Meadowbrook Behavioral Health Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to maintain an infection prevention and control program (prevents or stops the spread of infections in healthcare settings) designed to provide a safe, sanitary (clean), and comfortable environment, and to help prevent the development and transmission of communicable diseases (illnesses that can spread from person to person) and infections for three of three sampled residents (Resident 4, Resident 5, and Resident 7) and infections by failing to: Ensure the facility implement appropriate precautions to prevent transmission of sexually transmitted infection (STI) among residents. Resident 7 who had a diagnosis of sexually transmitted diseases had unprotected sex (Sexual intercourse without a condom) with Resident 4. Resident 4 had also unprotected sex with Resident 5. This failure had a potential risk for Resident 4 and Resident 5 to be exposed or to get sexually transmitted infection. Findings: During a review of Resident 4's admission Record, the admission…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow its' policy and procedures (P&P) by not allowing one of three sampled residents (Resident 1) to return to the facility. Resident 1 was admitted to General Acute Care Hospital (GACH) on [DATE] and was had an order to dicharge back to the facility on [DATE]. This deficient practice resulted in Resident 1 remaining at the hospital longer than necessary (24 days as of [DATE]) and had the potential to affect the resident ' s psychosocial wellbeing. Findings: During a review of the admission record for Resident 1 indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including paranoid schizophrenia (a mental illness that is characterized by disturbances in thought) and diabetes mellitus (DM-a high blood sugar). During a review of the Minimum Data Set (MDS – a resident assessment tool) dated [DATE], indicated Resident 1 had moderate cognitive impairment (a stage of cognitive decline that affects short-term memory and the ability to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure resident's right to examine the results of the most recent survey (an annual inspection of the facility by State or Federal surveyors) and any plan of correction in effect with respect to the facility by not posting the information in a readily accessible place for four of four sampled residents (Residents 68, 22, 74, and 29). This failure resulted in the denial of the resident's rights to information regarding there care while in the facility. Findings: During record review, the admission record indicated Resident 68 was admitted on [DATE], with diagnoses that included, diabetes mellitus (DM-a disease characterized by elevated levels of blood sugar), Schizophrenia (a mental illness that causes people to lose touch with reality), hyperlipidemia (an abnormally high concentration of fats or lipids in the blood). During record review, the Minimum Data Set (MDS - a resident assessment tool) dated 11/20/24, indicated Resident 68'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 observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and preparation practices when: 1. Container of cooked leftover chicken was noted in the refrigerator without a date on it. 2. Opened and unboxed bags of meatballs, egg rolls, and some type of meat were not labeled or dated in the kitchen's freezer. 3. A pan of uncooked chicken stored on top of raw vegetables in the refrigerator. These deficiencies had the potential to result in harmful bacteria growth that could place the residents at risk for food borne illness or contamination. Findings: During the initial tour of the kitchen and comcurrent interview with the Dietary Supervisor (DS) on 01/21/25 at 08:11 am, the following were observed: 1. Unlabeled and undated opened and unboxed bags of meatballs, egg rolls, and identified meat in the kitchen's freezer. 2. A pan of uncooked chicken sitting on top of raw vegetables. 3. A container of undated cooked chicken. 4. There was no documentation on the cooling down log for the cooked chicken that was stored in the refrigerator…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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. Used a quality cleaning agent to prevent the spread of infection. 2. Maintain adequate supply of N95 Masks (a personal protective equipment used to protect the wearer from particles or from liquid). These failures had the potential to result in the spread of infection to residents, staff, and guests. Findings: a. During an observation and concurrent interview on [DATE] at 2:36 pm, the Housekeepers cart parked by the conference room next to the Housekeeping Supervisor. A bottle of rapid multi surface disinfectant cleaner, and a bottle of bio-enzymatic odor eliminator was observed on top of the housekeeping cart. The Housekeeping Supervisor (HS) stated housekeepers use the disinfectant to clean the entire facility, however, the disinfectant did not indicate if the disinfectant can be used for bacteria/viruses. HS stated if the solution does not kill the bacteria or viruses the residents could get an infection and the infection can…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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. Repair leaking pipe under kitchen sink. 2. Repair entire wall panel from the sink that was completely separated from the wall. These deficient practices could result in: 1. Growth in mold and become a breeding ground for bacteria due to the damp environment it creates. 