Manchester Healthcare Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain fingernails clean and neat for one of six sampled residents (Resident 18). This deficient practice had the potential to result in a negative impact on Resident 18's quality of life and self-esteem and had the potential for development of infection.Findings: During a review of Resident 18's admission Record, the admission Record indicated Resident 18 was admitted to the facility on [DATE]. Resident 18's diagnoses included legal blindness (vision loss), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), muscle weakness (loss of muscle strength), and dysphagia (difficulty swallowing). During a review of Resident 18's Minimum Data Set (MDS - a resident assessment tool), dated 3/19/2026, the MDS indicated Resident 18's cognitive skills for daily decision making (the ability to think and process information) was intact. The MDS indicated Resident 18 required moderate (helper does less than…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 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 care and treatment were provided with professional standards of practice for two of three sampled residents (Residents 3 and 14) by failing to ensure:1. Resident 3 and 14's tube feeding bottles were correctly labelled.2., Staff verified Resident 14's gastrostomy tube ([g-tube]- a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems) placement and patency prior to medication administration. These deficient practices had the potential to place Residents 3 and 14 at risk for unsafe care, improper treatment administration, and avoidable complications and serious medical complications requiring medical intervention and hospitalization.Findings:1. During a review of Resident 3's admission Record, the admission Record indicated Resident 3 was admitted to the facility on [DATE]. Resident 3's diagnoses included presence of a gastrostomy tube (g-tube, a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the low air loss mattress (LALM, therapeutic support surfaces designed to prevent and treat pressure ulcers [PU, localized damage to the skin and/or underlying tissue usually over a bony prominence]) was set to the correct weight setting for one of two sampled residents (Resident 3). This deficient practice created the potential for Resident 3 to develop a PU.Findings: During a review of Resident 3's admission Record, the admission Record indicated Resident 3 was admitted to the facility on [DATE]. Resident 3's diagnoses included hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) following a cerebral infarction (stroke, loss of blood flow to a part of the brain). During a review of Resident 3's Minimum Data Set (MDS, a resident assessment tool), dated 3/10/2026, the MDS indicated Resident 3 had moderately impaired cognition (noticeable decline in memory, language, thinking). The MDS indicated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure accident hazards were identified and care planned for two of four sampled residents (Resident 14 and Resident 32) when: 1. Staff did not conduct quarterly fall risk evaluations for Resident 14. 2. Staff did not develop care plans for Resident 32's high fall risk and diagnosis of convulsions (sudden, uncontrolled electrical disturbances in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness). This deficient practice increased the potential for Resident 14 to experience falls and fall-related complications. This deficient practice also increased the likelihood that Resident 32 would not receive the care and services required to prevent falls, and to prevent convulsions and/or complications from convulsions (e.g., falls, injuries). Findings: 1. During a review of Resident 14's admission Record, the admission Record indicated Resident 14 was admitted to the facility on [DATE] and re-admitted [DATE]. Resident 14's…

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

Based on interview, and record review, the facility failed to ensure trauma-care evaluation was conducted for one of one sampled resident's (Resident 5) who had a history of trauma (a lasting emotional response to distressing events that overwhelm a person's ability to cope, causing fear, helplessness, and shattered safety). This failure had the potential to result in Resident 5 experiencing re-traumatization.Findings:During a review of Resident 5's admission Record (Face Sheet), the admission Record indicated the facility admitted resident on 2/13/2026 with diagnoses that included post-traumatic stress disorder (PTSD - a disorder in which a person has difficulty recovering after experiencing or witnessing a traumatic event), and aphagia (a language disorder caused by brain damage that impairs speaking, writing, reading, and understanding).During a review of Resident 5's History and Physical (H&P), dated 2/14/2026, the H&P indicated, Resident 5 was able to make decisions for activities of daily living.During a review of Resident 5'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 observation, interview, and record review, the facility failed to ensure signage for enhanced barrier precautions (EBP, an infection control intervention designed to reduce transmission of multidrug-resistant organisms [MDROs]) and personal protective equipment (PPE, clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments) were placed outside of the room for one of 12 sampled residents (Residents 3). This deficient practice increased the potential for spread of infection to Resident 3 and other residents.Findings: During a review of Resident 3's admission Record, the admission Record indicated Resident 3 was admitted to the facility on [DATE]. Resident 3's diagnoses included presence of a gastrostomy (a feeding tube placed through the abdominal wall directly into the stomach, providing nutrition for people unable to eat normally). During a review of Resident 3's Minimum Data Set (MDS, a resident assessment tool), dated 3/10/2026, 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 interview and records review, the facility failed to create an individualized care plan and implement interventions to prevent, one of three sampled residents, Resident 1, who was identified on admission with a significant actual risks for wandering (traveling/ walking from place to place, especially without any clear aim or purpose) and elopement (a situation in which a resident leaves the premises or a safe area without the facility's knowledge and supervision), from leaving the facility unsupervised.This deficient practice without an individualized intervention resulted in Resident 1 leaving the facility on 1/30/2026, between 8:30 pm and 8:45 pm, undetected and was later found at a recovering unit in a general acute care hospital (GACH) after 2 days (2/2/2026).Findings: During a review of Resident 1 admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including encephalopathy (any disease or malfunction of the brain that alters the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide supervision for 2 of 6 sampled residents (Residents 2 and 3), who were assessed as requiring supervision while smoking. This failure had the potential to cause accidental burns and injuries to Residents 2 and 3. Findings:During a concurrent observation and interview on 12/16/2025 at 11:25 a.m. with the Activity Director (AD), on the patio, Resident 2 was observed smoking a cigarette without staff supervision. The AD stated Resident 2 should be supervised while smoking. The AD stated failure to supervise residents may increase the risk of residents getting burned or having accidents while smoking.