Mid-Wilshire Health Care Cntr

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to implement a Foley catheter dignity care plan for Resident 5 and ensure the Certified Nursing Assistant (CNA) 2 was seated at eye level during feeding one out of six sampled residents (Resident 16).This deficient practice has a potential for Resident's 5 and Resident's 16 dignity was not maintained.Findings:During a review of admission record Resident's 16 admission record (Face sheet) indicated Resident 16 was admitted to the facility on [DATE] with diagnoses of Alzheimer's disease (impaired cognitive function, leading to dependence on others), depression (mood disorder characterized by sadness, hopelessness, helplessness), glaucoma (severe blurred vision), hearing loss, right shoulder osteoarthritis (pain and stiffness in joints), lack of coordination, dysphagia (difficulty swallowing).During a record review on 03/10/2026 of Minimum Data Set (MDS, Resident assessment tool) MDS (resident assessment tool) dated 01/06/2026, 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 protect Resident 47's right to be free from physical abuse (the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish) by Resident 78 when he hit Resident 47 on the face. This failure had the potential to result in Resident 47 being exposed to the risk of physical injury. Findings:During a record review of Resident 47's admission record indicated Resident 47 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of epilepsy (a disorder in which nerve cell activity in the brain is disturbed causing seizures), dementia (a progressive state of decline in mental abilities), and depression (a mood disorder that causes persistent feeling of sadness and loss of interest). During a record review of Resident 47's Minimum Data set [MDS-a resident assessment tool), dated 2/2/26 indicated that Resident's cognitive was moderately impairment. 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 observation, interview and record review the facility failed to implement it's written abuse polies and procedures (P&P), titled, Abuse and Neglect Prohibition Policy designed to prevent, respond to and report abuse- related incidents after physical abuse (includes, but is not limited to, hitting, slapping, punching, biting, and kicking) when staff did not immediately separate roommates Residents 47 and 78 who had physical altercation on 11/7/2026.This failure demonstrates the facility did not effectively implement its abuse prevention and response policy and procedures and did not ensure resident safety as required.Findings:During a record review of Resident 47's admission record , the admission record indicated Resident 47 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of epilepsy (a disorder in which nerve cell activity in the brain is disturbed causing seizures), dementia (a progressive state of decline in mental abilities), and depression (a mood disorder that causes…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to report allegations of abuse to the California Department of Public Health (CDPH) within the regulated time frame of two hours. a. by failing to report an allegation of physical abuse which occurred between Resident 47 and Resident 78 who are roommates on 11/07/2025. This deficient practice resulted in CDPH's inability to investigate the allegation of abuse timely and had the potential for other allegations of abuse to go unreported.Findings:During a record review of Resident 47's admission record indicated Resident 47 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of epilepsy (a disorder in which nerve cell activity in the brain is disturbed causing seizures), dementia (a progressive state of decline in mental abilities), and depression (a mood disorder that causes persistent feeling of sadness and loss of interest). During a record review of Resident 47's Minimum Data set [MDS-a resident assessment tool), dated 2/2/26…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 baseline care plan for physician orders for pain management and physical therapy (a healthcare specialty that helps individuals restore, maintain, and improve physical function, movement, and strength while reducing pain) for one of three sample residents (Resident 77).This failure had the potential to result in inadequate communication among staff regarding resident's 77 pain management needs and therapy interventions. Findings:During a record review of Resident 77's admission record it indicated Resident 77 was admitted to the facility on [DATE] with diagnoses of multiple fractures (broken bone) of pelvis (located at the lower part of the trunk), hyperlipidemia (abnormally high levels of fats in the blood), and osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage). During a review of Resident 77's History and Physical (H&P), dated 3/3/2026, the H&P indicated, Resident 77 has the capacity…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to revise resident care plans for two of four sampled residents (Resident 31 and 62). This failure had the potential to result in Resident 31 and 62 receiving inappropriate care due to conflicting information between care plan and medication orders. Findings: During a review of Resident 31's admission Record (Face sheet), the admission record indicated Resident 31 was admitted to the facility on [DATE] with diagnoses of dementia (a progressive state of decline in mental abilities) and major depressive disorder (a serious, common mental health disorder characterized by persistent sadness, low mood, and a loss of interest in activities). During a review of Resident 31's Minimum Data Set (MDS) dated [DATE], The MDSSection B indicated that Resident 31 uses glasses and hearing aides The MDS indicated that Resident 31 has moderate mental impairment. The MDS also indicated that besides the occasional feeling of loneliness, Resident 31 does not show…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, the