Montecito Heights Healthcare & Wellness Centre, LP

Based on observation, interview, and record review, the facility failed to promote and maintain residents' quality of life by not conducting and documenting a change of condition (COC) assessment for two of two sampled residents (Residents 90 and 89) who were roommates and experiencing an interpersonal conflict.This deficient practice had the potential to cause emotional distress and affect the residents' self-esteem and cause a loss of dignity and decline in psychosocial wellbeing. During a review of Resident 90's admission Record (AR), the AR indicated the facility admitted Resident 90 on 6/18/2026, with a diagnoses including congestive heart failure (a chronic condition where the heart muscle is too weak or stiff to pump blood), anemia (body lacks enough healthy red blood cells or hemoglobin to carry adequate oxygen to your tissues), and Diabetes Mellitus (DM-chronic condition where your body cannot properly process sugar from the food you eat). During a review of Resident 90's History and Physical (H&P), dated 6/19/2026, the H&P indicated Resident 90 can understand and make own…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure an Interdisciplinary Team (IDT- a group of healthcare professionals from different disciplines who work together to assess, plan and coordinate care) meeting for Resident 25 about noncompliance with keeping her nephrostomy tube (a thin catheter that drains urine from the kidney into a bag) off the floor was conducted for one out of one sampled resident.This failure had the potential for Resident 25's Urinary Tract Infection (UTI- an infection in the bladder/urinary tract) to worsen.Findings:During a review of Resident 25's admission Record, the admission Record indicated that Resident 25 was originally admitted on [DATE] and readmitted on [DATE] with a diagnosis of UTI, chronic kidney disease (damaged kidneys that prevents blood filtration), and malignant neoplasm of the cervix uteri (a type of cancer that causes healthy cells in the cervix to become abnormal).During a review of Resident 25's Minimum Data Set (MDS- a resident…

