate Resident 71's was admitted to the facility on [DATE], and was re-admitted on [DATE], with a diagnosis including heart failure (a chronic condition in which the hear doesn't pump blood as well as it should), type 2 diabetes mellitus (a long term condition in which the body has trouble controlling blood sugar and using it for energy), chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe), pulmonary hypertension (a type of high blood pressure that affects arteries in the lungs and in the heart), polyneuropathy (the simultaneous malfunction of many peripheral nerves throughout the body). A review of Resident 71's History and Physical (H&P), dated 5/23/2024, the H&P indicated Resident 71 has the capacity to understand and make decisions. A review of Resident 71's Minimum Data Set ([MDS]a standardized assessment and care screening tool), dated 5/15/2024,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to: 1. Ensure a change of condition was completed for two of seven sampled residents (Resident 117 and 7) skin assessments. This deficient practice has the potential to negatively affect the provision of necessary care and services. Findings: a. A review of Resident 7's admission Record (Face Sheet), dated 5/23/2024, the face sheet indicated Resident 7 was admitted to the facility on [DATE], and was re-admitted on [DATE], with a diagnosis including type 2 diabetes mellitus (a long term condition in which the body has trouble controlling blood sugar and using it for energy), muscle weakness (can have causes that aren't due to underlying disease), major depression (persistently depressed mood or loss of interest in activities), urinary tract infection (an illness in any part of the urinary tract, they system of organs that makes urine), thrombocytopenia (a disorder causes bleeding into the tissues, bruising). A review of Resident 7's History and Physical…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY b. During observations and interviews, on 5/22/2024 at 1:11 p.m., with Resident 150 in his room, Resident 150 stated he had difficulty in reading the newspaper and he had been asking the nursing staff to schedule him for eye surgery. Resident 150 further stated that he was anxious and afraid of losing his sight. A review of Resident 150's admission Record, the admission Record indicated, Resident 150 was admitted to the facility on [DATE] and readmitted on [DATE]. Resident 150's diagnoses included left eye visual loss and type 2 diabetes mellitus ([DM] a chronic condition that affects the way the body processes blood sugar). A review of Resident 150's History and Physical (H&P), dated 7/19/2023, indicated, Resident 150 had the capacity to understand and make decisions. A review of Resident 150's Minimum Data Set ([MDS]) resident assessment and care screening tool) under Section B (Hearing, Speech, and Vision), dated 5/3/2024, the MDS indicated Resident 150's vision was moderately impaired. A review of Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to: 1. Provide a complete Restorative Nursing Assistant (RNA) treatment per physician's order by failing to provide hand rolls and splints seven days a week for three of 14 sampled residents (Residents 115, 124, and 145). This deficient practice had the potential to promote the worsening development of contractures (condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints) to the residents' extremities. Findings: a. A review of Resident 115's admission Record indicated Resident 115 was initially admitted on [DATE] and readmitted on [DATE], with diagnoses that include respiratory failure (a condition in which your blood doesn't have enough oxygen or has too much carbon dioxide), dysphagia (difficulty swallowing foods or liquids), fibromyalgia (a long-term condition that involves widespread body pain and tiredness) and epilepsy (a disorder in which nerve cell activity 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: 1. Ensure accurate destruction of all medications including narcotic (drug which relieves pain and induces drowsiness, stupor, or unconsciousness) were conducted with the signature of licensed nurse, per facility's Policy and Procedure (P&P) titled, Discarding and Destroying Medications. This deficient practice increased the risk of loss or diversion of controlled medication. Findings: During a concurrent observation and interview on 5/23/2024 at 12:14 p.m., with the Director of Nursing (DON) in his office, controlled medication area inspection was conducted. The DON produced multiple Controlled and Antibiotic Drug Record sheets (a log containing the time, quantity, and nurse's signature each time a dose is administered) that had been destroyed by him and facility's pharmacy consultant. The DON stated the facility's Controlled and Antibiotic Drug Record dated 5/8/2024, there were twenty resident medications disposed without signature of licensed nurse witnessing the destruction of the medications. The…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to: 1. Ensure an informed consent was obtained from resident representative for the use of psychotropic drug (any drug that affects brain activities associated with mental process and behavior) for one of one sampled resident (Resident 2). This deficient practice had the potential for the resident representative to have a lack of knowledge to make an informed consent and not knowing in advance the potential risk and benefits of the psychotropic drug. Findings: A review of Resident 2's admission record, the admission Record indicated, Resident 2 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 2's diagnoses included hypertensive heart disease (heart condition caused by high blood pressure), acute kidney failure (a condition in which the kidneys can't filter waste from the blood), and anxiety disorder (a condition in which a person has excessive worry and feelings of fear, dread, and uneasiness). A review of Resident 2's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to: 1. Ensure the low loss air mattress was in functioning condition for one of one sampled resident (Resident 177). This deficient practice resulted in Resident 177 sleeping in a bed that was not functioning