facility failed to follow physician's order for pain management for one of three sampled resident (Resident 77). This failure had the potential to place Resident 77 at risk for adverse medication effects, including oversedation, respiratory depression and decline in overall health status. Findings:During a record review of Resident 77's admission record it indicated Resident 77 was admitted to the facility on [DATE] with diagnoses of multiple fractures (broken bone) of pelvis (located at the lower part of the trunk), hyperlipidemia (abnormally high levels of fats in the blood), and osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage). During a review of Resident 77's History and Physical (H&P), dated 3/3/2026, the H&P indicated, Resident 77 has the capacity (ability) to understand and make decisions. During a review of Resident 77's Order Summary Report (OSR), dated 3/12/2026, the OSR included the following orders 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 ensure safe care of an arteriovenous (AV) fistula (abnormal connection of an artery and vein) for one of three sampled residents (Resident 28) receiving dialysis treatment (a procedure that cleanses the blood of waste and excess fluids when the kidneys have failed) by not using the correct arm to check blood pressure (B/P). This failure has the potential to result in injury for Resident 28 that can potentially damage the AV fistula. Findings: During a review of Resident 28's admission Record (Face Sheet) indicated Resident 28 was initially admitted to the facility on [DATE] with diagnoses including end-stage renal disease (irreversible kidney failure), type 2 diabetes (a disorder characterized by difficulty in blood sugar control and poor wound healing), and dependence on dialysis. During a review of Resident 28's Minimum Data Set (MDS- a resident assessment tool), dated 1/25/26, MDS indicated that Resident 28 does not have cognitive…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 bed dimensions were inspected for appropriate size and weight for one of five sampled residents (Resident 47). This deficient practice has the potential to result in compromised resident safety associated with possible entrapment with bed rail use. Findings:During a record review of Resident 47's admission record it indicated Resident 47 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of epilepsy (a disorder in which nerve cell activity in the brain is disturbed causing seizures), dementia (a progressive state of decline in mental abilities), and depression (a mood disorder that causes persistent feeling of sadness and loss of interest). During a record review of Resident 47's Minimum Data set [MDS-a resident assessment tool), dated 2/2/26 indicated that Resident's cognitive was moderately impairment. The MDS indicated that Resident 47 required supervision assistance with eating . 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 observation, interview and record the facility failed to:Accurately account for Resident 62's home medications upon admission.Ensure the pharmaceutical waste container contained adequate liquid or chemical solution to render discarded tablets and capsules inaccessible and ensure the container's lid was secured according to manufacturer instructions.These deficient practices had potential to result in misappropriation or diversion of the medications.Findings:During record review of the admission Record, the record indicated Resident 62 was admitted to the facility on [DATE] with diagnoses of hypertensive heart failure (heart's muscle inability to pump blood efficiently due to long term untreated high blood pressure), abnormal gait and mobility (difficulty walking and maintaining balance), thrombocytopenia (disfunction in blood clotting causing bleeding, bruising) anemia (low red blood cells needed for oxygen transport to organs), chronic kidney disease (long term impairment in blood filtering ability and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to act upon a medication irregularity identified by the Pharmacy Consultant (PharmC/PC 2) for one of four sampled residents (Resident 62). This failure had the potential for Resident 62 receiving a repeated subtherapeutic dose (below the dosage amount needed for effective treatment) of eliquis (medication that thins blood, decreasing likelihood of blood clots in individuals who have higher risk factors for clots ) and had the potential to cause harm by increasing risk of blood clots. Findings: During a review of Resident 62's admission Record (Face Sheet),the record indicated Resident 62 was initially admitted to the facility on [DATE] with diagnoses including heart failure (condition where the heart muscle isn't strong enough to pump enough blood to meet the body's needs) , chronic kidney disease (condition where the kidneys are damaged and can't properly filter out waste and fluid), and atrial fibrillation (heart condition which affects…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 monitor and document the signs and symptoms of depression for one out of one sampled resident (Resident 51) on Remeron (an anti-depressant medication).This failure had the potential to result in physical and psychosocial harm to Resident 51. Findings:During a review of Resident 51's admission record, the admission record indicated Resident 51 was admitted to the facility on [DATE] with diagnoses but not limited to major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), Alzheimer's disease (a disease characterized by a progressive decline in mental abilities), and diabetes mellitus (a disorder characterized by difficulty in blood sugar control).During a review of Resident 51's Minimum Data Set (MDS - a comprehensive resident assessment tool), dated 1/16/2026, the MDS indicated an active diagnosis of depression.During a review of Resident 51's physician's orders, dated 7/24/2024, the orders 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.