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 paranoid schizophrenia (a mental illness that is characterized by disturbances in thought), major depressive disorder (a mood disorder that causes persistent feeling of sadness and loss…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to obtain informed consent for psychotropic medications (drugs that alter brain chemistry to manage mental health conditions like depression, anxiety, schizophrenia) prior to administering psychotropic medications to one of four sampled residents (Resident 2). This deficient practice placed Resident 2 at risk for experiencing unexpected and/or unwanted adverse effects or complications from the medications, including increased risk of suicidal thoughts, cognitive impairment, and tardive dyskinesia (a chronic movement disorder that causes involuntary, repetitive movements in the body).Findings: During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was initially admitted to the facility on [DATE] and most recently readmitted on [DATE]. Resident 1's diagnoses included paranoid schizophrenia (a subtype of schizophrenia, a chronic mental health disorder characterized by significant disturbances in thought, perception, 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 ensure an accurate Level I Preadmission Screening and Resident Review (PASRR, a screening tool that helps identify possible serious mental illness [SMI], and if the resident requires specialized services) was submitted for one of four sampled residents (Resident 1). This deficient practice placed Resident 1 at risk of not receiving recommended or required treatments for diagnosed SMIs, or appropriate placement in a facility to meet Resident 1's needs.Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE]. Resident 1's diagnoses included schizophrenia (a mental illness that is characterized by disturbances in thought). During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 8/21/2025, the MDS indicated Resident 1 had severe cognitive impairment (significant trouble with thinking, memory, learning, concentrating, or decision-making).…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to care plan the psychiatric (relating to mental illness or its treatment) diagnoses for one of four sampled residents (Resident 2). This deficient practice prevented facility staff from identifying and developing interventions to address Resident 2's behavior of striking out at others, due to his diagnosis of schizophrenia (a mental illness that is characterized by disturbances in thought).Findings: During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was initially admitted to the facility on [DATE] and most recently readmitted on [DATE]. Resident 2's diagnoses included paranoid schizophrenia (a subtype of schizophrenia, a chronic mental health disorder characterized by significant disturbances in thought, perception, and behavior), restlessness and agitation, and emotional lability (rapid, intense, and often uncontrollable mood swings). During a review of Resident 2's Minimum Data Set (MDS, a resident assessment…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide a low-air-loss-mattress (LALM, a mattress designed to distribute the patient's body weight over a broad surface area and help prevent skin breakdown) as ordered to one of four sampled residents (Resident 1). This deficient practice placed Resident 1 at risk for the development of pressure ulcers (localized damage to the skin and/or underlying tissue usually over a bony prominence).Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was initially admitted to the facility on [DATE]. Resident 1's diagnoses included generalized muscle weakness. During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 8/21/2025, the MDS indicated Resident 1 had severe cognitive impairment (significant trouble with thinking, memory, learning, concentrating, or decision-making). The MDS indicated Resident 1 required supervision or touch assistance for rolling left 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 obtain a written informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered) from the resident and/or conservator (a person appointed by court to manage a person deemed unable to manage their life, such as health, and medical treatment) prior to treatment with Olanzapine (a psychotropic medication [a medication that affect brain activities associated with mental processed and behavior]) for one of four sampled residents (Resident 1). The deficient practice of failing to obtain informed consent prior to initiating treatment with psychotropic medication could have prevented Resident 1 from exercising their right to decline treatment with antipsychotic medications. This increased the risk that Resident 1could have experienced adverse effects (unwanted, uncomfortable, or dangerous effects that a drug may have) leading to impairment or decline in his mental or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to develop a comprehensive care plan with interventions that addressing the resident's schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior) for one of four sampled residents (Resident 1). This deficient practice had the potential to negatively affect Resident 1's physical well-being and placed the resident at risk of not receiving care and resident-centered interventions to meet and address Resident 1's needs. Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses which included schizoaffective disorder, epilepsy (a brain disorder), and hypertension ([HTN]- high blood pressure). During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 4/16/2025, the MDS indicated Resident 1's cognition (process of thinking) was intact. The MDS indicated Resident 1 required moderate (helper does less…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 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 Situation, Background, Assessment, Recommendation ([SBAR]-a communication tool used by healthcare workers when there is a change of condition among the residents) was completed for one of four sampled residents (Resident 1) when Resident 1 had a change of condition and eloped (the act of leaving a facility unsupervised and without prior authorization) on 7/1/2025. This deficient practice had the potential to result in miscommunication among staff and Resident's 1 attending physician to have a detailed explanation of what happened to Resident 1 before he eloped on 7/1/2025, and lack of appropriate response. Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses which included schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), epilepsy (a brain disorder), and hypertension ([HTN]- high blood pressure).…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 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 Procedures (P&P) titled, Insulin Administration which indicated individual administering the medication must check to verify the right dosage before giving the medication, for one of 3 sampled residents, (Resident 1), by failing to: 1). Ensure Resident 1's physician's order for Insulin Glargine-yfgn (injection medication for diabetes) was correct. 