and uncomfortable, which had the potential not to meet the resident's needs. Findings: A review of Resident 177's admission Record, the admission Record indicated, Resident 177 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 177's diagnoses included type 2 diabetes mellitus (abnormal blood sugar), acute respiratory failure (a serious condition that makes it difficult to breathe on your own), and anxiety disorder (persistent and excessive worry that interferes with daily activities). A review of Resident 177's History and Physical (H&P), dated 4/2/2024, indicated Resident 177 had the capacity to understand and make decisions. A review of Resident 177's Minimum Data Set ([MDS]- a standardized assessment…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to: 1. Ensure a Preadmission Screening and Resident Review (PASRR- a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care) assessment screening was resubmitted to determine the facility's ability to provide special care and needs for one of 7 residents (Resident 38). This deficient practice has the potential to negatively affect the provision of necessary care and services. Findings: A review of Resident 38's admission record (face sheet) indicated Resident 38 was initially admitted on [DATE] and readmitted on [DATE], with diagnoses that include metabolic encephalopathy (a broad term for any brain disease that alters brain function or structure), heart failure (a chronic condition in which the heart doesn't pump blood as well as it should), anxiety (a feeling of worry, nervousness or unease about everyday situations) and paranoid schizophrenia (a mental health condition where a person feels…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to: 1. Correctly fill out the Preadmission Screening and Resident Review ([PASRR], a tool to determine if the person had, or was suspected of having, a mental illness, intellectual disability, or related condition) level one screening and refer one of seven sampled residents (Resident 147) who had a diagnoses of schizoaffective disorder (a mental illness that can affect thoughts, mood and behavior) and anxiety disorder (a condition in which a person has excessive worry and feelings of fear, dread and uneasiness) to the appropriate state-designated authority for PASRR level two evaluation and determination. This deficient practice had the potential to result in Resident 147 not receiving appropriate treatment recommendations for schizoaffective and anxiety disorder. Findings: A review of Resident 147's admission record, the admission Record indicated, Resident 147 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 147's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to: 1. Ensure the low air loss mattress ([LALM] a mattress designed to prevent and treat pressure ulcer (injuries to skin and underlying tissue resulting from prolonged pressure on the skin) was set and maintained at correct setting for one of three sampled residents (Resident 82). This deficient practice placed Resident 82 at risk for further skin breakdown. Findings: A review of Resident 82's admission record, the admission Record indicated, Resident 82 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 82's diagnoses included dysphagia (difficulty of swallowing), cerebral infarction (damage to tissues in the brain due to a loss of oxygen to the area), and muscle weakness (lack of strength in the muscles). A review of Resident 82's History and Physical (H&P), dated 5/17/2024, indicated, Resident 82 was able to make decisions for activities of daily living. A review of Resident 82's Minimum Data Set ([MDS]…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to: 1. Ensure Resident 164 did not have a cigarette lighter in his possession. This failure had the potential to result in a fire being started in the facility. Findings: During a concurrent observation and interview on 5/23/24 at 8:10 a.m. on the smoking patio with Resident 164, Resident 164 stated he keeps his own cigarettes and lighter. A lighter was observed in Resident 164's hand. During a concurrent observation and interview on 5/23/24 at 1:55 p.m. in Resident 164's room, a lighter was observed on the nightstand. Resident 164 states staff is aware he has a lighter and they didn't say anything. Resident 164 states staff did not provide education on keeping a lighter in his room. During an interview on 5/23/24 at 2:08 p.m. with AA1, AA1 stated the Activity Assistants monitor the residents when they smoke. The Activity Assistant keeps the lighter. Residents can't keep lighters because they might smoke in their room or light things 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 observation, interview, and record review, the facility failed to: 1. Remove opened expired medication of diltiazem solution (medication to treat high blood pressure and chest pain) in subacute medication refrigerator room storage for Resident 115. This deficient practice had the potential to result in prolonged use and loss of strength of the expired medication and can lead to ineffective treatment of Resident 115's hypertension ([HTN] high blood pressure) and possibly can cause severe adverse reactions (an unintended effect of a medication that is harmful or unpleasant) including hospitalizations. Findings: A review of Resident 115's admission record, the admission Record indicated, Resident 115 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 115's diagnoses included HTN, cerebral infarction (damage to tissues in the brain due to a loss of oxygen to the area), and atrial fibrillation (irregular heartbeat). A review of Resident 115's History and Physical (H&P),…

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