Based on observation, interview, and record review, the facility failed to ensure a garbage dumpster lid was properly covered.This failure had the potential to attract pests and spread infection to facility residents.Findings:During an observation on 3/9/2026 at 7:45 a.m. in the parking garage, a garbage dumpster was filled with trash bags to the point that the lid could not fully close.During an interview on 3/10/2026 at 12:45 p.m. with the Dietary Supervisor (DS), the DS stated insects or animals could travel inside the garbage dumpster if the lid is left open and this could result in the residents becoming sick.During a record review of the facility's policy and procedure (P&P) titled, Waste Management, dated August 2017, the P&P indicated waste containers must be closable.During a review of Food Code 2022, dated 1/18/2022, the Food Code 2022 indicated garbage receptables must be constructed with tight-fitting lids or covers to prevent the scattering of the garbage or refuse by birds, the breeding of flies, or the entry of rodents.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of fourteen sampled residents (Resident 53) had call light within reach.This deficient practice had the potential to put Resident 53's at risk during emergency situations.Findings:During record review of the admission record, the admission record indicated Resident 53 was admitted to the facility on [DATE] with diagnoses of Alzheimer's disease (impaired cognitive function, leading to dependence on others), embolism and thrombosis of deep veins of right lower extremity (blood clots in deep veins of a leg, obstructing normal blood flow to organs), anemia (low red blood cell count essential for oxygen transport), hypertension (chronic high blood pressure), osteoporosis (low density of bone tissue, prone to fractures), lack of coordination, dysphagia (difficulty swallowing), urinary retention (incomplete emptying of bladder during urination).During a review of the Minimum Data Set (MDS - resident assessment tool) indicated that 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 Licensed Vocational Nurse (LVN) 2 and Housekeeper (HK) 1 received abuse, neglect and exploitation training. This failure had the potential to place residents at risk for abuse, neglect, or exploitation due to lack identification and training.Findings:During a concurrent interview and record review on 3/11/2026 at 8:34 a.m. with Director of staff Development (DSD), the DSD stated that the facility had not provided staff with training on abuse, neglect and exploitation. The DSD stated that this training is important to ensure staff can recognize and protect residents. The DSD further stated that without this training, staff may fail to detect abuse, which could place residents at risk During an interview on 3/11/2026 at 1:41 p.m. with LVN 2, LVN 2 stated that the facility did not provide him with abuse or neglect training. LVN 2 stated that staff need proper training before working in the facility so they can provide safe care to the residents. LVN 2 further stated that staff assignments and workload at 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 include the resident's next of kin (NOK) during the care plan conference for one of four sampled residents (Resident 2). For Resident 2, the facility failed to include Resident 2's NOK during the care plan meeting on 8/1/25.This deficient practice resulted in Resident 2 and Resident 2's 's NOK's not given their right to participate in the care planning for Resident 2.Findings:During a review of the admission Record indicated the facility admitted Resident 2 on 12/24/18 and readmitted on [DATE] with diagnoses including heart failure (when the heart muscle doesn't pump blood as well as it should) and lack of coordination. During a review of the Minimum Data Set (MDS, resident assessment tool) dated 7/16/25 indicated Resident 2 was cognitively intact. Resident 2 was dependent with staff on putting on/taking off footwear, substantial assistance (helper does more than half the effort) with lower body dressing, toileting hygiene, moderate assistance (helper…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to notify the residents and/or their responsible party (RP) of room change for one of four sampled residents (Resident 1). For Resident 1, the facility failed to:1.Notify Resident 1's RP before moving Resident 1 to another room on 2/7/25, 2/10/25, 3/4/25 and 3/26/25.2.Provide a written notice including the reason for room change before moving Resident 1 to another room. 3.Document in Resident 1's medical record the room change and the notification of Resident 1's RP. These deficient practices resulted in Resident 1 and Resident 1's RP not given their right to know before the room changes occur. During a review of the admission Record indicated the facility admitted Resident 1 on 9/20/24 and readmitted on [DATE] with diagnoses including dementia (a progressive state of decline in mental abilities) and anxiety disorder. During a review of the Minimum Data Set (MDS, resident assessment