Miracle Mile Healthcare Center, LLC

Based on observation, interview and record review, the facility failed to ensure the standardized recipes for lunch menu were followed on 3/17/2026 by failing to:1.Ensure minced and moist texture bread and cabbage was prepared according to the IDDSI- Level Five minced and moist foods- (All foods prepared for this diet must be soft, moist with all excess fluid drained, and minced to size no larger than 4mm fits through the gaps of fork prongs) when 5 residents received bread and cabbage with carrots that was not small (minced) did not fit through the fork prongs.2. Ensure cooks followed the food production recipe for 28 residents on the soft and bite size diet (food particle are soft and chopped into 1/2 inch pieces) who received minced (ground beef consistency) corned beef instead of chopped into 1/2 inch pieces. These deficient practices had the potential to result in meal dissatisfaction, decreased nutritional intake and increased choking risk for the five residents on minced and moist diet. Findings: 1.During an observation of the tray line (tray line - a system of 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 safe and sanitary food storage and preparation practices in the kitchen when:1.Two open packages of hot dog with dates 3/10/26-3/13/26 expired and stored in the walk-in refrigerator. Fully cooked Corned beef was stored on the bottom shelf below raw ground beef. One box containing 70 single serve containers of juice with a thaw date of 3/5/26 expired exceeding storage period for frozen juice and stored in the walk-in refrigerator. 2. There was water accumulation around the grease trap (A kitchen grease trap (or interceptor) is a plumbing device designed to capture fats, oils, and grease (FOGs) from wastewater/dish machine before they enter drainage systems, preventing clogs, backups, and odors.), oil-like substance was floating over the water build up. Potential for contamination of food, utensils, equipment, food contact surfaces and attract pests to the kitchen area.3. One can opener blade was dirty with dried brown residue, and…

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

Based on observation, interview and record review, the facility failed to ensure the trash stored in the dumpster area was maintained in a sanitary manner. Three of four trash bins were overfilled, lids kept open and flies were present inside the dumpster room. There was trash (plastic cups, food containers, plastic utensils, gloves and paper) scattered on the ground, and under the trash bins. This deficient practice had the potential for harborage and feeding of pests. Findings: During an observation in the main dumpster area located in an alley behind the facility on 3/17/2026 at 10:30AM; The facility dumpster area was behind a locked gate. Three of four trash bins were overfilled, and trash lids were open. The trash room was filled with flies. During a concurrent observation and interview with Maintenance Supervisor (MS) and Dietary Supervisor (DS) on 3/17/2026 at 10:30AM, MS stated trash lids should stay closed, so it doesn't bring in pests like flies and rats. MS stated the ground is full of trash and should be swept more often by housekeeping. DS stated there are plastic…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 standard infection control practices for one of one residents (Resident 115) and for three of three sampled staff by failing to: Change Resident 115's Peripherally Inserted Central Catheter (PICC-a long, thin, flexible tube inserted into a peripheral vein in the arm and advanced to the heart used to deliver medication intravenously (IV-into a vein) access for weeks or months) dressing within 7 days according to the facility's P&P titled, Central Venous Catheter Dressing Changes.Fit test three of three sampled staff (Certified Nursing Assistant [CNA] 2, Licensed Vocational Nurse [LVN] 2 and LVN 3) for their N95 mask (also known as a respirator, it is a respiratory protective device designed to achieve a very close facial fit and provide efficient filtration of airborne particles)These deficient practices placed the Resident 115 at risk for infection had the potential to result in blood stream infections through contamination of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility's staff and practitioner failed to assess one (1) out of 1 sampled resident (Resident 115's) mental and physical abilities to determine whether self-administering medications are clinically appropriate for the Resident prior to leaving medications at Resident 115's bedside.This deficient practice paused the risk of improper use/ingestion, and accidents with the potential for adverse reactions, unnecessary hospitalization and possible poor outcomes for Resident 115 and for residents with wandering behavior. Findings: A review of Resident 115's admission Record indicated the resident was admitted to the facility on [DATE], with diagnoses that included peritoneal abscess (a pocket of pus and infected fluid in your belly), Abdominal actinomycosis (bacterial infection caused by Actinomyces species), Pneumonia due to Klebsiella Pneumoniae (bacterial infection caused by Gram-negative, encapsulated Klebsiella pneumoniae bacteria), Surgical aftercare…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 prevent employing a staff member who had been found guilty of abuse or mistreatment by a court of law when one of 10 contracted therapy staff (Physical Therapy Assistant [PTA] 1) continued to work at the facility after PTA 1 was cited by the Physical Therapy (PT, a rehabilitation profession that restores, maintains, and promotes optimal physical function) Board of California (PTBC) on 2/5/2025 for a conviction of a misdemeanor (criminal offense) violation of inflict corporal injury (willful, direct application of physical force) and failure to notify the PTBC. This deficient practice had the potential for PTA 1 to abuse or mistreat any resident residing at the facility. Findings: During a review of the facility's Therapy Department Rehabilitation Staff Schedule, the Rehab Staff Schedule indicated PTA 1 was a current full time therapy staff at the facility. During a review of PTA 1's PTBC PTA license, PTA 1's PTBC license indicated a citation was issued on 2/5/2025. During a review of the PTBC citation issued…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 resident or their representative were notified timely in writing of resident transfer and bed hold provision according to the facility's policy & procedures (P&P) titled Bed-Holds and Returns with review date 1/20/2026 for one of five sampled residents (Resident 110). This deficient practice resulted in Resident 110 and/or their representative not being aware of the facility's bed hold policy upon transfer to the hospital from the facility. Findings: A review of Resident 110's admission Record indicated the facility admitted Resident 110 on 12/23/2025 with diagnoses including peripheral vascular disease (PVD - a slow, progressive circulation disorder where blood vessels outside the heart and brain-usually in the legs-become narrow, blocked, or spasm), hypertension (HTN-high blood pressure), and hyperlipidemia (HLD -too much fats in the bloodstream). A review of Resident 110's Bed hold informed consent indicated Resident 110 was admitted…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 s speech and language pathology (SLP, profession that identifies, assesses, and treats speech, language, cognitive communication and swallowing disorders) services to improve communication for one of 25 sampled residents (Resident 92) who had difficulty with speech and communication. This deficient practice had the potential to prevent Resident 92 from communicating effectively with other residents, staff, healthcare providers, and the community. Findings: During a review of Resident 92's admission Record (AR), the AR indicated Resident 92 was initially admitted [DATE] and readmitted [DATE] with diagnoses including, but not limited to hemiplegia (weakness to one side of the body) and hemiparesis (inability to move one side of the body) following cerebral infarction (blockage of the flow of blood brain, causing or resulting in brain tissue death) affecting right dominant side and dysarthria (difficulty speaking) and anarthria (loss…

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

Based on observation, interview and record review the facility failed to ensure the environment remained free of accident hazards for one of seven sampled residents (Resident 38) by failing to provide Resident 38 with a wheelchair with two hand brakes. This deficient practice has the potential to result in Resident 38 falling or sustaining an injury. Findings: A review of Resident 38's admission Record indicated the facility admitted the resident on 3/2/2026 with diagnoses that included muscle wasting (weakening, shrinking, and loss of muscle) and atrophy (decrease in size and thinning of muscle tissue), osteoarthritis (aka arthritis, when the cushion between the bones wear down causing bones to rub together) and asthma (condition that causes your airways to swell, narrow and fill with mucus). A review of Resident 38's admission Fall Evaluation, dated 3/2/2026, indicated the resident was not able to perform the gait/balance and was not able to walk straightforward nor was able walk through a doorway and turn. A review of Resident 38's Fall Risk Care Plan, initiated 3/4/2026,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to effectively manage a resident's pain by not making a pain consultation appointment as ordered by the physician for one of one residents (Resident 16) sampled residents for pain management. This deficient practiced had the potential to negatively affect the residents' physical comfort and psychosocial well-being and had the potential to increase the resident's pain level. Findings: A review of Resident 16's admission information indicated Resident 16 was admitted to the facility on [DATE] with diagnoses that included low back pain, paraplegia (loss of movement and/or sensation, to some degree, of the legs) and stage 4 pressure ulcers (Full-thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage, or bone) of the left and right buttock. A review of Resident 16's Risk for Pain Care Plan (CP), initiated on 7/23/2025, indicated the goal was for the resident's pain to be minimized. The CP interventions included to medicate the resident…