Based on observation, interview, and record review, the facility failed to: 1. Ensure the cook was wearing a beard restraint (device used to keep hair from falling onto food) while working in the kitchen. This failure had the potential to result in food being contaminated with hair. Findings: During an observation on 5/23/24 at 11:35 a.m. in the kitchen, CK1 was standing at the steam table taking temperatures and stirring food. CK1 had a beard of approximately two inches long that was not covered with a beard restraint. During an interview on 5/23/24 at 11:40 a.m. with CK1, CK1 stated he should be wearing a beard restraint. CK1 stated since he did not have on a beard restraint he could have gotten hair in the food. During an interview on 5/23/24 at 11:45 a.m. with DM1, DM1 stated CK1 should be wearing a beard restraint or regular face mask. The beard restraint prevents cross contamination (movement of germs from one place to another). A review of the facility's policy and procedure (P&P) titled, Preventing Foodborne Illness- Food Handling, dated October 2017, the P&P indicated beard…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 monitor, document and inventory emergency crash cart supplies for 2 of 2 facility crash carts. This failure had the potential for the emergency crash cart supplies not completely available and a poor quality emergency medical intervention during an emergency. Findings: During a concurrent record review and interview on 3/15/2024 at 1:15 p.m. with the Registered Nurse (RN 1) in the facility ' s skilled nursing station, the monthly emergency crash cart supplies ' log was reviewed. The emergency crash cart log from February 25 through February 28, 2024, did not indicate that emergency supplies were present in the cart. RN 1 stated, if the crash cart was not checked, the facility may not have all the lifesaving equipment available in the crash cart when there is an emergency. During a concurrent record review and interview on 3/15/2024 at 1:50 p.m. with the Registered Nurse (RN 2) in the acute nursing station, the monthly emergency crash cart supplies log was reviewed. The emergency crash cart log on February 4, and 25, March…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the Physician ' s Order for Life Sustaining Treatment (POLST, a written medical order from a physician, nurse practitioner or physician assistant that helps give people with serious illnesses more control over their own care by specifying the types of medical treatment they want to receive during serious illness) for 1 of 5 residents (Resident 1) was completed, discussed with resident ' s representative and followed up with the attending physician. This failure had violated Resident 1 ' s right to decide and request the preferred medical services in the event of medical emergencies. Findings: During a review of Resident 1 ' s admission record, the admissions record indicated Resident 1 was originally admitted to the facility on [DATE] and was re-admitted on [DATE], with diagnosis of gastrotomy (a tube surgically inserted into the stomach for nutrition and medication administration) infection, epilepsy (a disorder of the brain characterized by…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one out of five sampled residents (Resident 1) received treatment and care in accordance with the physician ' s orders by failing to: 1. Monitor and identify when the resident last had a bowel movement. 2. Administer medications as ordered by the physician. This deficient practice had the potential to cause fecal impaction in Resident 1. Findings: During a review of Resident 1 ' s admission Record (Face Sheet), the Face Sheet indicated Resident 1 was initially admitted to the facility on [DATE]. The Face Sheet indicated Resident 1 ' s diagnosis included difficulty in walking, acquired absence of left leg below knee, acquired absence of right leg above knee, hemiplegia (one-sided paralysis) and hemiparesis (one-sided muscle weakness) following cerebral infarction (disrupted blood flow to the brain) affecting right side. During a review of Resident 1 ' s Minimum Data Set ([MDS], a standardized assessment and care planning tool), dated 2/5/2024,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to report Coronavirus Disease ([Covid-19] a highly contagious infection caused by a virus that could easily spread from person to person) outbreak (at least one confirmed case of COVID-19 who had resided in the facility for at least 7 days) to the California Department of Public Health (CDPH) District Office for 3 out of 4 residents (Residents 1, 2 and 3) as indicated in the All Facilities Letter (AFL, a letter to all nursing facilities informing of new changes or updates) 23-09. This deficient practice delayed the infection control investigation by the DO and had the potential for further residents to be infected and become ill requiring hospitalization. Findings: 1). During a review of Resident 1 ' s admission record (Face sheet), the face sheet indicated Resident 1, a [AGE] year-old male, was admitted to the facility on [DATE], with a diagnosis that included diabetes (high blood sugar), metabolic encephalopathy (neurological disorder), and muscle…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure three of four sampled residents (Resident 1, Resident 2, and Resident 3), were provided clean bed linens and Resident 1 with clean wheelchair and curtains. This deficient practice resulted to an unclean resident's environment and had the potential to affect the highest practicable mental, physical, and psychosocial wellbeing of the affected residents. Findings: a). During a review of Resident 1 ' s admission record, the admission record indicated Resident 1 was admitted on [DATE] and re-admitted on [DATE] with a diagnosis that included hemiplegia and hemiparesis cerebral infarct (paralysis of partial or total body function on one side of the body, whereas hemiparesis is characterized by one-sided weakness, but without complete paralysis), diabetes (DM-high blood sugar), and muscle weakness (reduced muscle strength). During a review of Resident 1 ' s history and physical (H&P) dated 12/6/2023, the H&P indicated Resident 1 does not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to report allegations and incidents of abuse for two of three sampled residents (Resident 1 and Resident 2) to the California Department of Public Health (CDPH) within 24 hours, and failed to implement its policy and procedure by not reporting Resident 1's allegation of abuse to the State Survey Agency (SSA) within two hours after being made aware of the allegation when: 1. Licensed Vocational Nurse (LVN) 1 was observed yelling and being physically and verbally abusive to Resident 1. 