tool) dated 6/27/25 indicated Resident 1 had moderately impaired cognitive…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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' abuse policy and procedures for two of nine sampled residents (Residents 2 and 3). This failure resulted in an employee-to-resident allegation of abuse incident not being reported to state licensing/certification office, police, and ombudsman, and the incident not investigated in a timely manner. Findings: During a review of Resident 2's admission Record, dated 6/11/25 indicated, Resident 2 was admitted to the facility on [DATE] with diagnoses including hypertension (HTN—high blood pressure), insomnia (inability to sleep), hyperlipidemia (HLD - a condition characterized by elevated levels of lipids (fats) in the bloodstream), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest) and abnormalities of gait and mobility. During a review of Resident 2 ' s History and Physical (H&P), dated 1/20/25 indicated, Resident 2 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.

Based on interview and record review, the facility failed to ensure five employees had annual performance evaluations. This failure had the potential to affect the quality of care for the residents. Findings: During a concurrent interview and record review on 3/12/25 at 10 AM with the Director of Staff Development (DSD), five facility employee files were reviewed. Licensed Vocational Nurse (LVN) 2, date of hire (DOH) 4/10/19, LVN 4 - DOH 9/1/22, Certified Nursing Assistant (CNA) 3 - DOH - 4/30/24, CNA 4 / Restorative Nursing Assistant (RNA) - DOH - 4/17/18, and CNA 5 - DOH -8/16/23. The DSD stated these performance evaluations were not done. The DSD stated she did not get trained / updated on performance evaluations and was unaware of the requirement. The DSD stated she did not review the facility policy on performance evaluations and that without performance evaluations the risk could be a delay in care to the residents. During an interview on 3/12/25 at 11:38 AM, the Director of Nursing (DON) stated employee files were required to have an annual performance evaluation. The DON…

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

Based on observation, interview and record review, the facility failed to ensure the standardized recipes and portion sizes for lunch menu was followed on 3/10/2025 when: -Facility failed to ensure staff followed food production recipes for the pureed diet (food that is blended to a pudding consistency, no chewing required) during tray line observation. Twenty-three residents on puree diet did not receive the pureed soybean paste stew and fern salad, they received pureed meat, pureed rice and beans. -Twenty-three residents on the pureed diet received a pureed diet texture that was thin and soupy instead of pureed food that was homogenous, cohesive and had a pudding like consistency. -The menu did not include the therapeutic (diets per physician order for specific disease condition such as kidney disease or high blood sugar) and texture modified diets (these are diets that are altered in texture to accommodate resident chewing or swallowing problems). The menu did not indicate the standard portions and serving guide at each meal. These deficient practices had the potential to result…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 in the kitchen when: -Meat to be used for lunch preparation was thawing on the kitchen counter. -Ice machine was not maintained in a sanitary manner, the inside compartment of ice machine was dirty and the ice scoop was last cleaned 3/5/2025. -Two gallons of milk and nine individual cups of beverages stored in the reach in refrigerator with no open or use by date. One bag of sliced cheese not in original packaging stored in plastic bag and 14 Individual cups of kimchi stored with no label or date in the walk-in refrigerator. One large container of previously cooked rice stored in the walk-in refrigerator with no label or use by date and six cups of thickened milk beverage stored in the walk-in refrigerator with date of 3/6/2025 exceeding storage period for milk. These deficient practices had the potential to result in harmful bacteria growth and cross contamination (transfer of harmful bacteria from one place to another) that could lead to food…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 a call light was within reach for one sampled resident (Resident 25). This deficient practice had the potential to result in a delay in meeting the resident's needs for hydration, toileting, and activities of daily living. Findings: A review of the admission record for Resident 25 indicated the resident was re-admitted to the facility on [DATE] with diagnoses including Alzheimer's Disease (a disease characterized by a progressive decline in mental abilities), Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), lack of coordination, and polyoseoarthritis (a degenerative disease that involves more than five joints). A review of Resident 25's Annual Minimum Data Set (MDS - a