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

Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 13), who had diagnosis of paranoid schizophrenia (type of schizophrenia associated with feelings of being persecuted or plotted against) was provided with the necessary behavioral health care as indicated in the plan of care and per physician order when the facility failed to monitor and document the targeted behaviors of Resident 13's psychotropic medications (drug that affects behavior, mood, thoughts, or perception). This deficient practice had the potential for Resident 13 to not receive the correct medication dosage or psychiatric care.Findings: A review of Resident 13's admission Record (Face Sheet) indicated the facility admitted the resident on 6/16/2025, with diagnoses including paranoid schizophrenia, schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior) and depression. disorder. A review of Resident 13's Psychotropic Medications Care Plan developed on 6/17/2025, indicated the resident was taking psychotropic…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 and consultant pharmacist (a professional responsible for reviewing each resident's medication profile monthly to identify and report changes) failed to identify irregularities during medication regimen review/ drug regimen review (MRR or DRR a comprehensive evaluation of a patient's current medication list to identify potential drug interactions, adverse effects, and other medication-related issues) related to administration of Keppra (generic name - levetiracetam, a medication used to treat or prevent seizures (a sudden, temporary surge of uncontrolled electrical activity in the brain that causes temporary changes in behavior, movement, feelings, or consciousness) when one of three residents (Resident 81) reviewed during medication pass observation, refused antiseizure medication, Keppra, 126 times between 12/2025 through 3/19/2026. This failure to identify and report irregularities resulted in Resident 81 failing to receive Keppra as ordered, inconsistent…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 follow doctor's orders to administer pain medication for severe pain at or above a pain score of eight out of ten (8/10- a numerical pain assessment tool where zero [0] is no pain and 10 is severe pain)for severe pain, per doctor's orders. This deficient practice did not provide treatment and care in accordance with professional standards of practice and physician's order for Resident 48. Findings: A review of Resident 48's admission Record indicated Resident 48 was admitted to the facility on [DATE], with medical diagnoses that included: Anemia (A condition where the blood lacks enough healthy red blood cells), hyperlipidemia (A common condition where there are too many fat particles in the bloodstream), and hypotension (a medical condition when the blood pressure is low). A review of Resident 48's Minimum Data Set (MDS - a resident assessment tool), dated 1/23/2026 indicates Resident 48's cognition (the mental ability to make decisions…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 proper storage, labeling, and/or disposal of medications by failing to ensure: 1. An open box of Assure Prism Blood Glucose (BG; amount of sugar in the blood) Control Solution (used to check blood glucose monitors) included an open date (the date the medication was first opened) to prevent the potential use of blood glucose control solution after expiration for residents with diabetes (a condition where the body has trouble controlling blood sugar) receiving diabetic treatment from Medication Cart 4 (MedCart) 4, in accordance with the manufacturer's specification for Assure Prism Blood Glucose Monitoring System, dated 12/2025. 2. Resident 12, who was no longer in the facility's medications were removed from MedCart 2 and not stored with active residents' medications. These deficient practices increased the risk of using expired or ineffective BG Control Solution, which could result in inaccurate BG readings, harm to diabetic…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to ensure a bed grab bar (a medical device designed to assist with mobility, allowing users to reposition, turn, and safely transfer in and out of bed) was maintained and in good working order for one out of one sampled Resident (Resident 76). This deficient practice had the potential to create severe safety risks, such as entrapment, asphyxiation and falls with injury. Findings: A review of Resident 76's admission Record indicated the resident was admitted to the facility on [DATE], with diagnoses that included dementia (progressive decline in cognitive function including memory, thinking, behavior, and language that is severe enough to interferes with activities of daily life), type 2 diabetes mellitus (high blood sugar (hyperglycemia)), Benign prostatic hyperplasia (noncancerous enlargement of the prostate gland), cognitive impairment (problems with thinking, memory, concentration, and decision-making that interfere with daily life) A review of Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of four sampled residents' (Resident 2) was free from abuse (the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish) and neglect (the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress) by failing to ensure staff checked on Resident 2 every 2 hours to assist the resident with toileting as needed and to provide care on 1/9/2026 on the 11PM to 7AM shift on 1/9/2026 on the 11 PM to 7 AM shift. This failure resulted in Resident 2 not receiving ADL care including incontinent care for 7 hours and 30 minutes from 1/9/2026 at 11 PM to 1/10/2026 at 5 AM when licensed vocational nurse (LVN) 2 found Resident 2 on the floor, sitting in feces (stool) placing Resident 2 at increased risk to suffer mental anguish or emotional distress.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that the Low Air Loss mattress (LAL- a bed that alternates pressure to help heal and prevent pressure injuries) was set at the correct pressure for one of four sampled residents (Resident 1) according to the manufacturer's guide titled Dynarex LAL mattress manual. Resident 1's weight was 106 pounds (lbs-unit of weight measurement) and the LAL mattress was set for someone who weighed 350 lbs on 2/3/2026. This failure placed Resident 1 at increased risk for skin breakdown and compromised dignity. Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnosis of complete paraplegia (a total loss of voluntary movement and sensation in the lower half of the body, legs, feet, toes, due to severe spinal cord damage, completely blocking nerve signals from the brain below the injury level, often affecting bladder and bowel control too, with arm…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 four sampled residents' (Resident 2) did not suffer an unwitnessed fall on 1/9/2026 on the 11 PM to 7 AM shift as evidenced by failing to: Ensure that staff checked on Resident 2 every 2 hours to assist the resident with toileting as needed and to provide care on 1/9/2026 on the 11Pm to 7AM shift as stated in Resident 2's Care Plan (CP-a personalized document that outlines a resident's needs, goals, and the specific services required to achieve them, ensuring consistent and holistic care) titled Resident is at Risk for falls . initiated on 3/6/2025. 2Place floor mats on the floor for safety on 2/3/2026 as ordered by physician. This failure resulted in Resident 2 being found in her room on the floor (unknown length of time) sitting in feces on 1/10/2026 at approximately 5 AM. Resident 2 remained on the floor on 1/10/2026 until 7 AM when the oncoming shift staff lifted Resident 2 off the floor. This failure resulted in.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to provide incontinent (lack of control over urination or defecation) care and appropriate pressure injury (an injury that breaks down the skin and underlying tissue when an area of skin is placed under pressure) prevention interventions for one of four residents (Resident 1) as evidenced by Resident 1 wearing the same incontinent (the involuntary loss of bladder control (urine) or bowel control (feces/stool) brief (designed for managing moderate to heavy bladder or bowel incontinence) that Certified Nursing Assistant (CNA) 1 applied on the resident on 1/6/2026 at 5:30 AM through 1/10/2026 at 1AM (approximately three days). CNA1 wrote his initials, time, and date when he applied the incontinent brief on Resident 1. This failure placed Resident 1 at risk for skin breakdown and compromised dignity. Findings; During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to immediately provide necessary and appropriate behavioral health care and services to one of three sampled residents (Resident 1) who was experiencing mental health crisis on 11/4/2025 during the 3pm to 11pm shift. As a result on 11/4/2025, Resident 1 broke a window with the metal object. Resident 1 stood on top of a nightstand in her room l on the floor. Resident 1 suffered swelling and severe pain to the right leg. On 11/4/2025 at . Resident 1 was transferred to a general acute care hospital (GACH) 1 for further evaluation and management. Resident 3 was afraid to sleep and be in the same room with Resident 1. Findings: A review of Resident 1's admission record indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE] with a diagnoses that included major depressive disorder (a serious mental health condition where a person experiences a persistent and intense feeling of sadness or a loss of interest in activities,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide a safe and comfortable environment for one of three sampled residents (Resident 2), by failing to ensure:1. Resident 2 was not admitted and remained in a cold room with a broken window on 11/4/2025 2. Repaired broken window in a timely manner.3. Checked and logged the resident's room temperature to ensure the room temperature was comfortable and not cold.4. Provide Resident 2 with extra blankets to keep the resident warm.5. Move resident 2 to another room with no broken window. These failures:1. Resulted in Resident 2 stating he was very angry and suffered/endured the from extreme cold temperature for two days and nights placing Resident 1 at increased risk to suffer hypothermia (a condition that occurs when core body temperature drops below 95 degrees Fahrenheit). Resident 2 was at risk suffer injury(ies) from the broken glass.2. Had the potential for insects/rodents to enter Resident 2's room through the broken window.Findings:…