2). Ensure Resident 1's blood sugar levels were documented in the resident's electronic medical record. These failures placed the resident at risk to receive high doses of insulin and had the potential to cause complications like severe hypoglycemia (low blood sugar), coma, hospitalization and death. Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including hypertension (high blood pressure), diabetes mellitus (DM- abnormal blood sugar level),…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide pharmaceutical services to meet resident's needs for three of three sampled residents (Residents 1, 2 and 3) when Licensed Nurses: 1. Failed to administer medications within one hour of scheduled time for Residents 1, 2 and 3. 2. Failed to ensure the Catapres transdermal patch (medication applied to the skin to treat hypertension [high blood pressure]) was available and administered for Resident 1 as ordered by the physician. 3. Did not monitor Resident 1, 2 and 3 for side effects and vital lights as ordered by the physician. 4. Failed to document medication administration for Residents 1, 2 and 3. These failures resulted in Resident 1 feeling scared and sad. These failures had the potential to result in adverse side effects, medication errors, worsening of symptoms and hospitalization for Residents 1, 2 and 2. Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to 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 promote the dignified existence and self-determination of 2 of 14 sampled residents (Resident 13 and 14) who required assistance with activities of daily living (ADLs), by failing to answer the resident's call lights in a timely manner. This deficient practice had the potential to result in Resident 13 and 14 feeling of angry for being ignored by nurses and could negatively affect the resident's psychosocial well-being. Findings: During a review of Resident 13's admission Record, the admission Record indicated Resident 13 was originally admitted to the facility on [DATE] and re-admitted on [DATE]. Resident 13's diagnoses included acquired absences of left and right leg above the knee (surgical removal of the portion of the leg above the knee), muscle weakness and movement disorder (group of involuntary movements). During a review of Resident 13's History and Physical (H&P) dated 12/21/2024, the H&P indicated Resident 13 had fluctuating mental 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 develop a care plan for two of twelve sampled residents (Resident 7 and Resident 9) who were a high risk for elopement (the act of leaving a facility unsupervised and without prior authorization). This deficient practice had a potential to result in unidentified interventions which could lead to Resident 7 and Resident 9 eloping from the facility leading to accidents and death. Findings: a. During a review of Resident 7 ' s admission Record, the admission Record indicated Resident 7 was admitted to the facility on [DATE] with diagnoses including dementia (a progressive state of decline in mental abilities), schizoaffective disorder (a mental illness that is characterized by disturbances in thought) and lack of coordination (difficulty in controlling and coordinating muscle movements). During a review of Resident 7 ' s History and Physical (H&P) dated 3/5/2025, the H&P indicated Resident 7 did not have the mental 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.

Based on observation, interview and record review, the facility failed to ensure two of four exit doors were locked and had alarms turned on. This deficient practice had the potential to result in resident's eloping (the act of leaving the facility unsupervised and without prior authorization) leading to accidents and death. Findings: During a concurrent observation and interview on 4/2/2025 at 5:37 a.m., Certified Nurse Assistant (CNA) 1 was observed pushing the front door open without using the door key. The front door was unlocked from the inside and did not alarm when the door was opened. CNA 1 stated she did not know why the front door alarm was off. During a subsequent interview on 4/2/2025 at 6:20 a.m. with CNA 1, CNA 1 stated the front door alarm should always be on so residents were not able to elope. CNA 1 stated, without the door alarm being activated, nurses would not be aware if Residents were attempting to leave the facility unsupervised. During an observation on 4/2/2025 at 6:45 a.m. at the back door next to the laundry room, CNA 2 was observed taking out containers…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 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 trim, three of six sampled Residents' (Resident 2, Resident 5 and Resident 6) long and dirty fingernails. This deficient practiced placed Resident 2, Resident 5 and Resident 6 at risk for infections, injury and bacterial growth under the fingernails. Findings: a). During a review of Resident 2 ' s admission Record, the admission Record indicated Resident 2 was admitted to the facility on [DATE] with diagnosis that included cerebral infarction (CVA-stroke, loss of blood flow to a part of the brain), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and other seizures (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness). During a review of Resident 2 ' s care plan titled, The resident has limited physical mobility related to stroke, dated, 10/11/2024, the care plan indicated to provide Resident 2…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 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 six sampled residents (Resident 1), did not wait 3 hours to get assistance from the Certified Nurse Assistant (CNA) 3 to get out of bed to the chair. This deficient practice had the potential to affect the resident ' s self-esteem, self-worth, and psychosocial well-being. Findings: During a review of Resident 1 ' s admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnosis that included cerebral cyst (brain lesions), hemiplegia unspecified affecting left side (total paralysis of the arm, leg, and trunk on the same side of the body), and weakness (lacking body strength.) During a review of Residents 1 ' s Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 10/30/2024, the MDS indicated Resident 1 had the ability to make self-understood and ability to understand others. The MDS indicated Resident 1 wasdependent with activities of daily…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 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 a complete and accurate Activities of Daily Living (ADLs) documentation for two of six sample residents, (Resident 1 and Resident 2). This deficient practice had the potential to cause miscommunication that ADLs were not provided to Resident 1 and Resident 2. Finding: a). During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and re-admitted on [DATE] with diagnosis including cerebral cyst (brain lesions), hemiplegia unspecified affecting left side (total paralysis of the arm, leg, and trunk on the same side of the body), and weakness (lacking body strength.) During a review of Resident 1's care plan for ADLs dated 3/16/2023, indicated Resident 1 has an ADL self-care performance deficit related to disease process neurological and musculoskeletal impairment. The ADL care plan interventions indicated Resident 1 is totally dependent in staff assistance with ADL…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 results of their last recertification survey was in a place easily accessible and viewed by residents/the public. This deficient practice had the potential to result in residents/the public not being well informed about the quality-of-care residents receive at the facility. Findings: During a concurrent observation and interview on 2/1/2025 at 8:40 a.m. with Licensed Vocational Nurse (LVN) 5 in the front lobby, the facility's last survey results were not in a place visible to residents/the public. LVN 5 stated family members need to know what kind of facility this is. LVN 5 stated the survey results tell visitors about infractions, strengths, and if there were any major incidents. Family members can receive information about where they are putting their loved ones. LVN 5 stated since the results are not visible, the public doesn't know what is going on inside the facility. LVN 5 found the survey results behind the nurse's station in a non-transparent file rack labeled 11-7 LVN's. LVN 5 stated…