resident assessment tool) dated 12/25/2024, indicated the resident had severe cognitive impairment (decline in thinking, memory, and reasoning abilities, impacting daily functioning)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 ensure one of 16 sampled residents (Resident 63) received treatment and care in accordance with professional standards of practice. Resident 63, who had a history of diabetic ketoacidosis (DKA - a serious, potentially life-threatening complication of diabetes that occurs when the body does not have enough insulin [a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication], causing it to burn fat for energy instead of sugar, leading to a buildup of harmful acids called ketones in the blood) had abnormally high blood sugar readings, and did not have defined parameters for blood sugar readings to notify the doctor. This deficient practice caused an increased risk in Resident 63 having another episode of DKA. Findings: A review of Resident 63's admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses including unspecified acidosis (your body fluids have become too…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure one of two sampled residents (Resident 57) received treatment and services to prevent complications of an enteral feeding tube (g tube, delivery of liquid nutrients through a tube directly into the gastrointestinal tract). Resident 57's enteral feeding tube bag was not changed every 24 hours per the facility's Enteral Feeding Via Pump Administration policy. This deficient practice had the potential to place Resident 57 at risk for infection and gastrointestinal (GI) complications. Findings: A review of the admission record indicated Resident 57 was admitted to the facility on [DATE], with diagnoses including dysphagia (difficulty swallowing), aphasia (a disorder that makes it difficult to speak), dementia (a progressive state of decline in mental abilities), and Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements). A review of Resident 57's Quarterly…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 sampled resident (Resident 23) with prescribed Ativan (anxiolytic, psychotropic medication) as needed (PRN) order had a documented clinical rationale to extend the medication beyond 14 days. This deficient practice caused an increased risk in Resident 23 experiencing adverse consequences. Findings: A review of Resident 23's admission record indicated the resident was admitted to the facility on [DATE] with a diagnoses including anxiety disorder (excessive fear or worry that interferes with daily life), dementia (a progressive state of decline in mental abilities), dysphagia (difficulty swallowing). A review of Resident 23's Minimum Data Set (MDS - a resident assessment tool) dated 12/26/24, indicated the resident was not alert and oriented, and did not have good recall. The MDS indicated Resident 23 rarely felt lonely or isolated. A review of the Physician's Order dated 2/27/25 indicated Resident 23 was prescribed Ativan 0.5 mg by mouth…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 competent staff and provide abuse training, per facility policy, to Certified Nursing Assistant (CNA) 1, who was accused of sexually abusing Resident 1. CNA 1 did not receive Abuse Training while employed at the facility for several months. This deficient practice caused an increased risk of sexual abuse to Resident 1 and other facility residents. Findings: A review of the facility's in-services dated 2/3/2023, titled, Elder Abuse: Mandated Reporter, at 2 PM, did not indicate CNA 1 attended the in-service. A review of the facility's in-services titled, Abuse: Signs of Suspected Abuse/Unknown Injuries, dated 4/15/2023 at 2 PM, did not indicate CNA 1 attended the in-service. A review of the facility's in-services titled, Abuse: Mandated Reporting-Reporters, dated 5/2/2023, did not indicate CNA 1 attended the in-service. A review of the facility's in-service titled, Elder Abuse dated 11/15/2023, did not indicate CNA 1 attended the in-service. A review of the facility's in-service titled, Reporting Unusual Occurrences…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 a call light (a device used by a patient to signal his or her need for assistance from a professional staff) was within reach for two of 18 sampled residents (Resident 12 and Resident 48) investigated for the call lights care area. This deficient practice had the potential to result in the residents not being able to call for facility staff assistance and increase their risk for injury or fall. Findings: a. A review of Resident 12's admission Record indicated the facility admitted the resident on 10/17/2021 with diagnoses including Alzheimer's disease (a brain disorders the slowly destroys memory and thinking skills and eventually, the ability to carry out the simplest tasks), pressure injuries (areas of skin that are damaged after being compressed for too long), and history of falling, and metabolic encephalic (a problem in the brain caused by a chemical imbalance in the blood). A