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

Based on observation, interview, and record review, the facility failed to maintain window screens in good repair for one of six sampled resident rooms (Room A). During observation on 9/16/25, the window in Room A was observed open and the window screen had a big hole in the lower corner. This deficient practice had the potential for insects to enter through the hole in the window screen and potentially cause diseases to residents, staff and visitors. During observation inside Room A and concurrent interview on 9/16/25 at 11:23 a.m., the certified nursing assistant (CNA 1) stated the window in Room A was slightly open. CNA 1 stated the window was open for ventilation. CNA 1 further added the window screen had a hole and .insects such as flies and mosquitoes can get inside the room and go to the residents. During an interview on 9/16/25 at 1:21 p.m., the infection preventionist (IP) stated when there's a hole in the window screen there is the potential for flies and mosquitoes to enter the residents room. During a review of the facility Policy titled Quality of Life- Homelike…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to keep the call light (the primary method of patient-nurse communication in a hospital setting, often used as a measure of nurse responsiveness) within reach for one of three random selected residents (Resident 3). This deficient practice had the potential to result in staff delay in meeting resident's needs for hydration, toileting, and activities of daily living as well as a delay in provision of assistance which may lead to falls and accidents.During a review of Resident 3's Record of Admission (undated), indicated, Resident 3 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including asthma (a chronic lung condition that causes the airways to become inflamed and narrow, making it difficult to breathe), osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage), and hyperlipidemia (a medical condition characterized by abnormally high levels of fats (lipids) in the bloodstream).…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to promote dignity and respect for one of three sampled residents (Resident 3) by failing to: 1. Provide clean clothings and linen. 2. Provide an incontinence (Inability to control the flow of urine from the bladder [urinary incontinence] or the escape of stool from the rectum [fecal incontinence] diaper. This deficient practice placed Resident 3 to feel uncared for and embarrassed. Findings: During a review of Resident 3 ' s admission record indicated the facility was initially admitted to the facility on [DATE] and readmitted on [DATE], with diagnosis that included End Stage Renal Disease (ESRD- the final, permanent stage of chronic kidney disease, where kidney function has declined to the point that the kidneys can no longer function on their own), dependence on renal dialysis (HD- a procedure that cleans your blood when your kidneys can't do it properly), and chronic obstructive pulmonary disease (COPD- a progressive lung disease that causes long-term…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 safe and orderly discharge from the facility to Residential Care Facility for the Elderly (RCFE) for one of three sampled residents (Resident 1) by failing to: 1. to have resident's physician document the reason for discharge in the medical record. 2. have documentation of communication with the receiving facility about Resident 1's discharge and follow up call to the facility on how the resident was adjusting to the new facility. These failures had the potential to result in ineffective discharge planning, with disruption in continuity of care, and complications in the resident's recovery. Cross reference with F712. Findings: During a review of Resident 1's admission Record , the record indicated the resident was admitted to the facility on [DATE] with diagnoses including; paranoid schizophrenia, anemia, diabetes mellitus (DM-, major depressive disorder and hypertensive (high blood pressure) heart disease. The same record further 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 provide one of six sampled residents (Resident 1) the Notice of Transfer Discharge form 30 days before non-emergency discharge. This failure resulted in the resident not being able to appeal his discharge thus infringing on his rights to do so. Cross reference with F622 Findings: During a review of Resident 1's admission Record , the record indicated the resident was admitted to the facility on [DATE] with diagnoses including; paranoid schizophrenia, anemia, diabetes mellitus (DM-, major depressive disorder and hypertensive (high blood pressure) heart disease. The same record further indicated Resident 1 was self- responsible. During a review of the Minimum Data Set (MDS - a resident assessment tool) dated 8/19/24 indicated Resident 1's cognitive (relating to mental action or process of acquiring knowledge and understanding) skills for daily decisions were severely impaired and had medically complex conditions. The MDS further indicated Resident 1…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 safe and orderly discharge for one of six sampled residents (Resident 1). This failure resulted in the resident not being involved in selecting the facility he would be discharged to. Cross reference with F622 Findings: During a review of Resident 1's admission Record , the record indicated the resident was admitted to the facility on [DATE] with diagnoses including; paranoid schizophrenia, anemia, diabetes mellitus (DM-, major depressive disorder and hypertensive (high blood pressure) heart disease. The same record further indicated Resident 1 was self- responsible. During a review of the Minimum Data Set (MDS - a resident assessment tool) dated 8/19/24 indicated Resident 1's cognitive (relating to mental action or process of acquiring knowledge and understanding) skills for daily decisions were severely impaired and had medically complex conditions. The MDS further indicated Resident 1 required set up or clean-up assistance to supervision or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to develop a care plan for history of memory problems for one of six sampled residents (Resident 1). This failure resulted in no plan of care for Resident 1's memory problems during his time at the facility. Findings: During a review of Resident 1's admission Record , the record indicated the resident was admitted to the facility on [DATE] with diagnoses including; paranoid schizophrenia, anemia, diabetes mellitus (DM-, major depressive disorder and hypertensive (high blood pressure) heart disease. The same record further indicated Resident 1 was self- responsible. During a review of the Minimum Data Set (MDS - a resident assessment tool) dated 8/19/24 indicated Resident 1's cognitive (relating to mental action or process of acquiring knowledge and understanding) skills for daily decisions were severely impaired and had medically complex conditions. The MDS further indicated Resident 1 required set up or clean-up assistance to supervision or touching…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the attending physicians came in to visit the resident as outlined in the regulation for one of five sampled residents (Resident 1). This failure had the potential to effect the residents plan of care and delivery of services. Cross reference with F622 Findings: During a review of Resident 1's admission Record , the record indicated the resident was admitted to the facility on [DATE] with diagnoses including; paranoid schizophrenia, anemia, diabetes mellitus (DM-, major depressive disorder and hypertensive (high blood pressure) heart disease. The same record further indicated Resident 1 was self- responsible. During a review of the Minimum Data Set (MDS - a resident assessment tool) dated 8/19/24 indicated Resident 1's cognitive (relating to mental action or process of acquiring knowledge and understanding) skills for daily decisions were severely impaired and had medically complex conditions. The MDS further indicated Resident 1 required set up…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 honor one of the four sampled residents (Resident 3) rights to be seen by a physician by failing to arrange reliable transportation for Resident 3. This deficient practice resulted in Resident 3 missing his appointment on 3/4/2025. Findings: During a review of the admission record for Resident 3 indicated Resident 3 was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses including depression (a common mental health condition characterized by a persistent low mood, loss of interest or pleasure in activities, and other symptoms that can significantly impact daily life), alcohol abuse (drinking in a manner, situation, amount, or frequency that could cause harm), and insomnia (trouble falling asleep or staying asleep) . During a review of a history and physical (a term used to describe a physician's examination of a patient. In an H&P, the physician obtains a thorough medical history from the patient, performs a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that one of the four sampled residents (Resident 4) who was cognitively impaired was provided at least 80 square feet (sq. ft. -unit of measurement for space) per resident in multiple resident bedrooms. This deficient practice had the potential to negatively impact Resident 4 ' s well-being by reducing privacy and dignity. Findings: 1. During a review of the admission record for Resident 4 indicated Resident 4 was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses including Parkinson ' s disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), dementia (a progressive state of decline in mental abilities), and diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 4's History and Physical (H&P, a term used to describe a physician's examination of a patient, the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation and record review, the facility failed to maintain a safe, functional and comfortable environment for residents, staff and public by failing to ensure the ceiling was free from water leaks for two of five sampled residents (Resident 2 and Resident 3). This failure had the potential to place Resident 2 and 3 at risk for falls or injury from fracture (break in bone). Findings: I. A review of the admission Record indicated Resident 2 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis including paroxysmal atrial fibrillation (afib- an irregular and very rapid heart rhythm that and can lead blood clots in the heart), hypertensive heart disease without heart failure (the heart is being affected by high blood pressure [hypertension] over a long period of time, causing changes to the heart muscle, but it's not yet weak enough to be considered heart failure where the heart can't pump blood effectively) and hyperlipidemia (abnormally high levels of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation and record review, the facility failed to maintain a safe, functional and comfortable environment for residents, staff and public by failing to: i. Ensure the ceiling was free from water leaks for two of five sampled residents, Resident 2 and Resident 3. ii. Ensure the one of the 13 thermostats in the facility were free from mechanical and electrical failure and were in safe operating condition These deficient practices have a potential to cause incidental accidents and had the potential for the resident ' s physical discomfort. Cross Reference F689. Findings: 1a. A review of the admission Record indicated Resident 2 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis including paroxysmal atrial fibrillation (afib- an irregular and very rapid heart rhythm that and can lead blood clots in the heart), hypertensive heart disease without heart failure (the heart is being affected by high blood pressure [hypertension] over a long period of time,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 that the elevator was in safe working condition. This failure had the potential to cause harm to the residents, staff, and visitors. Findings: During an observation on 1/4/2025, at 12:25 p.m., the Monitor Aide (MA) was observed seated by the facility elevator back exit and Garage exit on the 1st floor. The MA stated he was monitoring the exits for possible elopement. The MA further stated the elevator would sometimes stop functioning. The MA stated when the elevator stops functioning, he notifies the receptionist to come monitor the exits for potential elopements while he (MA) would go inside the parking garage to reset the breaker for the elevator to function again. The MA stated this happens at least 3-4 times during his 7am-3pm work shift. The MA stated the Maintenance Supervisor, Administrator, and all of the Nursing Supervisors are aware of the elevator not functioning properly. During an interview on 1/4/2025 at 5:19 p.m., the Certified Nursing Assistant (CNA) 1, stated they had previously been…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 three of 25 residents (Resident 48, Resident 97, and Resident 105) had the Advance Directives (written statement of a person's wishes regarding medical treatment made to ensure those wishes are carried out should the person be unable to communicate them to a doctor) or Advanced Directives Acknowledgement forms (a signed acknowledgment indicating the resident and/or resident representative were provided with information regarding creating an Advanced Directive) documented in the residents' active medical record. This deficient practice violated the residents' and/or the representatives' right to be fully informed of the option to formulate their advance directives and had the potential to cause conflict with the residents' wishes regarding health care. And had the potential for Resident 48, Resident 97, and Resident 105 to be denied the right to request or refuse medical care and treatment. Findings: a. A review of Resident 97's admission Record…

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

Based on observation and interview, the facility failed to ensure the facility staff stored and discard controlled (s (medications that the use and possession of are controlled by the federal government), and non-controlled medications properly as indicated in the facility's policy and procedures (P&P) titled Controlled Medication Disposal. This failure had the potential to result in lack of accountability for these medications, and presented a potential for the diversion of the controlled substances Findings: During a concurrent observation and interview on 01/04/25 at 8:07 a.m., of the facility's medication storage room with Registered Nurse Supervisor (RNS) 1, RNS 1 stated expired medications are being destroyed by two-night shift License Nurses. RNS 1 further stated the disposal of narcotics are to be destroyed by the Director of Nursing (DON) and stored in the DON's office. During a concurrent observation and interview on 01/04/25 at 8:37 a.m., with the DON, it was noted that the storage container for the narcotics was not a locked permanently or locked affixed compartment. It…