2. Resident 2 disclosed to staff of receiving verbal mistreatment from LVN 1. These deficient practices delalyed the investigation of the abuse allegations by the CDPH, and had a potential to place Resident 1 and Resident 2 and other residents at risk for abuse. Findings: During a review of Resident 1 ' s admission Record (Face sheet), the face sheet indicated Resident 1 was admitted to the facility on [DATE] and re-admitted on [DATE], with diagnoses that included diabetes…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow its policy and procedure (P&P) by not placing Licensed Vocational Nurse (LVN) 1 on immediate suspension after he was observed mishandling one of three sampled residents (Resident 1). This deficient practice had the potential to expose other residents to the same harsh treatment and care, potentially causing physical, emotional, and psychosocial injury and requiring hospitalization. Findings: During a review of Resident 1 ' s admission Record (Face sheet), the face sheet indicated Resident 1 was admitted to the facility on [DATE] and re-admitted on [DATE], with diagnoses that included diabetes (high blood sugar), dementia (impairment of memory and judgement) with behavioral disturbance, and encephalopathy (disturbance of the brain function). During a review of Resident 1 ' s History and Physical (H&P) dated 7/20/2023, the H&P indicated Resident 1 was able to make decisions for activities of daily living (ADLs, daily self-care activities 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 interview and record review, the facility failed to ensure one of 3 residents (Resident 1) was evaluated for Physical Therapy ([PT], treatment of disease, injury, or deformity by methods such as exercises to relieve pain, help resident move better or strengthen weakened muscles) in a timely manner per physician ' s order and facility policy and procedure (P&P). This deficient practice had the potential to cause harm to Resident 1 ' s newly amputated right lower limb and placed him at risk for decline in health and delay in recovery. Findings: During a review of Resident 1 ' s admission record (Face sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE], with diagnoses including diabetes (high blood sugar), hypertension (high blood pressure), acquired absence of right leg below the knee (amputation). During a review of Resident 1 ' s history of physical (H&P) dated 11/26/2023, the H&P indicated Resident 1 had the capacity to understand and make medical decisions. During 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 maintain complete and accurate medical records in accordance with accepted professional standards and practices for one out of three sampled residents (Resident 2) by failing to accurately document administration of medications in the residents Medication Administration Record (MAR). This deficient practice placed Resident 2 at risk for medication errors and of not receiving appropriate medication due to incomplete medication administration documentation. Findings: During a review of Resident 2 ' s admission Record (face sheet), the face sheet indicated Resident 2 was admitted to the facility on [DATE] with diagnoses that included cervical disc disorder with myelopathy (compression of the spinal cord), human immunodeficiency virus [(HIV) a virus that attacks the body ' s immune system), paranoid schizophrenia (a mental disorder that affects a person ' s ability to think, feel and behave clearly with feelings of distrustfulness and suspicious of others).…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) had bilateral (both) bed rails up and padded to prevent injuries according to the physician's order, the bed in lowest position and the bedside table within reach according to the facility's policy and procedures (P&P). These deficient practices had the potential to cause further falls and accidents with injury for Resident 1. Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted on [DATE], and re-admitted on [DATE] with a diagnoses including hemiplegia (complete paralysis) and hemiparesis (weakness or partial paralysis) following a cerebral infarction (disrupted blood flow to the brain causing lack of oxygen causing parts of the brain to die off), nontraumatic intracerebral hemorrhage (brain bleed) and epilepsy (disorder which causes seizures [uncontrolled electrical activity in brain which can cause changes in behavior 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 report an injury of unknown origin for one of three sampled residents (Resident 1) within two hours after being made aware of the injury. This deficient practice had the potential to result in unidentified abuse in the facility and a failure to protect residents from abuse. Findings: During a review of Resident 1's admission Record, the admission record indicated Resident 1 was admitted to the facility on [DATE] with admitting diagnoses that included acute respiratory failure (a condition where the lungs can't get enough oxygen into the blood), dependence on a ventilator (a machine or device used to support or replace a person's breathing), chronic pain syndrome (persistent pain that lasts weeks to years), and aphasia (a language disorder that affects a person's ability to communicate). During a review of Resident 1's History and Physical (H&P), dated 3/10/23, the H&P indicated Resident 1 did not have the capacity to understand and make…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 bed was in a low position, with a fall mat at the bedside, for one of three sampled residents (Resident 2), who was at risk for falls. This deficient practice had the potential to cause avoidable harm to Resident 2 from falling onto the floor from an elevated height and landing onto the floor without a fall mat in place. Findings: During a review of Resident 2's admission Record, the admission record indicated Resident 2 was admitted to the facility on [DATE] with diagnoses including hemiplegia (inability to move one side of the body) and hemiparesis (muscle weakness on one side of the body) affecting Resident 2's left side of the body, and legal blindness. During a review of Resident 2's Minimum Data Set (MDS, a standardized assessment and screening tool), dated 7/19/23, the MDS indicated Resident 2 required limited, one-person physical assistance from staff for transfers between surfaces (e.g. moving from the bed to 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, Licensed Vocational Nurse (LVN) 2 failed to implement infection control measures for one of three sampled residents (Resident 3), when the following occurred: 1. LVN 2 did not perform hand hygiene (cleaning one's hands by washing hands with soap and water or antiseptic hand rub [i.e. alcohol-based hand sanitizer]) prior to or after providing direct patient care to Resident 3. 