review of Resident 12's History and Physical dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to properly set the low air loss mattress (LALM) settings for two of two sampled residents (Resident 12 and Resident 19). This deficient practice had the potential to cause harm to Resident 12 and Resident 19 by not providing services to promote the prevention pressure ulcer development. Findings: a. A review of Resident 12's admission Record indicated the facility admitted the resident on 10/17/2021 with diagnoses including Alzheimer's disease (a brain disorders the slowly destroys memory and thinking skills and eventually, the ability to carry out the simplest tasks), pressure injuries (areas of skin that are damaged after being compressed for too long), and history of falling, and metabolic encephalic (a problem in the brain caused by a chemical imbalance in the blood). A review of Resident 12's History and Physical dated 3/14/2023, indicated the resident did not have the capacity to understand and make decisions. A review of Resident 12's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide necessary respiratory care services for two of eighteen sampled resident (Resident 27 and Resident 61) by failing to: a. Change Resident 27's nasal cannula (device used to deliver supplemental oxygen placed directly on a resident's nostrils) and humidification bottle every 7 days. b. Ensure Resident 61 had a date on the nasal cannula to ensure prompt weekly changing of the nasal cannula. These deficient practices had the potential to cause complications associated with oxygen therapy, including infection or respiratory distress. Findings: a. A review of Resident 27's admission record indicated the facility admitted the resident on 7/8/2022 with diagnoses including Alzheimer's disease ( a brain disorder that gets worse over time, usually affects memory, thinking and behavior) and dysphagia (difficulty swallowing). A review of Resident 27's risk for respiratory distress care plan, initiated 7/8/2022, indicated the resident had 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 a current copy of the resident's advance directive and/or advance directive acknowledgement form (a 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) was complete and in the resident's medical chart for one of one sampled resident (Resident 1) medical records. This deficient practice had the potential for the facility to not honor the resident's medical decisions regarding end-of-life treatment. Findings: A review of Resident 1's admission record indicated the facility admitted the resident on 11/3/2022 and readmitted on [DATE], with diagnoses including vascular dementia (decline in mental ability severe enough to interfere with daily functioning/life), Type II diabetes mellitus (a chronic condition that affects the way the body processes blood sugar [glucose]), and major depressive disorder (mood disorder that causes 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 report unusual occurrences to the state survey agency (SSA) within 2 hours for two of two sampled residents (Resident 6 and Resident 58). The facility failed to report: -Resident 58 sustained a right 10th rib fracture (broken bone) after a fall on 9/21/2023. -Resident 6 sustained a temporal subdural hematoma and right frontal hematoma on 12/21/2023. These deficient practices resulted in a delay of State Survey Agency from investigating the circumstances of the injuries and potentially placed Resident 6 and 58 at further risk for injury. Findings: a.A review of Resident 58's admission record indicated the facility admitted resident on 3/17/2023, with diagnosis including dementia (loss of memory, language, problem solving and other thinking abilities that are severe enough to interfere with daily life), lack of coordination, and abnormalities of gait and mobility. A review of Resident 58's Minimum Data Set (MDS- a comprehensive 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 ensure resident was provided a communication device or board with the language that the resident was able to understand for one of one sampled resident (Resident 33). This deficient practice prevented the resident from communicating with the staff and had a potential to delay receiving care/treatment the resident needed. Findings: A review of Resident 33's admission Record indicated the facility admitted the resident on 1/14/2017, and readmitted on [DATE], with diagnoses including dementia (decline in mental ability severe enough to interfere with daily functioning/life), Parkinson's disease (degenerative disorder affecting the motor system with symptoms that included shaking, rigidity, slowness of movement and difficulty with walking and gait), and epilepsy (a broad term used for a brain disorder that causes seizures [may cause loss of consciousness, falls, or massive muscle spasms]). A review of Resident 33's Minimum Data Set (MDS-…

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