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

Based on observations, interviews, and record reviews, the facility failed to ensure safe and sanitary food storage and preparation practices when: 1. [NAME] 1's cell phone and speaker were placed on the preparation sink (prep sink: area where food is prepared). 2. Opened bags of hashbrowns in the kitchen's chest freezer were not labeled with an open date. 3. Dietary Aide (DA1) loaded dirty pots and pans into the dish machine and then removed cleaned and sanitized dishes to air dry without washing hands between the two actions. These deficiencies had the potential to result in harmful bacteria growth and cross contamination (transfer of harmful bacteria from one place to another) that could place the residents at risk for food borne illness or contamination. Findings: During an observation in the prep sink area of the kitchen and interview on1/2/2025 at 5:04 PM, a cell phone and personal speaker were observed on the prep sink. [NAME] 1 stated the items belonged to [NAME] 1 and [NAME] 1removed the items from the area. [NAME] 1 stated personal items should not be in the kitchen area…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 industrial washing machine used to wash facility linen for residents was in operating condition to provide clean linen daily and as needed for all facility residents. This deficient practice had the potential to result in a significant delay in providing clean and sanitary linen for all 111 medically compromised residents. Cross reference: F584 Findings: During an observation of the laundry service area on 1/4/2025 at 4:03 pm, the laundry room was clean, no water on the floor, or rust on the pipes, machine lint traps clean, folding area full of unfolded clothes, one laundry service worker on duty, LSW 1. Laundry room had two industrial size washing machines, with one industrial washing machine was not working. During an interview on 1/4/2025 at 4:13 pm with Assistant Maintenance Supervisor (AMS) and Assistant Laundry Supervisor (ALS), the ALS stated he was temporarily in charge of the laundry service as acting laundry services supervisor. AMS stated that the washing machine had been out of service…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to obtain informed consent (a process during which residents or caregivers are educated regarding the potential risks and benefits of medication therapy) from the resident or their responsible party (a person delegated to make medical decisions for the resident in the event they are unable to do so) prior to treatment for 2 out of 30 sampled Resident's (Resident 50 and Resident 84). The deficient practice of failing to obtain informed consent prior to initiating treatment with psychotropic medications (medications that affect brain activities associated with mental processes and behavior) could have prevented Resident 50 and 84 from exercising his right to decline to take psychotropic medications. Findings: 1. A review of Resident 50s admission indicates Resident 50 was originally admitted to the facility on [DATE] and re-admitted to the facility on [DATE], with diagnoses that included schizophrenia (a mental disorder characterized by disruptions in…

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

Based on observation, and interview, the facility failed to ensure a comfortable, homelike environment for one out of five residents (Resident 3). This failure resulted in Resident 3 feeling uncomfortably cold while resting in her bed without bed covering such as, a top sheet and blankets, in addition resident had no pillowcase for her pillow. Cross Reference: F908 Findings: A review of Resident 3's admission record indicated the facility initially admitted Resident 3 on 8/8/2024 with diagnoses that included hypertension (high blood pressure), diabetes mellitus (a disease characterized by elevated levels of blood sugar), chronic obstructive pulmonary disease (COPD) (a lung disease that damages the lungs and makes breathing difficult). A review of Resident 3's minimum data set (MDS- a standardized assessment and care screening tool) dated 11/13/2024, indicated Resident 3 was cognitively intact (able to make decisions concerning care, alert to situation and oriented to place and time). The MDS indicated the resident required supervision and touching assistance (helper provides verbal…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide activities of daily living (ADL-such as bathing, showering, toileting, and mobility) for one of seven sampled residents (Residents 96). This failure resulted in Resident 96 feeling angry and had the potential to develop skin infections, skin irritation, and foul odor. Findings: A review of Resident 96's admission Record indicated Resident 96 was re-admitted to the facility on [DATE] with diagnoses including cerebral palsy (a condition that affects a person's ability to move, balance and maintain posture), and muscle wasting (the loss of muscle mass that occurs when muscles weaken and shrink). A review of resident 96's Minimum Data Set (MDS- a resident assessment tool) dated 11/27/24, indicated Resident 96's (cognitive skills- the core skills your brain uses to think, read, learn, remember, reason, and pay attention) for daily decision making was intact. The same MDS further indicated Resident 96 needed extensive assistance with Activities of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to prevent skin surrounding the ostomy free of excoriation (abrasion, breakdown) to the colostomy ( (a surgical procedure that brings one end of the large intestine out through the abdominal wall to allow waste to leave the body) site for one of seven sampled residents (Resident 114). This failure resulted in Resident 114's colostomy site and surrounding site to become excoriated and at risk for infection. Findings: A review of Resident 114's admission Record indicate Resident 114 was admitted to the facility on [DATE] with diagnoses including colostomy malfunction (can occur when there are problems with the stoma, which is the opening in the abdominal wall created during a colostomy procedure) and gastro-esophageal reflux disease (a common condition in which the stomach contents move up into the esophagus). A review of Resident 114's History and Physical dated 11/01/24, indicated resident 114 has to capacity to make medical decisions. 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 interviews and record reviews the facility failed to complete a post-hemodialysis (dialysis is the removing of waste, salt, and extra water to prevent build up in the body for residents who have loss of kidney function) assessment for one of 18 sampled residents (Resident 47). This deficient practice placed the resident at risk for a delay in detecting if the resident had a non-functioning arteriovenous shunt (AV- a connection or passageway between an artery and a vein used for hemodialysis) and a delay in detecting complications including infections and bleeding. Findings: A review of Resident 88's admission record indicated the facility originally admitted the resident on 10/14/2022 and re-admitted the resident on 6/7/2024 with diagnoses that included end stage renal disease (ESRD - loss of kidney function in which the kidneys no long work to meet the body's needs) and dependence on renal dialysis (the process of removing waste products and excess fluid from the body using a machine when the kidneys are not able to do so) and diabetes (high blood sugar). A review of the…

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

Based on interview and record review, the facility failed to ensure the social service designee follow up with the sending facility (F2) the resident's personal belonging for one out of 30 sampled Residents (Resident 48) This deficient practice had the potential for personal property misplaced and or lost. Findings: A review of Resident 48's admission Record, indicated F1 originally admitted Resident 48 on 4/25/2024, with diagnoses that included, hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side (weakness or paralysis on the left side of their body due to a stroke that damaged the right side of their brain), muscle wasting and atrophy (the loss or thinning of muscle tissue), hyperlipidemia (a medical condition characterized by abnormally high levels of lipids (fats) in the blood), hypertension (High blood pressure), and morbid obesity (A serious health condition that results from an abnormally high body mass that is diagnosed by having a body mass index (BMI) greater than 40). A review of Resident 48's history and physical (H&P) dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility staff failed to observe infection control measures by: 1. Storing a clean bedside table, clean linen and a wheelchair in the bathroom for one out of nine bathrooms (room [ROOM NUMBER]'s bathroom). 2. Failing to doff used gloves after applying topical medication to a resident in room and then went out in the hallway for one out of five Licensed Vocational Nurse (LVN 5). These deficient practices had the potential to cause cross contamination and spread infections to the facility. Findings: During a facility tour on 1/2/25 7:22 PM a bedside table was observed to have clean linen inside the bathroom of Resident room [ROOM NUMBER]. During concurrent interview, Certified Nursing Assistant (CNA2) stated she did not know who placed the bedside table, clean linen, and a wheelchair inside room [ROOM NUMBER]'s bathroom. CNA2 further stated the items are not supposed to be in the bathroom, because of infection control. During a facility tour on 1/3/2025 6:35…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 seven sampled residents (Resident 68) did not have a broken trim on the wall near his bed, missing knobs to his closet door, and a exposed wire that ran from his television to the window in room [ROOM NUMBER]. This failure had the potential to put Resident 68 at risk for injury. Findings: A review of Resident 68's admission Record, indicated Resident 68 was admitted to the facility on [DATE] with diagnoses that included but not limited to cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it) and hyperlipidemia (excess of lipids or fat in your blood). During an observation and interview on 01/03/25 at 7:11 p.m., Resident 68 was observed lying in bed watching television (TV). Resident 68 stated the broken trim on the wall near his bed was like that when he was admitted to room [ROOM NUMBER]. Resident 68 further stated the walls and the missing knobs,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 staff receive required abuse training for one of five employees (Sitter 1 [STR 1]), who did not receive abuse training upon hire on 6/18/24. This failure has the potential to delay identification or protection of residents from possible abuse, neglect, and exploitation. Findings: A review of STR 1's employee file indicated STR 1 was hired on 6/18/2024. A review of STR 1's in-service trainings indicated STR 1 did not receive training on abuse upon hire. During an interview on 1/4/2025 at 1:16 PM, STR 1 stated he has been employed by the facility since June 2024. STR 1 stated received abuse training in December 2024 after a resident made an allegation of abuse. During a concurrent interview and record review on 1/4/2025 at 5:56 PM, STR 1's employee file was reviewed with the facility's staffer (STFR - person that prepares the work schedule for the facility's employees). The STFR stated there was no evidence STR 1 received abuse training upon his hire on 6/18/2024. STFR stated STR 1 was in-serviced on abuse on December…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of five sample residents (Resident 2) was free from medication errors. By failing to ensure Resident 2 received the prescribed clonidine oral tablet 0.1 milligram (mg -metric unit of measure) give 1 tablet by mouth every six hours as need for hypertension for SBP more than 160 or diastolic blood pressure (DBP - blood pressure during the phase between heartbeats) more than 100 as ordered on 12/6/24, 12/7/24, and 12/15/24. This failure resulted in Resident 2 not receiving the prescribed medication as needed for systolic blood pressure (SBP - blood pressure in your arteries when your heart beats and pumps blood out) over 160. Placing Resident 2 at risk for uncontrolled blood pressure and stroke. Findings: A review of Resident 2 ' s admission Record dated 12/19/24, indicated Resident 2 was admitted to the facility on [DATE], with diagnoses including muscle wasting, hypertensive (high blood pressure) heart disease, chest pain, hyperlipidemia…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 protection from abuse by a facility staff, for one of the three sampled residents (Resident 1). By failing to ensure CNA3 did not slap Resident 1 on 12/5/2024. This deficient placed all facility residents at risk for further abuse. Findings: A review of Resident 1's face sheet (admission record - a document containing demographic and diagnostic information) indicated Resident 1 was admitted to the facility on [DATE] and was re-admitted on [DATE] with the following medical diagnoses: acute kidney failure (when kidneys suddenly cannot remove waste from the blood), hyperkalemia (a condition where the potassium level in the blood is too high), type 2 diabetes mellitus (DM - a disorder characterized by difficulty in blood sugar control and poor wound healing), benign prostatic hyperplasia with lower urinary tract symptoms (difficulty starting to urinate), paraplegia (paralysis of the legs and lower body), major depressive disorder (a…