2. Rodents entering in the kitchen. Findings: During the initial tour and interview to the kitchen on 01/21/25 at 8:11 am, with Dietary Supervisor (DS), the following were observed: 1. Unlabelled and undated opened and unboxed bags of meatballs, egg rolls, and some types of meat in the kitchen's freezer. 2. A pan of uncooked chicken sitting on top of raw vegetables. 3. A container of cooked chicken without a date on it. 4. No documentation on the cooling down log for the cooked chicken that was stored in the refrigerator. 5. Water leaking under the sink where the dishes are being washed. There was a red bucket underneath the leaking pipe to catch the water. 6. A rodent trap along the wall in the kitchen near the dishwashing area, holes…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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. Accurately code the Minimum Data Set (MDS - a resident assessment tool) for the section relating to Antipsychotic Medication (a class of medications that treat mental illness) use for one of four sampled residents (Resident 48). 2. Transmit the quarterly and annual assessments within 14 days after completion for two of four residents sampled (Residents 45 and (52). These deficient practices had the potential to incorrectly reflect Resident 48's plan of care, care, and services received Residents 45, 48, and 52. Findings: a. During record review, the admission record indicated Resident 48 was admitted to the facility on [DATE] with diagnoses of paranoid schizophrenia (a mental illness that is characterized by disturbances in thought), hyperlipidemia (high fat level in a person's blood) and high blood pressure. During record review, the Physician's Orders, dated 8/27/2021, indicated the facility to administer Zyprexia (medication to treat mental…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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/create and implement a person-centered comprehensive care plan plan (a resident-specific plan with defined clinical goals and interventions used to manage identified medical issues or other areas of concern) that addressed: 1. The psychotropic medication (a medication that affects behavior, mood, thoughts, or perception) medications and or medications and or medical needs and for one of six sampled residents (Resident 14). 2. The medical needs and goals for one of six sampled residents (Resident 16). These deficient practices had the potential to result in increased risks for Residents 14 and 16 to receive suboptimal care from facility staff in these care areas leading to diminished physical, mental, and psychosocial well-being. Findings: A review of Resident 16's admission record indicated Resident 16 was admitted to the facility on [DATE] with diagnoses that included herpes viral infection (a virus causing contagious sores, most often around…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 staff are competent on what cleaning agents is effective to clean the facility to prevent the spread on viruses, bacteria, and infections. 2. Staff completed infection control skills competencies. These failure can cause or have the potential to cause a resident to contract an infection. Findings: During an interview on 01/23/25 at 02:36, Housekeeping Supervisor (HS) stated the disinfectant that the housekeepers clean the entire facility does not indicate what if any bacteria, infection, or viruses the disinfectant kills. HS stated if the solution does not kill the bacteria, infection, or virus the residents could get an infection that can spread to another resident and can make the residents very sick. HS stated he has never had an in-service or completed an infection control competency since being employed with the contracted cleaning service or with the facility. During an interview on 01/24/25 at 10:56 am, Director of Staff Development (DSD) stated she does not keep the files for any of the housekeepers due…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 staffing information was posted and placed in a visible and prominent place daily. As a result, the total number of staff and the actual hours worked by the staff was not readily accessible to the residents and guests. Findings: During an observation on 1/22/2025 at 11:03 AM, the facility's Daily Nurse Staffing form was observed. The Daily Nurse Staffing form indicated the number of certified nursing assistants (CNAs), Licensed Vocational Nurses (LVNs) and Registered Nurses (RNs) scheduled to work the three