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

Based on interview and record review, the facility failed to: 1. Ensure four out of five sampled employees had a completed orientation skills check list upon hire. This deficient practice had the potential to result in residents receiving substandard quality of care because staff had not been deemed competent through a skills assessment. Findings: During a concurrent interview and record review on 2/1/2025 at 4:15 p.m. with the Director of Staff Development (DSD), the employee files of three Certified Nursing Assistants (CNA) and one Licensed Vocational Nurse (LVN) was reviewed. The DSD stated everyone needs to have a skills check list to ensure they know what they are doing. The DSD stated the skills checklist should be completed upon hire and every year. The check list gives a summary of what you need to do and that you have been trained. The DSD stated whomever trains the employee needs to sign the form to accept responsibility for providing the training. If the form is not signed, it wasn't done. The DSD stated if you don't have a completed skills checklist they don't know you…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 Nursing Hours Per Patient Day ([NHPPD]- a measure of the average number of hours of nursing care provided to each patient in a hospital or nursing facility) information was posted in an area that was easily viewable by residents/the public. This deficient practice had the potential to result in residents/the public not being aware if the facility had enough staff to provide safe/quality care. Findings: During a concurrent observation and interview on 2/1/2025 at 7:45 a.m. with Licensed Vocational Nurse (LVN) 5 at the nurse's station, it was observed there was no NHPPD information posted. LVN 5 stated the NHPPD information is supposed to be posted on the bulletin board. LVN 5 stated NHPPD has to be in a place that is visible to everyone so they know what the census is and if there is enough staff. LVN 5 stated the facility has to meet staffing requirements to meet the needs of the residents. During an interview on 2/1/2025 at 2:15 p.m. with the Director of Staff Development (DSD), the DSD stated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to: 1. Ensure four out of eight sampled residents (Residents 4, 5, 10, and 24) had a Medication Regimen Review ([MRR]- a review of medications to identify problems/errors) completed monthly by the pharmacist. This deficient practice put Residents 4, 5, 10, and 24 at risk of having a drug interaction or being overmedicated. Findings: a. During a review of Resident 4's admission Record, the admission Record indicated Resident 4 was admitted to the facility on [DATE] with diagnoses including hypertension (HTN-high blood pressure), diabetes (a disorder characterized by difficulty in blood sugar control and poor wound healing), and dementia (a progressive state of decline in mental abilities). During a review of Resident 4's History and Physical (H&P), dated 8/22/2023, the H&P indicated Resident 4 does not have capacity to understand and make decisions. During a review of Resident 4's Minimum Data Set ([MDS] a resident assessment tool) dated 2/7/2025, 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.

Based on observation, and interview, the facility failed to: 1. Keep the dry food pantry area clean and free from food debris. 2. Ensure open packages of food are sealed and closed. 3. Ensure leaking food items in the freezer are cleaned up. These deficient practices had the potential for cross-contamination and can attract pests and rodents to the area. Findings: During an observation on 2/1/2025 at 7:53 a.m. in the dry food pantry, a whitish granule substance was found on the floor underneath the shelves and on top of the lid of a container on the food shelf. During an observation on 2/1/2025 at 7:53 a.m. in the dry food pantry, one package of Pure Grade A Dried Milk was opened and placed inside a clear resealable plastic bag which was also open and had the product exposed. During an observation on 2/1/2025 at 7:59 a.m. in the kitchen, a can of opened soda and a cup with clear liquid was found on top of a desk. During an observation on 2/1/2025 at 8:04 a.m. in the kitchen, the bottom shelf of the freezer had one package of ground turkey with an already frozen red substance leaking…

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

Based on interview and record review, the facility failed to: 1. Ensure payroll-based journal (PBJ) data was submitted to CMS quarterly as mandated by the Centers for Medicare and Medicaid Services (CMS). This deficient practice prevented CMS from knowing if the facility was meeting required staffing levels for safe/quality patient care. Findings: During a review of the PBJ Staffing Data Report, dated 1/29/2025, the report indicated for fiscal year quarter four (July-September 30) of 2024, the facility failed to submit PBJ data. During an interview on 2/01/2025 at 10:40 a.m. with the Administrator (ADM), the ADM stated he was not aware the PBJ data had not been submitted. The ADM stated the PBJ must be submitted to CMS so they can verify the facility has adequate staffing. During an interview on 2/01/2025 at 4:36 p.m. with the Director of Nursing (DON), the DON stated the PBJ should be submitted by the payroll department. The DON stated the payroll staff was not aware he was responsible for sending it. PBJ must be submitted so CMS can see if you have safe staffing for patient care.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to: 1. Ensure routine room temperature monitoring and documentation were in place to ensure medications were within the temperature ranges as specified by the drug manufacturers, in one of one medication storage room. 2. Label with an opened date one vial (a small container, usually made of glass or plastic used to store liquids) of Aplisol (a medication that is used as a diagnostic tool to help identify tuberculosis infections in individuals who are at a higher risk of developing the active disease) solution found at medication storage refrigerator. 3. Label with an opened date one vial of lorazepam (a medication indicated for treatment of anxiety) for Resident 9 found at medication storage refrigerator. 