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

Based on observation, interview and record review, the facility failed to develop a dementia (a progressive state of decline in mental abilities) care plan (a personalized document outlining a person's health conditions, care services, and treatment goals) within 48 hours of admission for one of the five sampled residents (Resident 87).This failure had potential to cause delay in care or nursing services for Resident 87. Findings:During a review of Resident 87's admission Record, dated 6/25/2026, the admission Record indicated, the facility initially admitted Resident 87 on 1/22/2026, and then readmitted Resident 87 on 6/18/2026 with medical diagnoses that included fracture part of neck of left femur (broken bone of left hip), dementia with behavioral disturbances (a progressive state of decline in mental abilities with aggression, agitation, wandering, and psychosis [behavior and thoughts are detached from reality]), depressive episodes (persistent low mood, loss of interest in activities, and deep feelings of hopelessness).During a review of Resident 87's History and Physical (H &…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 initiate an anticoagulant (blood thinner- a medication or substance that prevents or slows down the clotting of blood) care plan for one of one sampled resident (Resident 82). This failure had the potential to negatively impact the resident's quality of life, as well as the quality of care and services received. During a review of Resident 82's admission Record (AR), the AR indicated the facility admitted the resident on 6/15/2026, with diagnoses including chronic obstructive pulmonary disease (a group of long term lung diseases that cause damaged airways and trapped air, making it difficult to breathe), pneumonia (an infection of the lungs that causes the tiny air sacs to become inflamed and fill with fluid), and sepsis (infection-fighting processes turn on the body, causing the organs to work poorly). During a review of Resident 82's History and Physical (H&P), dated 6/16/2026, the H&P indicated Resident 82 has limited decision-making capacity. During a review of Resident 82's order, dated 6/15/2026, 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 update and revise the care plan (a plan of care that summarizes a resident's health conditions, current treatments, and specific care and services facility staff [in general] need to provide a resident to promote healing and prevent a worsening of a condition) for Trazadone (a type of medication used to treat depression, a serious mood disorder that causes a persistent feeling of sadness, emptiness, and a loss of interest in activities) for one out of five sampled residents (Resident 11).This failure had potential for Resident 11 to receive care that was not in alignment with the resident's physician orders and needs.Findings:During a review of Resident 11's admission Record, the admission Record indicated the facility re-admitted the resident on 4/12/2026 with diagnoses that included insomnia (trouble falling asleep or staying asleep), unspecified psychosis (a severe mental condition in which thought and emotions are so affected that contact is lost with reality), and Post-Traumatic Stress Disorder (PTSD, a disorder 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 document a follow-up assessment after a change of condition (COC- a significant alteration in a resident's health status requiring physician notification) for one out of one sample resident (Resident 83).This failure had the potential for Resident 83 to continue experiencing nausea without appropriate monitoring and interventions.During a review of Resident 83's admission Record, the admission Record indicated that Resident 83 was admitted on [DATE] with a diagnosis of acute respiratory failure with hypoxia (a condition where the lungs cannot supply enough oxygen to the bloodstream), pneumonia (an infection/inflammation in the lungs), and immunodeficiency (when the immune system's ability to fight off infectious diseases is weakened).During a review of Resident 83's Minimum Data Set (MDS- a resident assessment tool), dated 6/19/2026, the MDS indicated that Resident 83 is cognitively intact (ability to think coherently and make decisions independently)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 monthly weights was being done and recorded to monitor and assess nutrition and hydration during continued poor meal intake (an ongoing, prolonged inability to consume enough food or beverages to meet the body's physiological energy and nutritional needs) for one of one sampled resident (Resident 17). This deficient practice had the potential to result in inadequate nutritional intake, continued weight loss, dehydration, worsening malnutrition, and functional decline. Findings: During a review of Resident 17's admission Record (Face Sheet), the resident was admitted to the facility on [DATE]. The resident with diagnoses including chronic obstructive pulmonary disease (COPD - a chronic lung disease characterized by airflow limitation with worsening respiratory symptoms), iron deficiency anemia secondary to chronic blood loss (a condition in which the body has insufficient healthy red blood cells due to chronic blood loss), chronic…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 1) reviewed for respiratory care, received the necessary respiratory care and services by failing to: -Ensure Resident 1's oxygen nasal cannula (a simple, lightweight plastic tube used to give a person extra oxygen) did not rest on the floor while Resident 1 used the oxygen nasal cannula on 6/22/2026 at 10:29 AM This failure had the potential for Resident 1 to experience an increased risk for respiratory infections (illnesses that affect the parts of your body involved in breathing). Findings: During a review of Resident 1's admission Record, the admission Record indicated the facility originally admitted Resident 1 on 2/17/2026 and readmitted Resident 1 on 5/19/2026 with diagnoses that included chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), other specified sepsis (a life threatening blood infection), muscle weakness, reduced mobility, dementia (a progressive state of decline in mental abilities), 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 one of one sampled resident (Resident 33) reviewed for hemodialysis (HD, treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney[s] have failed) received care and services consistent with professional standards of practice by failing to: 1. Ensure Resident 1's weight was accurately assessed and documented after dialysis on 6/17/2026. 2. Ensure Resident 33's permcath dialysis catheter (a soft, flexible plastic tube inserted into a large vein, usually in the neck) was accurately assessed and documented on 6/17/2026, 6/22/2026, and 6/23/2026. These failures had the potential for inaccurate information to have been used to calculate Resident 33's dialysis, leading to improper dialysis care treatment orders, infection, serious injury and/or harm. Findings: During a review of Resident 33's admission Record, the admission Record indicated the facility originally admitted Resident 33 on 4/22/2021 and readmitted Resident 33 on 6/3/2026 with diagnoses that…