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

Based on interview and record review the facility failed to have a Director of Nursing (DON) employed at the facility consistently over the past two months. This failure had the potential to affect resident care, clinical outcomes, and assessment. Findings: A review of the facility's Director of Nursing Services job description (undated) indicated, The primary purpose of your job position is to plan, organize, develop and direct the overall operation of our Nursing Service Department in accordance with current federal, state, and local standards, guidelines and regulations that govern our facility, and as may be directed by the Administrator and the Medical Director to ensure the highest degree of quality of care is maintained at all times. During an interview with Medical Records Director (MRD) on 11/14/24 at 1:54 pm, the MRD stated there has been no DON consistently employed at the facility the last DON lasted about three weeks and then quit, then they hired this new one and he was here only an week and quit. The facility does not have a system in place for the DON ' s job to be…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain a , well-kept environment for two of three sample residents (Resident 3 and 4), by failing to maintain a comfortable, warm room overnight, and a neutral odor environment. This deficient practice resulted in Residents 3 and 4 feeling cold at during the night and the unit having offensive odors. Findings: 1. During a review of the admission record indicated Resident 3 was admitted to the facility on [DATE] with diagnoses that included atrial fibrillation (a type of heart arrhythmia that causes the upper chambers of the heart to beat irregularly and often very fast), myocardial infarction (heart attack a medical emergency where your heart muscle begins to die because it isn't getting enough blood flow), and hyperlipidemia (an abnormally high concentration of fats or lipids in the blood). During a review of Resident 3's Minimum Data Set (MDS - a resident assessment tool) dated 10/9/2024, the MDS indicated Resident 3 was cognitively…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 3) who is continent (the inability to control the flow of urine or stool) of bladder (is a hollow, stretchy organ in the lower part of your abdomen that stores urine before it leaves your body through your urethra) and bowel (a long, tube-shaped organ in the abdomen that is part of the digestive system and is responsible for digesting food and expelling waste) received services and assistance to maintain continence. This failure had the potential to result in skin problems such as pressure ulcers (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence), skin irritation, rashes, redness, and peeling. Findings: During a review of the admission record indicated Resident 3 was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses including cerebral palsy (a group of neurological disorders that affect a person'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 two-person assist with Activities of Daily Living (ADL, routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) care for one of three sampled residents (Resident 1). These deficient practices resulted in Resident 1 falling to the floor during ADL care, was transferred to a general acute care hospital (GACH) sustaining a sprain to her left ankle. Findings: During a review of Resident 1's admission record indicated Resident 1 was re-re-admitted to the facility on [DATE], with a diagnoses including cerebral palsy ( a group of neurological disorders that appear in infancy or early childhood and permanently affects body movement and muscle coordination), muscle wasting ( a weakening, shrinking, and loss of muscle caused by disease or lack of use), and osteoporosis ( a bone disease that develops when bone mineral density and bone mass decreases). During a review of Resident 1's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to serve food consistent with the preferences of one of three sampled residents (Resident 2) who was noted to be allegic (occurs when a person's immune system reacts to substances in the environment that are harmless to most people) to coconut, when staff served Resident 2's food tray was noted with a piece of chocolate cake noted with coconut on it. This failure resulted to Resident 1's getting a piece of chocolate cake noted with coconut on it which was listed as food allergy. Findings: During a review of Resident 2's admission record indicated Resident 2 was re-admitted to the facility on [DATE], with a diagnoses that included and not limited to chronic obstructive pulmonary disease (a common lung disease causing restricted airflow and breathing problems), heart failure (a condition that develops when your heart doesn ' t pump enough blood for your body ' s needs), morbid obesity (if their weight is more than 80 to 100 pounds above their…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 medical record for two of four sampled residents (Resident 1 and 3) was accurate and compete for: 1. Resident 1's Medication Administration Record (MAR), 2. Resident 1 and 3's informed consent (resident's authorization to receive treatments or medications after risks and benefits are discussed by physician, physician's assistant, or nurse practitioner) form. These failures resulted in an inaccurate and incomplete medical record and informed consent forms. for Resident 1 and 3. Findings: 1. A review of Resident 1's Face sheet (summary of residents personal and demographic information, cover sheet of the medical record) dated 6/7/24, indicated Resident 1 was admitted to the facility on [DATE], with diagnoses including cerebral palsy (abnormal brain development before birth with loss of motor function), muscle wasting and atrophy (decrease in size), schizophrenia (mental illness that affects how a person thinks, feels, and behaves), and anxiety…