4. Label with an opened date one vial of Admelog (type of insulin medication) insulin (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication) for Resident 4 found at medication…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review the facility failed to: 1. Ensure one of two residents (Resident 21) had a physician order to transfer out to the hospital. This deficient practice had the potential to result in miscommunication amongst the facility staff and physician. Findings: During a review of Resident 21's Face Sheet, it indicated Resident 21 was originally admitted on [DATE] and readmitted on [DATE] with diagnoses that included seizures, hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body), and hemiparalysis (weakness or paralysis on one side of the body). During a review of Resident 21's Minimum Data Set (MDS - a resident assessment tool) dated 10/1/2024, it indicated Resident 21 was cognitively intact (ability to reason, understand, remember, judge, and learn). During a review of Resident 21's Progress Notes dated 6/29/2024 at 8:05 a.m., it stated Resident 21 left the facility to the general acute care hospital (GACH). During a review of Resident 21's Transfer Form…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to: 1. Ensure Resident 21 had a Change in Condition Form completed when they had to be transferred to the general acute care hospital (GACH). This deficient practice had the potential for staff to miss appropriate monitoring and interventions for Resident 21. Findings: During a review of Resident 21's Face Sheet, it indicated Resident 21 was originally admitted on [DATE] and readmitted on [DATE] with diagnoses that included seizures, hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body), and hemiparalysis (weakness or paralysis on one side of the body). During a review of Resident 21's Minimum Data Set (MDS - a resident assessment tool) dated 10/1/2024, it indicated Resident 21 was cognitively intact (ability to reason, understand, remember, judge, and learn). During a review of Resident 21's Progress Notes dated 6/29/2024 at 8:05 a.m., it stated Resident 21 left the facility to the general acute care hospital (GACH). During…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to: 1. Transmit the Minimum Data Set ([MDS] - a resident assessment tool) within 14 days after completion to Center of Medicare and Medicaid Services (CMS) for two of 12 sampled residents (Resident 29 and 34). This deficient practice had the potential to result in billing error and inaccurate data on resident care needs. Findings: a. During a review of Resident 29's admission Record (front page of the chart that contains a summary of basic information about the resident), the admission Record indicated, Resident 29 was initially admitted to the facility on [DATE]and readmitted on [DATE]. The admission Record indicated Resident 29's diagnoses included hypertension ([HTN] high blood pressure) and congestive heart failure ([CHF] - a heart disorder which causes the heart not to pump the blood efficiently, sometimes resulting in leg swelling). During a review of Resident 29's MDS assessment, dated 12/20/2024, the MDS indicated, Resident 29's cognitive (ability…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 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 out of four sampled residents (Resident 40) received a Pre-admission Screening and Resident Review ([PASRR] - a federal assessment requirement to help ensure that individuals who have a mental disorder or intellectual disabilities are placed in facilities that can provide the appropriate care) level II assessment. This deficient practice had the potential to result in Resident 40 not receiving the required services for her mental health condition. Findings: During a review of Resident 40's admission Record, the admission Record indicated Resident 40 was admitted to the facility on [DATE] with diagnoses including hypertension (HTN-high blood pressure), schizophrenia (a mental illness that is characterized by disturbances in thought), and diabetes (a disorder characterized by difficulty in blood sugar control and poor wound healing) During a review of Resident 40's History and Physical (H&P), dated 12/21/2024, the H&P indicated Resident 40…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to: 1. Develop a care plan for a peripherally inserted central catheter (PICC- a thin, soft tube that is placed into a vein, usually in the upper arm to deliver fluids or medication) line for one of three sampled residents (Resident 18). This deficient practice had the potential to result in a lack of meeting necessary care goals. Findings: During a review of Resident 18's Face Sheet, it indicated Resident 18 was admitted on [DATE] with diagnoses that included unspecified respiratory disorder, and other disorders of the kidney and ureter (the tube that carries urine from the kidney to the bladder). During a review of Resident 18's (MDS - a resident assessment tool) dated 1/23/2025, it indicated Resident 18 was unable to complete a brief interview for mental status. During a review of Resident 18's Progress Note dated 1/2/2025 to 1/10/2025, it indicated Resident 18 had a PICC line to the right upper arm and no swelling or redness was noted. 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: 1. Ensure one out of three sample residents (Resident 21), had vital signs taken every shift as ordered by the physician. This deficient practice had the potential for Resident 21 to experience a delay in interventions if there were any significant changes in their vital signs. Findings: During a review of Resident 21's Face Sheet, it indicated Resident 21 was originally admitted on [DATE] and readmitted on [DATE] with diagnoses that included seizures, and shortness of breath. During a review of Resident 21's Order Summary Report, an order was placed on 5/8/2024 to monitor vital signs every shift. During a review of Resident 21's Minimum Data Set (MDS - a resident assessment tool) dated 10/1/2024, it indicated Resident 21 was cognitively intact (ability to reason, understand, remember, judge, and learn). During a review of Resident 21's Vitals Summary, dated 01/2025, a sample of Resident 21's vital signs is recorded as follows: Blood Pressure:…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 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 vision care service was provided for one of one sampled resident (Resident 15). This deficient practice had the potential to result in Resident 15's worsening of eye vision that would negatively affect his quality of life. Findings: During a review of Resident 15's admission Record (front page of the chart that contains a summary of basic information about the resident), the admission Record indicated, Resident 15 was initially to the facility on 9/20/2018 and readmitted on [DATE]. The admission Record indicated, Resident 15's diagnoses included optic atrophy (a condition that occurs when the optic nerve fibers are damaged , causing vision loss), macular degeneration (an eye disease that can blur your central vision), and hypertension ([HTN] - high blood pressure. During a review of Resident 15's History and Physical (H&P), dated 8/12/2024, the H&P indicated, Resident 15 had the 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 observation, interview, and record review, the facility failed to: 1. Ensure resident with long thick elongated (nail plate grows linger than the nail bed) toenails received podiatry (profession dealing with the specialized care of the feet) care services for one of one sampled resident (Resident 24). This deficient practice had the potential to result in foot discomfort, infection, and decline in physical mobility for Resident 24. Findings: During a review of Resident 24's admission Record (front page of the chart that contains a summary of basic information about the resident), the admission Record indicated, Resident 24 was initially admitted to the facility on [DATE] and readmitted on [DATE]. The admission Record indicated, Resident 24's diagnoses included cellulitis (a skin infection that causes swelling and redness), osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage), and schizophrenia (a mental illness that is characterized by disturbances in thought).