2. LVN 2 did not don (put on) the required personal protective equipment (PPE, specialized clothing or equipment worn by an employee for protection against infectious materials) while providing care to Resident 3, who required enhanced standard precautions (ESPs, a resident-centered and activity-based approach for preventing transmission of multi-drug resistant organisms [MDROs] in skilled nursing facilities [SNFs]). These deficient practices had the potential to spread disease-causing pathogens from one resident to another, and from facility staff to residents, causing avoidable…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 provided one-on -one supervision to prevent one of three sampled residents (Resident 2), who had a history of inappropirately touching a female resident from entering another resident's room (Resident 1) without permission from the staff as indicated in Resident 2's care plan. This deficient practice resulted in Resident 2 entering Resident 1 ' s room at night and was accused of raping Resident 1. Findings: 1.During a review of Resident 1 ' s admission Record (face sheet), the face sheet indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including metabolic encephalopathy (a disorder in the brain that can lead to personality changes), epilepsy (a disorder in the brain that causes recurring seizures), bipolar (a disorder associated with episodes of mood swing), anxiety disorder (a disorder associated with feeling of worries and fear) and schizoaffective disorder (a mental health condition where one experiences psychosis as well 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.

Based on observation, interview, and record review the facility failed to: 1. Ensure unopened insulin (a medication used to control high blood sugar) was stored in the refrigerator per the manufacturer's requirements in seven (7) out of seven (7) medication carts (Station 1 Cart, Station 2 Cart, Station 1 & 2 Extender Cart, Station 3 Cart, Sub-Acute Cart 1, Sub-Acute Cart 2, Station 5 Cart) affecting residents 10, 56, 60, 68, 76, 77, 82, 119, 132, 136, 150, 152, 163, and 569. 2. Ensure liquid medications requiring refrigeration were stored in the refrigerator per the manufacturers or pharmacy's requirements in two out of seven medication carts (Station 1 Medication Cart and Sub-Acute Medication Cart 2) affecting residents 13 and 74. 3. Remove expired insulin from the cart in two of seven medication carts (Station 1 Medication Cart and Sub-Acute Medication Cart 2.) affecting Residents 12 and 136. These deficient practices of failing to store or label medications per the manufacturer's requirements and remove expired medications from the medication carts increased the risk that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure residents' medical records were updated to show documentation the advance directive ([AD] legal document of a resident's wishes regarding medical treatment) were discussed and written information was provided to the resident and/or responsible party ([RP] individual responsible for making medical decisions for a resident) for 5 of 20 sampled residents (Resident 70, 110, 367, 138, 578). This deficient practice violated the residents' and/RP's right to be fully informed of the option to formulate their AD and had the potential to cause conflict with the residents'/RP's wishes regarding health care. Findings: A. During a review of Resident 70's admission Record (facesheet), the face sheet indicated Resident 70 was admitted to the facility on [DATE]. Resident 70's diagnoses included schizophrenia (chronic and severe mental disorder that affects how a person thinks, feels, and behaves), anxiety (intense, excessive, and persistent worry and fear about…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that its medication error rate was less than five percent (%). Four medication errors out of 27 total opportunities contributed to an overall medication error rate of 14.81 % affecting three of eight residents observed for medication administration (Residents 30, 66, and 567.) The deficient practice of failing to administer medications in accordance with the attending physician's orders increased the risk that Residents 30, 66, and 567 may have experienced health complications related to incorrect medication administration which could have negatively impacted her health and well-being. Findings: a. During an observation of the medication administration for Resident 30 on 2/8/22 at 8:33 AM, Licensed Vocational Nurse (LVN 1) was observed administering benztropine (a medication used for movement disorders) 0.5 milligrams (mg - a unit of measure for mass), docusate sodium (a stool softener) 100 mg, lamotrigine (a mood stabilizer) 100…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 lunch menu and standardized recipes when: 1. [NAME] 1 used a small scoop to serve food resulting in Residents on puree diet and residents on mechanical soft diet receiving less protein. 2. [NAME] 1 served boiled green beans for the renal diet instead of seasoned green beans per recipe and made garlic parmesan spinach without measuring the portion of cheese needed. 3. [NAME] 1 did not have a replacement for the beef patty for vegetarian diet for the lunch. Two residents on vegetarian diet did not receive vegetarian protein equivalent with their meal. This deficient practice had the potential to affect nutrient adequacy of 16 residents on puree diet, 33 residents on mechanical soft diet and two residents on vegetarian diet and decreased food intake for residents who consumed spinach and green beans on 2/7/21 lunch meal service. Findings: 1. A review of the facility's lunch menu on 2/7/22, indicated that the following items would be served: Southern style beef patty (puree diet: use #6 scoop providing 5…