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

Based on observation, interview and record review, the facility failed to ensure one of five sampled residents (Resident 8 [R8]) was provided care and services to main good grooming, personal hygiene, and clean and organized environment. This deficient practice resulted in R8 being left unattended in bed with a blanket, linen, gown, and trash on the floor. Findings: A review of R8's Facesheet indicated the facility originally admitted R8 on 3/1/2024 with diagnoses including metabolic encephalopathy (a chemical imbalance in the blood affecting the brain), acute psychosis (acute mental health condition when there is a loss of contact with reality) and anxiety disorder (is a mental disorder in which a person is often worried or anxious about many things and finds it hard to control the anxiety). A review of R8's Minimum Data Set (MDS - a comprehensive standardized assessment and care-screening tool) dated 4/25/2024, indicated R8 had some difficulty in new situations and required moderate assistance from staff for activities of daily living (ADLs-toileting hygiene, upper and lower body…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide care, services, and advocacy for eight of 21 sampled residents (Residents 1, 2, 3, 4, 5, 6, 7, and 8 ) as per professional standards of practice, when the resident had a change in condition (COC, a sudden clinically important deviation from a patient's baseline in physical, cognitive, behavioral, or functional domains) by failing to: 1. Failing to check blood sugar levels (FS) before meals and/ checking dinner and bedtime within minutes of each other. 2. Failing to administer insulin (a naturally occurring hormone your pancreas makes that's essential for allowing your body to use sugar (glucose) for energy. If your pancreas doesn't make enough insulin or your body doesn't use insulin properly, it leads to high blood sugar levels (hyperglycemia). A synthetic insulin [insulin is any pharmaceutical preparation of the protein hormone insulin that is used to treat high blood glucose for people whose insulin does not function appropriately]) with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure appropriate competencies to provide nursing and related services to assure resident safety by failing to: 1. Maintain and update basic life support/ Cardiopulmonary Resuscitation (BLS/CPR) certification to one of six sampled facility staff (Minimum Data Set Nurse 1[MDS1]). 2. Ensure two of six sampled facility staff (Licensed Vocational Nurse 2 [LVN2], and Licensed Vocational Nurse 9[LVN9]) had the specific competencies and skill sets necessary to care for the residents in the facility. These deficient practices had the potential to place resident at risk of not getting proper immediate care during a life-threatening situation. Findings: During a concurrent interview and record review with the Director of Staff Development (DSD) on [DATE] at 5:31 p.m., all six sampled staff files were reviewed. Staff files indicated that MDS1 was missing an updated BLS/CPR. Staff files also indicated that LVN2 and LVN9 was missing skills check competencies. DSD…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 meet professional standards of quality of care to ensure documentation were completed after administration of medications to each resident for four of eight sampled residents (Resident 1, 3, 4, 5). This deficient practice had the potential to result in medication error, which could negatively impact residents' health and safety. Findings: A review of Resident 1 (R1)'s admission Record indicated the facility originally admitted the resident on 4/15/2022 and readmitted on [DATE] with diagnoses including epilepsy, unspecified, intractable (not easily managed or relieved), without status epilepticus (refers to a prolonged seizure that manifests primarily as altered mental status as opposed to the dramatic convulsions), Schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly), respiratory failure (condition in which your blood does not get enough oxygen or has too much carbon dioxide) and dysphagia…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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: 1. One of three sampled residents (Resident 8 [R8]) received Risperdal (medication used to treat certain mental illnesses and or/mood disorders such as schizophrenia [a disorder that affects a person's ability to think, feel, and behave clearly]) as prescribed by the attending physician (MD1). 2. MD 1 was made aware R8 was refusing to take Risperdal as ordered and was exhibiting psychosis (a mental disorder characterized by a disconnection from reality) episodes manifested by (m/b) R8 refusing to treatments, sitting on the floor, and refusing to get back into bed while yelling and threatening staff when asked to into bed. These deficient practices had the potential to place R8 at risk for unnecessary psychotropic drugs (medications used to treat mental health disorders) side effect and adverse consequence such as a decline in quality of life and functional capacity. Findings: A review of R8's Facesheet indicated the facility originally admitted R8 on 3/1/2024 with diagnoses including acute psychosis…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 observe infection control measures to ensure the indwelling catheter (or known as Foley catheter, a tube that allows urine to drain from the bladder into a bag that is usually attached to the thigh) drainage bag was not touching the floor for one of one sampled resident (Resident 8). This deficient practice had the potential for cross contamination and placed the residents at risk for infection. Findings: A review of Resident 8's admission Record indicated the facility originally admitted the resident on 4/6/2024 with diagnoses including congestive heart failure (CHF- a progressive condition that affects the pumping power of the heart muscle), type 2 diabetes mellitus (DM-a chronic condition that affects the way the body processes blood sugar [glucose]), muscle wasting and atrophy (characterized by a significant shortening of the muscle fibers and a loss of overall muscle mass) and benign prostatic hyperplasia (BPH - a noncancerous enlargement of the prostate gland, is the most common benign tumor found in…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 observations, interviews and record reviews, the facility failed to notify a physician of changes for one of three Residents (Resident 1). This deficient practice resulted Resident 1 not assessed by psychiatrist (a medical practitioner specializing in the diagnosis and treatment of mental illness) after altercation with Resident 2. Cross Reference F600 Findings: A review of Resident 1's Face Sheet indicated the resident was admitted to the facility on [DATE], with diagnoses that included major depressive disorder (persistently depressed mood or loss of interest in activities, causing significant impairment in daily life) and cognitive communication deficit (when a person does not recognize everyday social cues, both verbal and non-verbal). A review of Resident 1's History and Physical dated 3/12/24, indicated, Resident 1 did not have the capacity to understand and make decisions. A review of Resident 1's Minimum Data Set (MDS; a standardized assessment and care screening tool) dated 2/28/24, 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 observations, interviews and record reviews, the facility failed to protect resident's right from physical and verbal abuse for one of three sampled residents (Resident 1). This deficient practice resulted in Resident 2 slapping Resident 1 on the face. Cross Reference F580 Findings: A review of Resident 1's Face Sheet indicated the resident was admitted to the facility on [DATE], with diagnoses that included major depressive disorder (persistently depressed mood or loss of interest in activities, causing significant impairment in daily life) and cognitive communication deficit (when a person does not recognize everyday social cues, both verbal and non-verbal). A review of Resident 1's History and Physical (H&P) dated 3/12/24, indicated, Resident 1 did not have the capacity to understand and make decisions. A review of Resident 1's Minimum Data Set (MDS; a standardized assessment and care screening tool) dated 2/28/24, indicated, Resident 1 did not have intact cognition (capable of remembering, learning…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 medications were administered as ordered by the physician for one of two sampled residents (Resident 1). For Resident 1, the facility failed to document medications were administered as soon as given and failed to document the reasons why the medications were not administered. These deficient practices resulted in the facility failing to determine if the medications were administered to Resident 1, prevent the potential for medication errors, medication duplication and delay in care and treatment to meet the needs of Resident 1. Findings: During a review of the admission Record indicated the facility admitted Resident 1 on 1/31/24 with diagnoses including schizoaffective disorder (chronic mental illness that causes a person to experience dramatic changes in their thoughts, moods, and behavior), major depression and anxiety disorder. During a review of Resident 1 ' s Care Plan dated 1/31/24 indicated Resident 1 had behavioral patterns related to psychosis (collection of symptoms that affect the mind, where there has…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 belongings were itemized for three of four sampled residents (Resident 1, Resident 2, and Resident 3). For Resident 1, Resident 2, and Resident 3, the facility failed to itemize their belongings upon admission and as new belongings were added during their stay at the facility. This deficient practice had the potential for Resident 1, Resident 2, and Resident 3 to lose their belongings without the facility knowing what belongings were missing. Findings. 1. A review of the admission Record indicated the facility admitted Resident 1 on 2/21/24 with diagnoses including cerebral palsy (a group of disorders that affect a person ' s ability to move and maintain balance and posture) and anxiety disorder. A review of the Minimum Data Set (MDS, standardized care and health screening tool) dated 2/28/24 indicated Resident 1 had moderately impaired cognition (ability to think and reason). Resident 1 was dependent (helper does all the effort) with toileting…