eight hour shifts. The Staffing sheet was located in an area secured by yellow and black quarantine tape that cuts off the space just before the exit door. The exit is locked to prevent residents from wandering outside the facility. The area has the staff restroom and the staff exit to the front lobby. Residents are not permitted to enter the area where the staffing is posted. During a concurrent interview and observation on 1/22/2025 at 12:57 PM, the facility's Staffing Hours Posting was observed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 thoroughly investigate non-consensual (without permission) sexual abuse allegation by Licensed Vocational Nurse (LVN) 2 for one of three sampled residents (Resident 1). This failure resulted in Resident 1 feeling afraid to remain in the facility because the resident felt LVN 2 would touch her and kiss her again. Findings: A review of Resident 1 ' admission Record indicated Resident 1 was admitted on [DATE], with a diagnoses not limited to schizoaffective disorder, bipolar type (mental illness that combines symptoms) and hypertension (a condition where the pressure of blood in your blood vessels is consistently too high). A review of Resident 1's Minimum Data Set (MDS- a resident assessment tool) dated 10/21/2024, indicated Resident 1 had intact cognition (mental ability to understand and make decisions). A review of Resident 2 ' s admission Record indicated Resident 2 was ad mitted on 11/4/2024 with a diagnoses not limited to paranoid…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that the nursing staff met the skills and staff competency evaluation requirements and place them in the employee files for for out of four staff. This deficient practice had the potential for a knowledge, training, and certification deficit among the nursing staff, leading to inadequate or delay resident care. Findings: During a concurrent interview and record review on [DATE] at 1:33 pm, Director of Nursing (DON) of employee files for Licensed Vocational Nurses (LVN) 3 and LVN 2, and Certified Nursing Assistants (CNA) 1 and 2 were reviewed. There was no current LVN license, updated CPR card, annual competencies, or updated background check, and CNA license, cardiopulmonary resuscitation (CPR) care, annual competencies, and no abuse training found. The DON stated employee files should have update/current nursing license, CPR cards, abuse training records. DON stated the facility complete competencies annually includig abuse training. DON 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 interviews, observations and record reviews, the facility failed to follow its policy and procedures (P&P) titled, Abuse Prohibition Policy and Procedure dated 2/23/21. By failing to supervise Residents 1 and 2 while the resident were in the facility ' s staircase on 5/10/24. As a result, on 5/10/2024 at 10:40 AM Resident 2 pushed Resident 1 in the staircase, placing Resident 1 at risk for serious injury, harm, or death. Findings: A review of Resident 1 ' s Face Sheet indicated the resident was admitted to the facility on [DATE], with diagnoses that included paranoid schizophrenia (extremely disorganized or unusual behavior. This may show in several ways, from childlike silliness, delusions, hallucinations to being agitated for no reason). A review of Resident 1 ' s Minimum Data Set (MDS; a standardized assessment and care screening tool) dated 4/13/24, indicated Resident 1 had intact cognition (capable of remembering, learning new things, concentrating, or making decisions that affect everyday life). 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 the rights for one of two residents (Resident 1), to be free from physical abuse from Resident 2. This deficient practice resulted in Resident 1 sustaining injuries to his face. Findings: A review of Resident 1's admission Record indicated the resident was originally admitted to the facility on [DATE], with diagnoses of, but not limited, essential hypertension (HTN- high blood pressure) and paranoid schizophrenia (a pattern of behavior where a person feels distrustful and suspicious of other people and acts accordingly). A review of Resident 1's Minimum Data Set (MDS- a comprehensive standardized assessment and screening tool) dated 10/4/2023, indicated Resident 1 was cognitively intact (relating to mental ability to make decisions of daily living) and required no assistance for Activities of Daily Living (ADL ' s- activities related to personal care). A review of Resident 1 ' s Progress Note dated 2/9/2024, indicated Resident 1 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 designate a registered nurse (RN) to serve as full-time Director of Nursing (DON) from 10/13/2023 until 12/26/2023. This deficient practice had the potential to result in the facility's inability to establish nursing standard of practices, compliance with the Stated and Federal agencies, handle emergencies in the facility, complete incident reports, initiate investigations on incidents, manage the entire nursing department and assume the responsibility for resident care in the absence of a physician, and the assume the responsibility of an Administrator in the absence of an Administrator. Placing all 77 residents at risk for harm due to lack of clinical oversight. Findings: A review of the facility's Licensed Nurse Schedule for the months of December 2023 and January 2024, indicated no DON was scheduled to work in the facility. A review of the facility's daily assignment sign in sheets for the months of December 2023 and January 2024 indicated there was no DON signed in as working in the facility. During an…