…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 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 one resident (Resident 18) had their peripherally inserted central catheter (PICC- a thin, soft tube that is placed into a vein, usually in the upper arm to deliver fluids or medication) line monitored and the dressing changed as indicated. This deficient practice had the potential for staff to miss any complications associated with a PICC line and for Resident 18 to experience a delay in interventions. Findings: During a review of Resident 18's Progress Note dated 1/2/2025, it indicated Resident 18 would be returning from the hospital with a PICC line for antibiotics. During a review of Resident 18's Face Sheet, it indicated Resident 18 was admitted on [DATE] with diagnoses that included unspecified respiratory disorder, and other disorders of the kidney and ureter (the tube that carries urine from the kidney to the bladder). During a review of Resident 18's (MDS - a resident assessment tool) dated 1/23/2025, it…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, and interview, the facility failed to: 1. Ensure one of one sampled residents (Resident 195), had a dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) emergency kit at the bedside. This deficient practice had the potential for Resident 195 to experienced delayed interventions due to bleeding of the dialysis site. Findings: During an interview on 2/1/2025 at 9:17 a.m. with Resident 195, Resident 195 stated he receives dialysis every Tuesday, Thursday, and Saturday. During an observation on 2/2/2025 at 1:56 p.m. at Resident 195's room, no dialysis emergency kit was seen on his nightstand or by his bedside. During a review of Resident 195's Face Sheet, it indicated Resident 195 was admitted to the facility on [DATE] with diagnoses that included chronic kidney disease, acute kidney failure, and is dependent on dialysis. During a review of Resident 195's (MDS - a resident assessment tool), dated 1/28/2025, it…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 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 a Narcotic Count Record (a log signed by licensed nurses during shift change endorsing over responsibility for the controlled substances in the cart) was completed accurately. This deficient practice increased the risk of loss or diversion of controlled medication. 2. Ensure Resident 96's medications of Zinc Sulfate (vitamin mineral supplement used to treat or prevent low levels of zinc) and Olopatadine HCL Ophthalmic solution (an eye drops used to treat itching of the eye) are available in the medication cart. This deficient practice had the potential to result in harm to Resident 96 by not administering medication and following physician orders to meet resident individual medication needs. Findings: 1. During a concurrent interview and record review on 2/1/2025 at 1:57 p.m., with Licensed Vocational Nurse 2 (LVN 2), medication cart 1 Narcotic Count Record was reviewed. LVN 2 stated there was at least one missing initials 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: 1. Ensure it was free of a medication error rate of five percent (5%) or greater, as evidenced by the identification of two out of 26 medication opportunities (observations during medication administration) for error, to yield a cumulative error rate of 7.69% for one of four sampled residents (Resident 96) observed during the medication administration facility task by failing to: 2. Administer Resident 96's Zinc Sulfate (vitamin mineral supplement used to treat or prevent low levels of zinc) and Olopatadine HCL Ophthalmic solution (an eye drops used to treat itching of the eye) as prescribed by the physician. This deficient practice had the potential to result in harm to Resident 96 by not administering medication and following physician orders to meet resident individual medication needs. Findings: During a review of Resident 96's admission Record (front page of the chart that contains a summary of basic information about the resident),…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to: 1. Ensure one of four sampled residents (Resident 5) had a Complete Blood Count ([CBC] a blood test that measures the number and type of cells in your blood), and Comprehensive Metabolic Panel ([CMP] a blood test that measures 14 substances in your blood to provide an overall picture of your body's chemical balance) completed monthly per physician's order. This deficient practice resulted in a lack of required monitoring of Resident 5's health status. Findings: During a review of Resident 5's admission Record, the admission Record indicated Resident 5 was admitted to the facility on [DATE] with diagnoses including hypertension (HTN-high blood pressure), diabetes (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). During a review of Resident 5's History and Physical (H&P), dated 11/22/2024, the 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to: 1. Implement the antibiotic stewardship program (coordinated program that promotes the appropriate use of antibiotics by clinician) by failing to monitor and address antibiotic (a drug used to kill bacteria or to treat infection) use for one of one sampled resident (Resident 96) who was on antibiotic for pneumonia (infection of the lungs) was not evaluated upon admission to the facility. This deficient practice had the potential for Resident 96 to receive an inappropriate antibiotic and develop antibiotic resistance (when bacteria change and becomes resistant to antibiotic). Findings: During a review of Resident 96's admission Record (front page of the chart that contains a summary of basic information about the resident), the admission Record indicated, Resident 96 was admitted to the facility on [DATE]. The admission Record indicated, Resident 96's diagnoses included pneumonia, hypertension ([HTN] - high blood pressure), and muscle weakness. During…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure four of five sampled residents (Residents 1, 2, 3, 5) were free from accident and hazards by failing to: 1. Complete a Wandering and Elopement (leaving the facility unsupervised and without prior authorization) Risk Assessment for (Residents 1, 2, 3, 5) upon readmission to the facility and quarterly according to its policy and procedure (P&P) titled, Wandering & Elopement. 2. Ensure facility door alarms were always armed according to Resident 1 ' s care plan. 3. Maintain a photograph in the medical record for Resident 1 who was a risk of elopement, according to the facility ' s undated P&P titled Wandering & Elopement These failures had the potential to result in Residents 1, 2, 3, and 5 eloping from the facility, be exposed to harsh environmental conditions, motor vehicle accident, and death. 1.) During a review of Resident 1 ' s admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] and…