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

Based on interview and record review the facility failed to ensure the primary physician was notified promptly when there was a change of condition for one of four sampled residents (Resident 1). For Resident 1 who had diarrhea on 3/4/24 at 8:46 a.m., the facility failed to notify Resident 1 ' s primary physician (MD) promptly on 3/4/24 and ensure the physician orders for the blood test were carried out timely. The primary physician gave order on 3/5/24 for blood test and the blood test was not done until 3/8/24. These deficient practices had the potential for Resident 1 to have dehydration due to the diarrhea and potentially delay the necessary treatment. Findings: A review of the admission Record indicated the facility admitted Resident 1 on 2/21/24 with diagnoses including cerebral palsy (a group of disorders that affect a person ' s ability to move and maintain balance and posture) and anxiety disorder. A review of the Minimum Data Set (MDS, standardized care and health screening tool) dated 2/28/24 indicated Resident 1 had moderately impaired cognition (ability to think 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's staff failed to revise a care plan for one of two sampled residents (Resident 2). This deficient practice had the potential to place Resident 2 at risk for altercations with other residents by wondering into other resident ' s rooms or coming onto the roommate ' s side of the room. Findings: A review of Resident 1 ' s admission record indicated Resident 1 was admitted to the facility on [DATE], with a diagnoses including hypertensive heart disease (heart problems that occur because of high blood pressure that is present over a long time), and generalized osteoarthritis (a degenerative joint disease, in which the tissues in the joint break down over time). A review of Resident 1's Minimum Data Set (MDS- a comprehensive assessment and screening tool) dated 2/14/2024, indicated the resident was cognitively intact, and required moderate assistance Activities of Daily Living (ADL ' s- activities related to personal care). During an interview with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to provide an odor free and home like environment by failing: 1. Ensure the second-floor unit where residents resided was free from a strong ammonia smell which smelled like urine. This deficient practice had the potential to exacerbate (to make something that is already bad even worse) allergic reactions in residents who have respiratory issues such as asthma (is a condition in which your airways narrow and swell and may produce extra mucus. This can make breathing difficult and trigger coughing, a whistling sound (wheezing) when you breathe out and shortness of breath). 2. Provide a comfortable sound level for one of six sampled resident (Resident 1) per facility ' s policy. This deficient practice placed residents exposed to loud noise in the facility. Findings: A. On 1/19/23 at 11:20 a.m. during a tour of the unit along with another surveyor while wearing surgical masks, a strong ammonia smell like that of urine was noted. The offending odor was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide necessary respiratory care services for one out of one sampled resident (Resident 3) by failing to: 1. Ensure Resident 1 ' s nasal cannula (NC -a connector attached to oxygen) tubing and humidifier (a device used to make supplemental oxygen moist) was changed per facility ' s policy. 2. Ensure there is a current physician ' s order for oxygen supplement therapy for Resident 1. These deficient practices had the potential for the residents to develop respiratory infection. Findings: A review of Resident 1 ' s admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including hemiplegia (paralysis of one side of the body) following cerebral infarction (CVA-also known as a stroke refers to damage to tissues in the brain due to a loss of oxygen to the area), noninfective gastroenteritis and colitis (a disorder characterized by inflammation of the colon-large intestines), muscle wasting and atrophy (it…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record reviews, the facility failed to ensure one of six sampled resident, Resident 1 ' s medication was properly stored and secured per facility policy. This deficient practice increased the risk for accidents and unintended complications from receiving more or less than the required medications dose for Resident 1. Findings: A review of Resident 1 ' s admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including hemiplegia (paralysis of one side of the body) following cerebral infarction (CVA-also known as a stroke refers to damage to tissues in the brain due to a loss of oxygen to the area), noninfective gastroenteritis and colitis (a disorder characterized by inflammation of the colon-large intestines), muscle wasting and atrophy (it is the decrease in size and wasting of muscle tissue) and major depressive disorder (a mental disorder that have a persistent feeling of loss of pleasure or interest in life). A review of Resident 1 ' s…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 the resident ' s(s ' ) right to be free from physical abuse by a Certified Nurse Assistant (CNA) for one of two sampled residents (Resident 1). This deficient practices placed Resident 1 at further risk for abuse. Findings: A record review of Resident 1 ' s admission Record, indicated Resident 1 was admitted on [DATE] with diagnoses including cellulitis of right lower limb (bacterial skin infection), cellulitis of left lower limb, muscle wasting and atrophy (the wasting of muscle mass), acute kidney failure (a condition in which the kidneys suddenly can ' t filter waste from the blood), asthma (inflamed airways), peripheral neuropathy (numbness and weakness from nerve damage), sacral pressure ulcer (bed sore), and osteoporosis (a disease that weakens bones). A review of Resident 1's Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated 12/ 29, 2023, indicated Resident 1 had intact cognition (the mental action or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to report immediately not later than two hours an allegation of abuse to the facility administrator, and to other officials (including to California Department of public Health [CDPH] and adult protective services where state law provides for jurisdiction in long-term care facilities) for one of two sampled residents (Resident 1). This deficient practice placed the residents in the facility at risks of abuse and a delay in a timely investigation. Findings: A record review of Resident 1 ' s admission Record, indicated Resident 1 was admitted on [DATE] with diagnoses including cellulitis of right lower limb (bacterial skin infection), cellulitis of left lower limb, muscle wasting and atrophy (the wasting of muscle mass), acute kidney failure (a condition in which the kidneys suddenly can ' t filter waste from the blood), asthma (inflamed airways), peripheral neuropathy (numbness and weakness from nerve damage), sacral pressure ulcer (bed sore), and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the Notice of Proposed Transfer and Discharge was provided to the resident as soon as practicable. The facility also failed to provide documentation to show that the State Long Term Care Ombudsman (public advocate) was notified of the transfer and discharge from the facility for one out of the three sampled residents (Resident 1). This deficient practice denied the residents additional protections from being inappropriately discharged and caused Resident 1to have increased depression and anxiety which required and increase in Lamotrigine (a medicine used to treat seizures which are bursts of electrical activity in the brain that temporarily affect how it works. It also helps prevent low mood [depression] in adults with bipolar disorder). Cross reference F842 Findings: A review of Resident 1 ' s admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses including displaced fracture (ends of the bone have come…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the accuracy of medical records for one of one sampled residents (Resident 1) by documenting a 30-day notice (notice to vacate/be discharged from the facility required to be provided to residents 30 days in advance) as served on 11/28/2023 instead of the actual date of 12/20/2023 (discharge date [DATE]) for one of the sampled residents (Resident 1). The deficient practice of falsifying the status of treatment records in such a way that the record does not accurately reflect information delivered to the residents had the potential to cause Residents 1 to experience anxiety and depression. Cross Reference: F623 Findings: A review of Resident 1 ' s admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses including displaced fracture (ends of the bone have come out of alignment) of medial malleolus (the small prominent bone on the inner side of the ankle at the end of the tibia) of right tibia (the shinbone, 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 respect the residents ' rights to dignity and respect for 1 out of 3 sampled residents (Resident 3). by failing to provide the resident clothing and by not utilizing privacy curtains or closing the door while resident was undressed. This deficient practice left Resident 3 exposed to facility staff, residents, and visitors leaving the resident vulnerable to exploitation, humiliation, and safety concerns. Findings: A review of Resident 1 ' s admission record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including allergic purpura (a disease that involves purple spots on the skin, joint pain, gastrointestinal problems, and glomerulonephritis [a type of kidney disorder]), generalized osteoarthritis (GOA- a chronic disease that involves changes to the joints. The factors resulting in the breakdown of cartilage in the joint occur more quickly than those that rebuild and repair it. Any joint in the body can be…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure one out of three sampled residents (Resident 3 ' s) medical records had accurately documented assessment and treatment reflective of the resident ' s status during a cardiac arrest (when the heart suddenly and unexpectedly stops pumping). This deficient practice resulted in Resident 1 ' s medical records being inaccurate and missing vital information of treatment and services provided while attempting to revive the resident. Findings: A review of the admission Record indicated the facility admitted Resident 3 on [DATE] with diagnoses including aphasia (difficulty speaking) following cerebral infarction (stroke), Diabetes Mellitus (a chronic, metabolic disease characterized by elevated levels of blood sugar), Alzheimer ' s disease (progressive mental decline due to generalized breakdown of the brain), and hypertension (high blood pressure). A review of the Minimum Data Set (MDS - an assessment and screening tool), dated [DATE], indicated Resident…

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

Based on observation, interview and record review, the facility failed to ensure 113 out of 113 residents were provided a safe, clean, homelike environment by having peeling paint throughout the facility including residents' rooms, hallways, handrails and dinning room. This deficient practice had the potential to negatively affect residents' psychosocial (mental, emotional, social, and spiritual health) well-being and affect the resident's quality of life. Findings: During an initial tour of the facility during an annual recertification survey on 12/12/2023 at 7:45 a.m., it was observed that the hallway halls were stripped of the paint, handrails were stripped of paint, residents' rooms had been stripped of paint and the dinning area walls had been stripped of paint. During an interview with Resident 228 on 12/12/2023 at 8:15 a.m., Resident 228 stated that she was recently admitted to the facility and felt the facility was in a state of disrepair. Stated that she did not like the fact that the walls in her room were not painted. Resident stated that the facility needed upgrading.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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. Maintain required accurate counts and documentation of controlled substances (a drug or medication that is monitored by the government) for one out of four medications carts (medication cart 3). 2. Maintain required accurate records and documentation of the use of drugs retrieved and administered from the emergency drug supply (e-kit) which included controlled substances. This deficient practice had the potential of drug diversion (used for a purpose or on a person not prescribed for) and/or medication errors. Findings: 1. During a concurrent interview and observation of medication cart 3 on 12/13/23 at 10:01 AM, Licensed Vocational Nurse 3 (LVN3) reviewed the Controlled Substance shift count record and confirmed the controlled substance shift count record was for the period from 12/2/23 to 12/15/23. LVN 2 stated there were 3 nursing shifts per day (7am to 3pm, 3pm to 11pm, and 11pm to 7am). The record had boxes for nurses to sign at each shift change (both in-coming and out-going nurses). A review of the…

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

Based on interview and record review, the facility failed to ensure one out of 35 sampled residents (Resident 70) were free from significant medication errors (an error in medication administration or omission [withholding] that jeopardizes a resident's health and/or safety). By failing to: Administer Resident 70's furosemide (generic for Lasix, a medication to treat high blood pressure, HTN), losartan (medication to treat high blood pressure) nifedipine (medication to treat high blood pressure) and Flomax (medication used to treat benign prostatic hyperplasia, a noncancerous enlargement of the prostate gland) on 11/5/23 and on 11/8/23 as per physician's orders. This deficient practice had the potential to cause harm to Resident 70 by causing uncontrolled blood pressure which could in turn cause cardiac arrest, stroke, and death. Cross Reference: F711 Findings: A review of Resident 70's admission record indicated the facility admitted the resident with diagnoses included heart failure and high blood pressure. A review of Resident 70's physician's orders dated 09/14/2023 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 prepare food by methods that conserved flavor and appearance. This deficient practice placed ninety-one (91) of one hundred thirteen (113) facility residents, who received food from the kitchen, at risk of not consuming adequate fiber, water soluble vitamins and unplanned weight loss, a consequence of poor food intake. Findings: A review of the facility's winter menu spreadsheets dated 12/12/2023, indicated regular diet (diet with no restrictions), consistent carbohydrate diet (diet with same amount of carbohydrates in each meal), no added salt (NAS), no salt packet in the received fresh green salad, ½ cup (c), and dressing ½ ounce (oz, a unit of measurement). During a test tray conducted with the Dietary Supervisor (DS) on 12/12/2023 at 12:51 p.m. for regular diet, the regular diet was presented in a Styrofoam container, fresh salad was mushy, watery (looked like soup), and drenched with salad dressing. The DS stated the test tray was served in Styrofoam because they ran out of domes and lids. The DS stated…