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

Based on observation, interview, and record review the facility failed to store and label food in accordance with professional standards and facility policy to ensure food service safety. By failing to: 1. Label food with expiration dates. 2. Discard expired food stored in the resident's refrigerator. 3. Ensure the resident's snack refrigerator had a functional thermometer. This deficient practice placed all 77 residents with compromised health status at risk for foodborne illnesses. Findings: During an observation of resident's snack refrigerator, on 1/9/2024 at 9:27 a.m., multiple food items were observed without labels, dates, and six food items were observed to be past labeled expiration date as well as a sport drink with a date of 9/26/23, and an electrolyte drink dated 9/26/23. The refrigerator was noted without a lock on it. The residents snack refrigerator thermometer noted to not be working properly. License Vocational Nurse1 (LVN 1) Stated housekeeping was supposed to clean the resident snack refrigerator. When asked what could happen if the residents were given expired…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 on Advanced Directives by failing to inform and documented notification to 4 of 6 sampled residents (Residents 67, 70, 51, and 40) and/or their representatives of their rights to formulate and advanced directive advance directives (written statement of a person's wishes regarding medical treatment made to ensure those wishes are carried out should the person be unable to communicate them to a doctor) upon admission to the facility. This deficient practice had the potential to deny the residents their rights to request or refuse medical care and treatment. Findings: a. A review of Resident 67's admission Record indicated the resident was admitted to the facility on [DATE], with diagnoses that included Essential (primary Hypertension [Abnormally high blood pressure that is not the result of a medical condition]) and Hypercholesterolemia (high levels of cholesterol in the blood). A review of Resident 67's Scheduled 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.

Based on interview and record review, the facility failed to ensure a water management program was in place to test the facilities water supply for disease causing pathogens (organisms that can cause disease) as part of the facility's infection control program. This deficient practice had the potential to place residents at risk for water borne diseases including pneumonia (lung infection), which could lead to hospitalization of residents. Findings: During an interview on 1/10/24 at 12:24 p.m., the Maintenance supervisor (MS) stated he did not have a diagram of the facility water system. The MS stated he had no idea where a map of the water systems might be. The MS provided a written description of the water management program. During an interview on 1/10/24 at 12:40 p.m., the regional Maintenance supervisor (RMS) in charge of training stated, the facility had not tested the water for Legionella (bacteria can cause a serious type of pneumonia), because there were no known cases of the disease in the facility. The RMS stated that if there is an outbreak then the water is to be tested…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 (3) of 27 resident rooms (Rooms 3,4, and 5) were accommodated no more than four residents in each room. rooms [ROOM NUMBERS] had six (6) residents in each room while five (5) residents occupied room [ROOM NUMBER]. This deficient practice had the potential to affect the delivery of care and safety of the residents especially during an emergency. Findings: During an observation on 1/10/2024 at 8:31 a.m., in room [ROOM NUMBER], six (6) beds were observed with curtains closed around bed. There was a clear path to the bathroom in between all rooms. All residents were in bed with eyes closed. During an observation and concurrent interview on 1/10/2024 at 8:35 a.m., room [ROOM NUMBER] had six (6) beds in which five (5) were occupied. Resident 65 was observed walking around and moving freely in the room where the needs of the resident were accommodated. The facility staff were able to provide care safely and without restrictions.