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

Based on interview and record review, the facility failed to have a Registered Nurse (RN) in the facility for at least 8 consecutive hours a day, 7 days a week. This failure resulted in the facility not having an RN responsible to oversee the care provided by Licensed Vocational Nurses (LVN) or Certified Nurse Aides (CNA), conducting residents' assessments and placed all the patients' health and safety in jeopardy. Findings A review of the staff employee phone numbers, dated 4/12/2024, indicated the Director of Nursing (DON) was the only Registered Nurse (RN) in the facility. A review of the staff schedule, dated 4/2024, did not indicate the DON was scheduled on the weekends between 4/19/2024 until 4/30/2024. During an interview with the LVN 1 on 4/23/2024 at 1:36 p.m., LVN 1 stated when the incident between Resident 1 and LVN 3 happened on 4/19/2024, LVN 1 stated the incident was not reported to the DON because the DON was not working on 4/23/2024, Tuesday. During an interview with the Administrator (ADM) on 4/23/2024 at 3:34 p.m., the ADM stated there were no RNs in the facility…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 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, Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating , which indicated to report immediately suspicions of abuse to the state licensing/certification agency within two hours of an allegation of abuse. This deficient practice delayed the investigation by the CDPH and placed Resident 1 at risk for further abuse. Findings: A review of Resident 1's admission record, dated 4/23/2024, indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including hypertension (high blood pressure), arthritis (joint pain and stiffness), and quadriplegia (paralysis of the arms and legs). A review of Resident 1's History and Physical (H&P), dated 10/31/2023 indicated Resident 1 had the capacity to understand and make decisions. A review of Resident 1's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 2/9/2024,…

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 provide adequate supervision to prevent one of five sampled residents (Resident 2), from eloping (when a resident who is cognitively, physically, mentally, emotionally, and/or chemically impaired wanders away, walks away, runs away, escapes, or otherwise leaves a care-giving facility or environment unsupervised, unnoticed, and/or prior to their scheduled discharge) the facility on 4/23/2024. This failure had the potential for Resident 2 to be exposed to medical complications,motor vehicle accidents, hospitalization or death. Findings A review of Resident 2's admission record, dated 4/24/2024, indicated Resident 2 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Alzheimer's disease (a progressive disease that destroys memory and other important mental functions), dementia (a group of conditions characterized by impairment of at least two brain function such as memory loss and judgement),…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 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 interviews, and record review, the facility failed to develop a comprehensive person-centered plan of care for three of four sample residents (Resident 1, 2 and 3) for the Restorative Nurse Assistance (RNA) therapy as ordered by doctor. This deficient practice has the potential to result in a lack of provision of necessary care and potential for further decrease mobility and possible contractions (prolonged static positioning of the limbs). Findings: During a review of Resident 1 ' s admission record, the admission record indicated Resident 1 was admitted on [DATE] with a diagnosis that included other muscle weakness (physical weakness or lack of energy), difficulty walking (gait disorders are an abnormal walking pattern), unspecified osteoarthritis (characterized by joint pain, stiffness, limited range of motion, and weakness). During a review of Resident 1 ' s history and physical (H&P) dated 12/12/2023, the H&P indicated Resident 1 does not have the mental capacity to understand and make medical…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 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 vocational nurses (LVNs) administered medications and provided nursing services in a timely manner for three out of three residents (Resident 1, 2, and 15) This deficient practice resulted in delayed in care and services and had the potential for harm to residents when care and treatment was not provided in a timely manner and could had led to coma, hospitalization, and death. Findings: a. During a review of Resident 1's Face Sheet (admission record), dated 2/4/2024, the face sheet indicated Resident 1 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis including Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills, and eventually, the ability to carry out the simplest tasks), essential primary hypertension ([HTN] abnormally high blood pressure), and benign prostatic hyperplasia ([BPH] condition in which an overgrowth of prostate tissue pushes against the urethra…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 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. Monitor the expiration dates of over the counter (OTC) medications. 2. Monitor the expiration date of hygiene products such as denture cleanser, hand & body lotion, and hand sanitizer. 3. Monitor the expiration date of medical supplies such as syringes, Excelginate (non-woven calcium alginate dressing) wound dressing, and Isosource feeding (nutritionally complete tube feeding formula). This deficient practice had the potential to cause resident harm, due to the loss of effectiveness of the OTC medications and the potential of loss of strength of the hygiene products and medical supplies, and the potential for residents for skin irritation along with abdominal discomfort. Findings: a. During an observation of the medication storage room on 2/3/2024 at 5:00 p.m., the observed 2 boxes with 65 Bisacodyl suppositories (relieves constipation) 10 milligrams (mg, a unit of measurement of mass) with an expiration date of 8/31/2022. b. During…

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