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

Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen when: 1. Several food items were not dated, labeled in the walk-in refrigerator (liquid egg, nectar thickened milk) 2. Several food items were leftover in the walk-in refrigerator past the three-day left-over timeframe. (Ten old ham and cheese sandwiches, liquid egg, and nectar thickened milk). 3. The Juice machine was covered with dried juice, the juice dispensing gun had red colored dried juice on it, the nozzle and the drip tray had juice in it and some dried juice, and one gnat (small fly) was flying around the drip tray. 4. Ice machine ice deflector (inner plastic cover in the ice storage bin) and the ice scoop and holder were dirty with white stains and streaks. 5. One Dietary aide (DA 1) did not wear facial hair restraints (beard Cover) in the kitchen. 6. Two cooks (Cook 1 and [NAME] 2) used the same glove that touched serving utensils, and cooking equipment to place bread on food during lunch observation. These…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 their infection prevention and control policies for the following: 1.Nursing staff failed to donn (to put on) appropriate Personal Protective Equipment (commonly referred to as PPE is equipment worn to minimize exposure to hazards that cause serious workplace injuries and illness, PPE includes items such as gloves, gowns and safety glasses), for Resident 422 who is on transmission based precautions (implemented for residents with documented or suspected diagnoses where contact with the resident, their body fluids, or their environment presents a substantial transmission risk) for Covid-19 (a contagious disease caused by severe acute respiratory syndrome coronavirus 2). 2.License staff failed to monitor and document oxygen saturation (Levels of oxygen in your blood), temperature, and respiratory rate (breaths taken per minute), every four (4) hours, for two (2) of two (2) residents who are positive for Coronavirus disease (Covid…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain dignity, comfort, and self-worth to four of thirty-four sampled residents (Residents 108, 163, 104 and 422) by failing to ensure: 1. Staff responded to call lights in a timely manner for residents 108, 163, 104 and 422. 2. DSD investigated and reported to Director of Nursing (DON) and Administrator (ADM) that a male Certified Nursing Assistant 1 (CNA1) was sleeping and talking on the phone in Resident 104 and 163's room during the 7-11 p.m., shift. These deficient practices led to residents having feelings of sadness, anger, discomfort, frustration, abandonment, and ignored resulting in Resident 422 breaking down in tears. Findings: 1. During a review of Residents 108's admission record, the admission record indicated the resident was admitted to the facility on [DATE], with diagnosis including type 2 diabetes mellitus (high blood sugar) and hyperlipidemia (high cholesterol) During a review of Resident 108's history and physical…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the resident and/or responsible party ([RP] designated person who makes medical decision on behalf of the resident, when the resident is unable to do so) were informed in advance, of the risks and benefits of psychotherapeutic medication (a drug that changes brain function and results in alterations in perception, mood, consciousness, or behavior) for one of 34 sampled residents (Resident 367). This deficient practice violated the resident and/or RP's right to make an informed decision regarding the use of psychotherapeutic medications. Findings: During a review of the admission Record for Resident 367, the admission record indicated Resident 367 was admitted on [DATE] with the diagnosis of schizophrenia (a disorder characterized by thoughts that seem out of touch with reality and affects a person's ability to think, feel, and behave clearly) and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss 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 involve the Responsible party ([RP] person who makes medical decisions for a resident, who could not make decisions for themselves) for one of one sampled resident (Resident 70), in care plan meetings to discuss Resident 70' s treatment for Schizophrenia (chronic and severe mental disorder that affects how a person thinks, feels, and behaves). This deficient practice violated Resident 70 RP ' s right to be an active participant in Resident 70 ' s care planning process. Findings: During a review of Resident 70 ' s admission Record (facesheet), the face sheet indicated Resident 70 was admitted to the facility on [DATE]. Resident 70 ' s diagnoses included schizophrenia, anxiety (excessive worry and fear about everyday situations) and convulsions (stiffness and uncontrollable jerky movements of the body). A review of Resident 70's Minimum Data Set ([MDS], a standardized assessment and care screening tool), dated 12/6/2021, indicated Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that one resident (Resident 66) did not self-administer medications without an interdisciplinary team (IDT - a team of professionals responsible for planning and coordinating a resident's care) assessment and physician order indicating it was clinically appropriate for him to do so. This deficient practice increased the risk that Residents 66 could have administered medications incorrectly, resulting in doses that were higher or lower than intended, or exposed other residents to medications not intended for them which could have resulted in a negative impact to their overall health and well-being. Findings: During a review of Resident 66's admission Record (a document containing diagnostic and demographic resident information), dated 2/8/22, the admission Record indicated he was admitted to the facility on [DATE] with diagnoses including