Based on observation, interview, and record review, the facility failed to implement the appropriate care and services to prevent urinary tract infections for one of one sampled resident (Resident 12) by failing to ensure that urinary bag tubing was not kinked. This deficient practice had the potential to result in catheter-associated urinary tract infection for Resident 12. Findings: A review of Resident 12's admission Record indicated the facility admitted the resident on 10/17/2021 with diagnoses including Alzheimer's disease (a brain disorder that slowly destroys the memory and thinking skills and eventually, the ability to carry out the simplest tasks), pressure injuries (areas of skin that are damaged after being compressed for too long), metabolic encephalic (a problem in the brain caused by a chemical imbalance in the blood), and a history of falling. A review of Resident 12's History and Physical dated 3/14/2023, indicated the resident did not have the capacity to understand and make decisions. A review of Resident 12's Minimum Data Set (MDS - an assessment and care…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure resident was properly arranged and prepared for safety discharge to home for one of one sampled resident (Resident 1). This deficient practice resulted in Resident 1 ' s delayed discharge due to the arrangement of the delivery of their durable medical equipment (DME). Findings: A review of Resident 1 ' s Record of admission indicated Resident 1 was originally admitted to the facility on [DATE] with diagnoses including malignant neoplasm of colon (a cancer of the large intestine located at the end of the digestive tract), malignant neoplasm of brain (tumors that occurs in the brain due to an abnormal growth or division of cells), and difficulty on walking. A review of the Minimum Data Set (MDS - a comprehensive assessment and care screening tool) dated 10/20/2023, indicated Resident 1 ' s cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions was moderately impaired. The MDS indicated Resident 3…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 a resident received appropriate treatment and services to prevent urinary tract infections (UTI-an infection in any part of your urinary system your kidneys, ureters, bladder and urethra) for one of one sampled resident (Resident 2) by failing to assess Resident 2 who had an indwelling urinary catheter (foley catheter - a hollow tube left implanted in a body canal or organ, especially the bladder, to promote drainage) and document mucus and sediments (visible particles in the urine that can be made up of a variety of substances, including sloughing of tissue [debris]). The most common cause of sediment in the urine is a UTI. As a result, Resident 2 was placed at risk for a delay in necessary care and services to treat a possible UTI. Findings: A review of the Record of admission indicated Resident 2 was originally admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses including Alzheimer ' s disease (a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide necessary respiratory care services for one out of one sampled resident (Resident 3) by failing to ensure Resident 3 ' s nasal cannula (NC -a connector attached to oxygen) tubing was changed per facility ' s policy. This deficient practice had the potential for the residents to develop respiratory infection. Findings: A review of Resident 3 ' s Record of admission indicated Resident 3 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including hemiplegia and hemiparesis (loss of the ability to move in one side of the body), dysphagia (difficulty swallowing food or liquid), and muscle weakness. A review of the Minimum Data Set (MDS - a comprehensive assessment and care screening tool) dated 11/30/2023, indicated Resident 3 ' s cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions was moderately impaired. The MDS indicated Resident 3 required…

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

Based on observation, interview, and record review, the facility failed to follow infection control practices as evidenced by: -Certified Nursing Assistant 2 ( CNA 2) was observed not wearing the appropriate N95 respirator mask (a respiratory protective device designed to achieve a very close facial fit and very efficient filtration of airborne particles) that was fit tested (a test protocol conducted to verify that a respirator is both comfortable and provides the wearer with the expected protection) for her. -CNA 1, CNA 3, and the Minimum Data Set (MDS- a standardized assessment and care screening tool) Coordinator were not N95 respirator mask fit tested. These deficient practices had the potential to expose residents, staff, and the community to Coronavirus (COVID-19, a virus that spreads from person to person causing respiratory illness). Findings: a. During an observation on 8/31/2023 at 10 AM, CNA 2 was observed wearing a Honeywell model N95 mask in the COVID-19 positive isolation area. CNA 2 stated she was not fit tested for the N95 respirator mask she was wearing. CNA 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.