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

Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen when: a. Dented (hallow or dip in a surface caused by pressure or blow) cans were found in the kitchen dry storage along with other cans not dented. b. Staff was not wearing a beard guard (a latex-free net use to prevent hair from falling to food). c. Six (6) clean carts used to deliver meal trays for lunch had dust residue on the racks. d. Refrigerator 1 door and gaskets (a rubber attached to outer edge of the refrigerator use for airtight seal) had dirt and dust build up. e. Walk in-freezer and chest freezer had ice buildups and ice crystals. f. Countertops and pots and pans storage areas were dusty to touch. g. Pots and pans were stacked wet and not air dried. h. Unlabeled and expired food was found in the resident's refrigerator. i. Refrigerator and Freezer were not maintained in the acceptable temperature in the nurse's station and activity room. These failures had the potential to result in harmful bacteria growth and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure the assessment entries on the Minimum Data Set (MDS-a standardized assessment and care screening tool) related to accurate diagnoses for one of three sampled residents (Resident 55) were correct. This deficient practice had the potential to negatively affect the plan of care and delivery of necessary care and services for Resident 55. Findings: A review of the admission record indicated Resident 55 was admitted to the facility on [DATE] with diagnoses that include dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), psychosis (a collection of symptoms that affect the mind, where there has been some loss of contact with reality), mood disorder (general emotional state or mood is distorted or inconsistent with a person's circumstances and interferes with the person's ability to function) and osteoarthritis (a type of arthritis that happens when the cartilage that lines joints is worn down…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 preadmissions screening and annual resident review (PASRR-mental health assessment used to identify a need for active treatment due to a mental illness) assessment screening was completed to determine the facility's ability to provide care for the special needs for one of four sampled residents (Resident 42). This deficient practice placed Resident 42 at risk of not receiving necessary care and services. Findings: A review of Resident 42's admission record dated 9/15/2023, indicated Resident 42 was admitted to the facility on [DATE] with diagnoses that include chronic lymphocytic leukemia (a type of cancer of the blood and bone marrow), respiratory failure (occurs when the lungs can't release enough oxygen into your blood), chronic obstructive pulmonary disease (COPD -a chronic inflammatory lung disease that causes obstructed airflow from the lungs) and muscle weakness. A review of Resident 42's history and physical dated 9/26/2023, 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 revise a care plan titled Noncompliance with restorative nursing assistant (RNA-assist the resident in performing tasks that restore or maintain physical function as directed by the established care plan) for one of three sampled residents (Resident 102), who continued to refuse RNA services. This deficient practice had the potential for Resident 102 to have decreased strength, mobility, increased weight gain, depression (feeling sad or within drawn for normal activities of daily life), and quality of life. Findings: A review of Resident 102's admission record dated 3/25/2022, indicated Resident 102 was admitted to the facility on [DATE] with diagnoses that included acute respiratory failure (occurs when the lungs can't release enough oxygen into your blood), obstructive sleep apnea (occurs when your breathing is interrupted during sleep, for longer than 10 seconds at least 5 times per hour throughout your sleep period), asthma (a condition in which…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the discharge summary included a final summary of the resident status, including reconciliation of all pre and post discharge medications and a post-discharge plan of care for one of three sampled residents (Resident 127). This deficient practice had the potential to delay assistance to Resident 127 for adjustment to a new living environment after discharge. Findings: A review of Resident 127's admission record dated 9/30/2023, indicated Resident 127 was admitted to the facility on [DATE] with diagnoses that include chronic obstructive pulmonary disorder (COPD -a chronic inflammatory lung disease that causes obstructed airflow from the lungs), dysphagia (difficulty swallowing), heart failure (condition that develops when your heart doesn't pump enough blood for your body's needs), anemia (a condition in which the body does not have enough healthy red blood cells), and type 2 diabetes (a condition that happens because of a problem in the way 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 implement its policy and procedures (P&P) titled Repositioning for one of three sample residents (Resident 64), by not repositioning Resident 64 every 2 hours. This deficient practice had the potential to negatively affect the resident's physical comfort, psychosocial well-being and had the potential for formation of pressure sores (injury to the skin and underlying tissue resulting from prolonged pressure on the skin) to Resident 64. Findings: A review of Resident 64's admission record dated 7/9/2023, indicated Resident 64 was admitted to the facility on [DATE] was readmitted to the facility on [DATE] with diagnoses that included, chronic obstructive pulmonary disease (COPD -a chronic inflammatory lung disease that causes obstructed airflow from the lungs), asthma (a condition in which your airways narrow and swell and may produce extra mucus in the lungs), type 2 diabetes (a condition that happens because of a problem in the way the body…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure its residents with or without limited range of motion (ROM - movement of the joints) received appropriate treatment and services to increase, prevent, or maintain the ROM mobility for one of six residents (Resident 113) with physician's orders for Restorative Nursing Assistant (RNA) exercises. This failure resulted in or had the potential to delay treatment and services for Resident 113 and placed the resident at higher risk for further decline. Findings: A review of Resident 113's admission Record indicated the resident was admitted to the facility on [DATE], with diagnoses of, but not limited to, Peripheral vascular disease (the reduced circulation of blood to a body part, other than the brain or heart, due to a narrowed or blocked blood vessel), acquired absence of left leg below knee (removal of the foot, ankle joint, distal tibia, fibula, and corresponding soft tissue). A review of Residents 113's physicians orders 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 assess, document, and provide care and services consistent with professional standards of practice for the care of a hemodialysis (a machine that filters waste, salts, and fluids from your blood when your kidneys are no longer health enough to do this work adequately) AV Shunt (arteriovenous shunt-abnormal connections between coronary arteries and a compartment of the venous side of the heart for dialysis access) post dialysis for one of one sampled residents (Resident 70). This deficient practice had the potential to allow for unidentified malfunctioning AV shunt, infections and bleeding from the AV shunt site which could all lead to serious harm and/or death. Findings: A review of Resident 70's face sheet indicated the facility admitted this [AGE] year-old male on 9/13/2023 with diagnoses including encounter for orthopedic aftercare following surgical amputation ( surgical removal of toes on right foot), acquired absence of right toes,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, and record review, the facility failed to ensure one out of 35 sampled residents (Resident 70's) physician signed and dated physician's orders for the month of September 2023. This deficient practice had the potential for inaccurate orders and/or medication errors. Cross Reference: F760 Findings: A review of Resident 70's admission record indicated the facility admitted the resident with diagnoses included heart failure and high blood pressure. A review of Resident 70's physician's orders dated 09/14/2023 indicated the resident had an active order for furosemide 20 mg give 1 tablet by mouth one time a day for high blood pressure and hold for SBP < (less than) 100 or HF <60. A review of Resident 70's physician's orders dated 09/14/2023 indicated the resident had an active order for losartan (medication to treat high blood pressure) dated 9/14/2023 to be given 100 mg 1 tablet by mouth one time a day every Tuesday, Wednesday, Thursday, Saturday, and Sunday for high blood pressure. Hold for SBP…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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's rehabilitation department failed to follow the facility's policy and procedure (P&P) to initiate a maintenance program with either nursing or restorative aids (certified nursing assistants primarily assigned to perform therapeutic exercises and activities to maintain or re- establish a resident's optimum physical function and abilities) following the completion of physical therapy (care that aims to ease pain and help you function, move, and live better) treatment for one (1) of three (3) sampled residents (Resident 67). This deficient practice resulted in the delay of treatment and services for Resident 67 and placed Resident 67 at risk for possible decrease in strength, mobility, and overall quality of life. Findings: A review of Resident 67's admission record dated 6/23/2023, indicated Resident 67 was admitted to the facility on [DATE] from the General Acute Care Hospital (GACH) with diagnoses that included, below knee amputation (removal of body part) of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of two sampled residents (Resident 2), who was identified as exhibiting aggressive behavior, had a 1:1 sitter (provide residents with supervision, companionship, and care) monitoring the resident while smoking on the patio. As a result, on 10/18/2023, Resident 2 punched Resident 1 in the face while on the smoking patio. Resident 2 fell on the floor and Resident 1 continued to punch Resident 2. Resident 1 sustained an abrasion (a superficial rub or wearing off on the skin) on the left cheek. Cross Reference F602 Findings: A record review of Resident 2 ' s admission record, indicated Resident 2 was admitted to the facility on [DATE], with a medical history that included schizophrenia, (a disorder that affects a person ' s ability to think, feel, and behave clearly), depression (a group of conditions associated with the elevation or lowering of a person ' s mood), multiple wasting and atrophy (the partial or complete wasting away of part of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of two sampled residents (Resident 2) who had episodes of aggressive behavior was provided with adequate supervision. As a result, on 10/18/2023, Resident 2 physically attacked Resident 1. Resident 2 punched Resident 1 in the face. Resident 1 fell on the floor and Resident 2 continued punching Resident 1. Cross Reference F600 Findings: A record review of Resident 2 ' s admission record, indicated Resident 2 was admitted to the facility on [DATE] with a medical history that included schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly), depression (a group of conditions associated with elevation or loweringof a person's mood), multiple wasting and atrophy (partial or complete wasting away of a part of the body), hypertension (elevated blood pressure), chronic obstructive pulmonary disease (COPD-a group of lung diseases that block airflow and make it difficult to breathe), alcohol abuse (a pattern 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 provide services in compliance with applicable state regulation that require facilities licensed for 100 beds or more shall always have at least one registered nurse (RN) on duty in the facility, day, and night, in addition to the director of nursing services (DON). The facility failed to ensure that an RN was always on duty during the 7 a.m. to 3 p.m. shift, 3 p.m. to 11 p.m. shift and 11 p.m. to 7 a.m. shift for the month of 9/2023. This deficient practice failed to ensure supervision were given to licensed vocational nurses, (LVN ' s), certified nursing assistants (CNAs) and oversee the care of the residents in the facility. Findings: During a review and concurrent interview on 10/19/23 at 11:11 a.m., the Nursing Staffing Assignment and Sign-in Sheet for the month of September 2023 was reviewed with licensed vocational nurse (LVN 1). During concurrent interview, LVN 1 stated the facility is licensed for 119 beds. LVN 1 added there should be a registered nurse on duty every shift. The following dates indicated there were…

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