osteoporosis (a medical condition causing bones to weaken and break more easily). During 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, the facility failed to provide one of one sample resident (Resident 14) a wheelchair to enable him go to the activity room for approximately 7 days. This deficient practice caused Resident 14 to feel upset and had the potential to cause feelings of isolation. Findings: During a review of Resident 14's admission Record (facesheet), the face sheet indicated Resident 14 was admitted to the facility on [DATE] and readmitted on [DATE]. Resident 14's diagnoses included anemia (Lack of healthy red blood cells [RBCs- are essential to carry oxygen to all parts of the body]), diabetes mellitus type 2 (high blood sugar), paraplegia (inability to move the lower half of body, unable to move legs and feet) and neuropathy (group of diseases resulting from damaged or malfunctioning of nerves that causes weakness, numbness and pain in hands and feet). A review of Resident 14's Minimum Data Set ([MDS] a standardized resident assessment and care screening tool), dated 1/24/2022,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow up with the status of a Pre-admission Screening and Resident Review ([PASRR] a federal requirement to help ensure individuals who have a mental disorder or intellectual disabilities are not inappropriately placed in nursing homes for long term care) level II (a comprehensive evaluation by the appropriate state-designated authority determines whether the individual has a Mental Disorder (MD), Intellectual Disability (ID), or a related condition, determines the appropriate setting for the individual and recommends what, if any, specialized services and/or rehabilitative services the individual needs) and integrate the level of care into a plan of care for one of one sampled resident (Resident 91). This deficient practice had the potential for Resident 91 not to receive appropriate care and services. Findings: During a review of Resident 91's admission Record, the admission record indicated Resident 91 was admitted to the facility on [DATE] with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement the care plan for one of one sampled residents (Resident 70) to involve Resident 70's RP in care plan meetings to discuss his treatment for Schizophrenia (chronic and severe mental disorder that affects how a person thinks, feels, and behaves). This deficient practice violated Resident 70 RP's right to be an active participant in his care. Findings: During a review of Resident 70's admission Record (facesheet), the face sheet indicated Resident 70 was admitted to the facility on [DATE]. Resident 70's diagnoses included schizophrenia (chronic and severe mental disorder that affects how a person thinks, feels, and behaves), anxiety (intense, excessive, and persistent worry and fear about everyday situations) and convulsions (stiffness and then uncontrollable jerky movements of the body). A review of Resident 70's Minimum Data Set ([MDS], a standardized resident assessment and care screening tool), dated 12/6/2021, indicated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement a physician's order to consult a psychiatrist for one of one sampled residents (Resident 70), who had a diagnosis of Schizophrenia (serious mental disorder that affects how a person thinks, feels, and behaves).' This deficient practice had the potential to delay the needed assessment, care and services for Resident 70. Findings: During a review of Resident 70's admission Record (facesheet), the face sheet indicated Resident 70 was admitted to the facility on [DATE]. Resident 70's diagnoses included schizophrenia (chronic and severe mental disorder that affects how a person thinks, feels, and behaves), anxiety (intense, excessive, and persistent worry and fear about everyday situations) and convulsions (stiffness and then uncontrollable jerky movements of the body) A review of Resident 70's Minimum Data Set ([MDS], a standardized resident assessment and care screening tool), dated 12/6/2021, indicated Resident 70 was completely…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 three of thirty-four sampled residents (Resident 108, 163, and 104) were kept clean and free of odors by providing incontinent care. This deficient practice caused residents to feel sad, angry, uncomfortable, frustrated, and abandoned. Findings: a. During a review of Resident 108's admission record, the admission record indicated Resident 108 was admitted to the facility on [DATE], with diagnosis including type 2 diabetes mellitus (high blood sugar) and hyperlipidemia (high cholesterol). During a review of Resident 108's history and physical (H/P) dated 1/10/2021, the H/P indicated Resident 108, had the capacity to understand and make decisions. During a review of Resident 108's Minimum Data Set ([MDS], a standardized assessment and care screening tool), dated 12/20/2021, the MDS indicated Resident 108 had the ability to understand and be understood by others. The MDS indicated Resident 108 required one-person assist for bed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, facility failed to ensure an accurate assessment was conducted for one resident out of 33 sampled residents (Resident 139). Resident 139 did not have an assessment documented on 2/5/2022. This deficient practice had the potential to result in Resident's 139 delay in necessary care and treatment. Findings: During a review of Resident 139's admission record (face-sheet) indicated Resident 139 was admitted to the facility on [DATE] and re-admitted on [DATE], with diagnoses of dependence of renal dialysis (The process of removing waste products and excess fluid from the body. Dialysis is necessary when the kidneys are not able to adequately filter the blood), and end stage of renal disease (ESRD, a medical condition in which a person's kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis or a kidney transplant to maintain life). During a review of the Minimum Data Set (MDS, a standardized assessment and 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 ensure an environment that was free from hazard for two of 33 sampled