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record reviews, the facility failed to ensure three out of six shower rooms (shower room near room [ROOM NUMBER], shower room near room [ROOM NUMBER], and the shower room near the activities room) were in safe operating condition free form safety and fire hazards. This deficient practice placed the residents at risk for falls, cuts, and other illnesses caused by unhygienic conditions, which could lead to serious injury and/or death. Findings: During an observation of a facility shower room near room [ROOM NUMBER] on 1/10/24 at 11:29 a.m., with the facility Administrator (ADM) and a facility Maintenance worker (MW). The shower room was observed to be missing lightbulbs, a light fixture cover and a drain cover for the drain on the floor of the shower. The shower room also had exposed rusted pipes, peeling paint on the shower walls, and the shower floor was missing non-skid strips. During an observation of a facility shower room near room [ROOM NUMBER] on 1/10/24 at 11:39 a.m.,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 (2) of five (5) sampled residents lived in a homelike environment by providing comfortable and safe temperatures. This deficient practice resulted in the residents living under comfortable and safe temperatures, which could cause the residents to lose body heat leading to hypothermia (dangerously low body temperature). Findings: 1. A review of Resident 380's admission Record, dated 10/15/2020, indicated the facility admitted the resident on 10/15/2020 with diagnoses including paranoid Schizophrenia (a serious mental illness that affects how a person thinks, feels and behaves), chronic idiopathic constipation (is constipation without a known cause), prediabetes (prediabetes is a serious health condition where blood sugar levels are higher than normal, but not high enough yet to be diagnosed as type 2 diabetes, a disease that occurs when your blood glucose [blood sugar], is too high). A review of the Minimum Data Set (MDS-a…

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

Based on record review and interview, the director of nursing (DON) failed to demonstrate knowledge of facility residents by incorrectly completing the Matrix for Providers (used to identify pertinent care categories for all residents) during a Recertification Survey (conducted to ascertain whether a provider/supplier meets applicable requirements for participation in the Medicare and/or Medicaid programs) for 77 of 77 sampled residents. This deficient practice had a potential not to meet the residents' needs due to lack of knowledge of residents' health conditions. Findings On 1/9/2024 at 7:30 a.m., the California Department of Public Health (CDPH) entered the facility to conduct a recertification survey. During an interview on 1/9/2024 at 10:30 a.m., the administrator (Adm) stated the total in-house census (number of residents physically in the building) was 77. The Adm stated the facility did not have any residents on Hospice (specialized care that provides comfort and support to the terminally ill whose doctor believes they have six months or less to live), dialysis (procedure…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for five of 12 sampled residents (Resident 1, 3, 5, 6, and 10) when Resident 1, 5, 6, and 10 refused pneumonia (PNA-infection that inflames air sacs in one or both lungs which may fill with fluid) vaccination in accordance with the facility's policy and procedures (P&P) titled, Care Plan Comprehensive, reviewed on 1/24/2023. Resident 3, who is high risk for PNA, was not offered a PNA vaccine. This deficient practice had the potential to result negative impact on Resident 1, 3, 5, 6, and 10's quality of care and services received. Findings: 1. During a review of Resident 1's admission Record, indicated the facility admitted Resident 1 on 4/6/2022, with diagnoses including schizophrenia (a mental health problem that primarily affects a person's emotional state), COVID-19 (Coronavirus- a deadly respiratory disease transmitted from person to person), overweight and diabetes mellitus (DM-a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure Pneumonia (PNA-infection that inflames air sacs in one or both lungs which may fill with fluid) vaccine was offered and/or re-offered to four of 12 sampled residents (Resident 3, 5, 6 and 10) in accordance with the facility's policy and procedures (P&P) titled, Pneumococcal (PNA) Vaccine, reviewed on 1/24/2023. This deficient practice placed Residents 2, 4 and 5 at a higher risk of acquiring and transmitting pneumonia infection to other residents in the facility. Findings: 1. During a review of Resident 3's admission Record, indicated the facility admitted Resident 3 on 2/5/2020, with diagnoses including schizophrenia (a mental health problem that primarily affects a person's emotional state), COVID-19 (Coronavirus- a deadly respiratory disease transmitted from person to person) and diabetes mellitus (DM-a chronic condition that affects the way the body processes blood sugar [glucose]). During a review of Resident 3's Minimum Data Set (MDS - a…

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