Based on observation, interview, and record review, the facility failed to properly clean their ice machine in the kitchen and properly store a bag of protein powder in the dry storage room. Thess deficiencies had the potential to cause foodborne illness to residents. Findings: During an observation of the kitchen at 2/3/2024 at 7:50 a.m., the ice machine was observed to have a crack and black dust on the ice flap in the machine and upon wiping the flap with a clean napkin, there were black dust and red streaks on the napkin. The air filter above the ice machine was observed to be dusty. The ice machine's cleaning log indicated it was last cleaned on 1/26/2024. During an observation of the dry storage area on 2/3/2024 at 8:01 a.m., an opened bag of protein powder dated 2/8/2022 was observed folded over and not sealed properly. During a concurrent observation and interview of the ice machine with the Kitchen Supervisor (KS) on 2/3/2024 at 12:31 p.m., the KS stated the ice machine flap was not supposed to have a crack in it and it could have been caused by putting it in the wash…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 submit the payroll-based journal quarterly as mandated by the Centers for Medicare and Medicaid Services (CMS). This deficient practice has the potential to cause the staffing data to not be accurate and quality of care could decline. Findings During a review of the Payroll-Based Journalling (PBJ) Staffing Data Report, dated 2/1/2024, the report indicated for the fiscal year of 2023 from October 1 until December 31, the facility failed to submit data for the quarter. During an interview with the Director of Nursing (DON) on 2/4/2024 at 1:59 p.m., the DON stated she did not know what the PBJ was, and she did not know who reported it. During an interview with the Administrator (ADM) on 2/4/2024 at 2 p.m., the ADM stated the Chief Executive Officer (CEO) was not reporting the PBJ because the pay roll company was not able to report it to CMS. The ADM stated the company would have their first training on Monday and they would submit the PBJ on March 1st. The ADM stated the facility was mandated to submit the PBJ report…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure two of twelve sampled residents' (Resident 15 and Resident 32) medical records were updated to show documentation the Advance Directive (AD - legal document of a resident's wishes regarding medical treatment) was discussed, and written information was provided to the resident and/or responsible party (RP - individual responsible for making medical decisions for a resident). This deficient practice violated Resident 15's and Resident 32's and/or their RP's right to be fully informed of the option to formulate their AD and had the potential to cause conflict with the residents' and/or RP's wishes regarding health care. Findings: During a review of Resident 15's admission Record, the admission record indicated Resident 15 was admitted to the facility on [DATE]. Resident 15's diagnoses included anxiety disorder (intense, excessive, and persistent worry and fear about everyday situations), insomnia (common sleep disorder that can make it hard to fall…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure two of four sampled residents (Resident 39 and Resident 46) fingernails and toenails were trimmed. This deficient practiced placed Resident 39 and Resident 46 at risk for an infection, injury, and bacteria growth of the fingernails and toenails. Findings: During a review of Resident 39's admission Record, the admission record indicated Resident 39 was admitted to the facility on [DATE] and re-admitted on [DATE]. Resident 39 diagnoses included mild cognitive impairment (decline in memory and thinking) major depressive disorder (mood disorder that causes a persistent feeling of sadness), and other stimulant dependence (the continued use of stimulants despite harm to the user). During a review of Resident 39's History and Physical (H&P), dated 8/23/2023, the H&P indicated Resident 39 had the mental capacity to understand and make medical decisions. During a review of Resident 39's Minimum Data Set ([MDS] a standardized care 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 observation, interview, and record review, the facility failed to implement the care plan for Restorative Nursing Aide (RNA) services for one of 25 sampled residents (Resident 18). This deficient practice had the potential to cause Resident 18 to have a decline of range of motion (ROM). Findings During a review of Resident 18's admission record (face sheet), dated 2/4/2024, the face sheet indicated Resident 18 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including aphasia following unspecified cerebrovascular disease (a language disorder that affects a person's ability to communicate following an unspecified brain damage), hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting right dominant side (weakness or paralysis on the right side of the body following an unspecified brain damage), and osteoarthritis (degeneration of the joint cartilage and bone). During a review of Resident 18's History and Physical (H&P), dated 9/22/2023,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of one sampled resident (Resident 15) received Admelog Solution ([insulin] medication used to treat elevated blood sugar) 100 unit/ml ([mg][ml] unit of measurement) and metformin HCL 850 mg at their scheduled time of 8:00 a.m. per standards of nursing. As a result of this failure, Resident 15 was without his blood sugar medication for three hours and twenty-four minutes which resulted in elevated blood sugars, and could have led to shakiness, fast heart rate, drowsiness, confusion, loss of consciousness, hospitalization, coma, and death. Findings: During a review of Resident 15's Face Sheet (admission record), dated 2/4/2024, the face sheet indicated Resident 15 was admitted to the facility on [DATE] with diagnoses including encephalopathy (disease of the brain where functioning is affected by a condition or toxins), type 2 diabetes mellitus [DM] abnormal blood sugar), and paranoid schizophrenia (a pattern of behavior 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 ensure one of 15 sampled residents (Resident 43) received prompt assistive devices to maintain vision abilities by not assisting in finding the prescribed eyeglasses (order written by an optometrist) since 11/2023. This failure had the potential to result in feelings of frustration when Resident 43 was unable to adequately read and watch television (TV). Findings: During a review of Resident 43's admission Record, the admission record indicated Resident 43 was admitted to the facility on [DATE] with diagnoses that included other psychoactive substance abuse (strong desire or sense of compulsion to take the substance), major depressive disorder (mood disorder that causes a persistent feeling of sadness), and anxiety disorder (mental health disorder characterized by feelings of worry, anxiety, or fear). During a review of Resident 43's History and Physical (H&P) dated 6/23/2023, the H&P indicated Resident 43 had the mental 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 document the administration of a controlled medications (medications that are regulated by a government), Norco (an opioid pain medication) 10-325 milligrams (mg-unit of measurement), and Tramadol (an opioid pain medication) 50 mg in the medication administration record (MAR) and in the narcotic log for two of three residents (Resident 1, Resident 2) as indicated in the facility policy. This failure resulted in a discrepancy between Resident 1 ' s and Resident 2 ' s narcotic log sheet and MAR and had the potential of not only drug diversion but double dosing Resident 1 and Resident 2. 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 a diagnosis that included Parkinson ' s disease (nerve cell damage), absence of right leg above knee, and hypertension (high blood pressure). During a review of Resident 1 ' s…

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