residents (Resident 76, Resident 368), and ensure they did not store cigarette lighters in their rooms. This deficient practice had the potential to cause fire and injury to Residents 76, Resident 368, and other residents, staff, and visitors in the facility. Findings: a. During a review of Resident 76's admission record (face-sheet), the Facesheet indicated Resident 76 was admitted to the facility on [DATE] and re-admitted on [DATE]. Resident 76's diagnoses included chronic obstructive pulmonary disease (a lung disease that causes obstructed airflow from the lungs), and hemiplegia (loss of strength/paralysis of one side of the body) and hemiparesis (slight weakness on one side of the body) affecting the left side. During a review of the Minimum Data Set ([MDS], a standardized assessment and care planning tool), dated 12/10/2021, the MDS indicated Resident 76 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 observation, interview and record review the facility failed to provide incontinence (loss of control of urine) care for one of four sampled residents (Resident 422) in a timely manner by leaving Resident 422 in urine for over an hour. This deficient practice had the potential to result in skin problems such as redness, rashes, and inflammation. Finding: During a review of Resident 422's admission Record the admission Record indicated, Resident 422 was admitted o the facility on 2/2/22, with diagnoses including chronic obstructive pulmonary disease ([COPD] a respiratory disease that causes difficulty breathing), and heart failure (when the heart does not pump like it normally does) During a review of Resident 422's History and Physical dated 2/2/22, the History and Physical indicated, Resident 422 had the capacity to understand and make decisions. During an observation on 2/07/22 at 12:29 p.m. Resident 422 was lying in bed, pressing the call light, wearing a urine-soaked diaper and her bed linen had dried yellow stains. During an observation and interview on 2/07/22 at 1:13…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 licensed staff failed to ensure residents who received dialysis (the process of removing waste products and excess fluid from the body using a machine when the kidneys are not able to do so) was assessed after dialysis treatment and this assessment was documented in the Dialysis Communication Records for one of 1 sampled resident (Resident139). This deficient practice had the potential for unidentified complications after dialysis treatment such as swelling, pain, bleeding and bruising. Findings: A review of Resident 139's admission record (face-sheet) indicated Resident 139 was admitted to the facility on [DATE] and re-admitted on [DATE], with diagnoses of dependence of renal dialysis (The process of removing waste products and excess fluid from the body. Dialysis is necessary when the kidneys are not able to adequately filter the blood), and end stage of renal disease (ESRD, a medical condition in which a person's kidneys cease functioning on 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 accurately account for the use of four doses of controlled substances (medications with a high potential for abuse) for three residents (Residents 19, 93, and 568) in two of seven inspected medication carts (Station 2 Medication Cart and Station 5 Medication Cart). This deficient practice increased the risk that Residents 19, 93, and 568 could have received too much or too little medication due to lack of documentation possibly resulting in serious health complications requiring hospitalization. Findings: During an interview and concurrent observation of Station 2 Medication Cart, on 2/7/22 at 2:38 PM, with Licensed Vocational Nurse 1 (LVN 1), the following discrepancy was found between the Controlled Drug Record (a log signed by the nurse with the date and time each time a controlled substance is given to a resident) and the medication card (a bubble pack from the dispensing pharmacy labeled with the resident's information that contains the individual doses of the medication): 1. Resident 93's Controlled…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 was free from unnecessary drugs for one of 34 sampled residents (Resident 113) by failing to adequately monitor for the continue need for heparin (used to prevent blood from clotting in the heart or blood vessels). This deficient practice resulted in prolonged use of heparin and had the potential to lead to adverse reactions including bleeding easily and bruising. Findings During a review of the facilities resident Face sheet (admission record) dated 9/17/21, the Face sheet indicated, Resident 113 was admitted to the facility with diagnoses that included a stage 4 pressure ulcer (injuries to the skin and underlying tissue resulting from prolonged pressure on the skin) of the sacral ( lower part of the back) area, dysphasia (difficulty in swallowing food or liquid) type 2 diabetes mellitus (insufficient production of insulin, causing high blood sugar), chronic embolism ( an obstruction in a blood vessel due to a blood clot or other foreign matter that gets stuck while traveling through the bloodstream) and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure licensed staff did not: 1. Administer blood pressure medication with hold parameters (conditions for administration indicated in the physician order based on vital sign measurements) for heart rate to two residents (Residents 66 and 567) without first checking the heart rate. 2. Administer 97 doses of expired insulin (a medication used to control high blood sugar) to one resident (Resident 136.) These deficient practices increased the risk that Resident 66, 136, and 567 could have experienced adverse effects (potentially harmful side effects) related to medication administration errors which could have resulted in medical complications possibly leading to hospitalization or death. Findings: During an observation of the medication administration for Resident 567 on [DATE] at 9:03 AM, LVN 1 was observed administering carvedilol (a medication used to treat high blood pressure) 12.5 mg to Resident 567 without first checking 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.