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

Based on interview and record review, the facility failed to obtain a Valproic Acid (a medication that is used to stabilize mood) level as recommended by the facility's consultant pharmacist (a healthcare professional who provides specialized expertise to healthcare facilities, typically focusing on ensuring the safe and effective use of medications) during the Monthly Medication Regimen Review (MRR, when a consultant pharmacist reviews and analyzes a resident's medication list, ensuring that the medications are appropriate, effective, and safe) for one of five sampled residents (Resident 61).This failure had the potential for Resident 61 to develop toxic levels (when an excessive amount of a medication accumulates in the bloodstream, leading to adverse, poisonous, or potentially life-threatening effects) of Valproic Acid and experience adverse effects (undesired and harmful effects that occur because of medication, treatment, or a procedure) from the medication.Findings:During a review of Resident 61's admission Record, the admission Record indicated the facility admitted the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure food preferences were honored for three of three sampled residents (Resident 50, Resident 86 and Resident 67) when: a. Resident 86's likes and dislikes was not reflected on the meal tray ticket. b. Resident 50's tray ticket was not updated reflecting food texture preferences and request for soups for three meals. c. Resident 67's did not provide food preference accommodation. These failures had potential to cause decreased food intake, weight loss, and decreased quality of life. Findings: a. During a review of Resident 86's Face Sheet (which includes a resident's identification, medical, and demographic information), dated 6/25/2026, the Face Sheet indicated Resident 86 was admitted on [DATE] with medical diagnoses that included metabolic encephalopathy (brain dysfunction caused by chemical imbalances, systemic illnesses, or organ failure), immunodeficiency (a state of body where immune system that fights diseases or infections is…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to document infection prevent education to one out of one sampled resident (Resident 25) in a consistent and timely manner.This failure of incomplete and missing documentation had the potential for Resident 25 to not receive necessary care and treatment.Findings: During a review of Resident 25's admission Record, the admission Record indicated that Resident 25 was originally admitted on [DATE] and readmitted on [DATE] with a diagnosis of UTI, chronic kidney disease (damaged kidneys that prevents blood filtration), and malignant neoplasm of the cervix uteri (a type of cancer that causes healthy cells in the cervix to become abnormal).During a review of Resident 25's Minimum Data Set (MDS- a resident assessment tool) dated 4/30/2026, the MDS indicated that Resident 25 is cognitively intact (ability to think coherently and make decisions independently) and uses a walker to ambulate (walk). The MDS indicated that Resident 25 requires supervision…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 to assess two of two sampled residents (Resident 7 and Resident 63) for pain levels by failing to: 1.Ensure licensed nurses (in general) followed Resident 7's physician orders to assess/monitor Resident 7's pain levels and document prior to administering hydromorphone (a strong medication used for moderate to severe pain, especially when other pain relievers haven't worked). 2. Ensure to reevaluate the pain level for Resident 63 within an hour after the administration of a pain relief medication as indicated in the facility's Pain Management policy and procedure. These failures had the potential for Resident 7 and Resident 63's pain not to be treated effectively and had the potential for Resident 7 to receive too much pain relief medication. Findings: 1. During a review of Resident 7's admission Record, the admission Record indicated the facility admitted Resident 7 on 3/20/2025 with diagnoses including displaced fracture (the broken pieces of bone have moved out of their normal alignment [straight line], creating a…

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

Based on observation, interview, and record review, the facility failed to ensure to follow safe and sanitary food storage and food preparation practices in the kitchen by failing to: 1.Ensure boxed food items were not stored directly on the floor. 2.Ensure the dispensing scoop was not stored inside the salt container These failures placed the residents of the facility at risk for foodborne illnesses (refers to illness caused by the ingestion of contaminated food or beverages). Findings: During a concurrent interview and observation in the dry storage room on 5/23/2025 at 6:42 PM with [NAME] 1 (CK 1), a scoop was observed stored directly in a clear storage container of salt and the following food items were observed stacked directly on the floor: a. One clear storage container of rice. b. One box of non-dairy creamer packets. c. One clear storage container of parsley. d. One box of mayonnaise. e. One clear storage container of salt. During a concurrent interview and observation in the dry storage room on 5/23/2025 at 6:42 PM with CK1, CK1 stated the new dietary supervisor (DS 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.

Based on interview and record review, the facility failed to provide a Notice of Medicare Non-Coverage (NOMNC, a notice that is provided to beneficiaries that indicates when their Medicare covered services are ending) to one of three sampled residents (Resident 129). This failure had the potential to result for Resident 129 not to be informed of her coverage end date and not being able to exercise her right to file an appeal of her discharge from the facility. Findings: During a review of Resident 129's admission Record, the admission Record indicated the facility admitted the resident on 8/16/2024 with diagnoses that included type 2 diabetes (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing), schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), hypertension (high blood pressure), and anxiety disorder (a mental health condition with feeling of worry, anxiety, or fear interfering with one's daily…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed ensure the Minimum Data Set (MDS, a resident assessment tool) was accurately performed for two of six sampled residents (Resident 67 and Resident 48) by failing to: 1.Ensure the MDS assessment for restraints (any physical, chemical, or mechanical device or method used to limit a patient's movement or restrict their freedom of movement, typically to prevent harm to themselves or others) was accurately performed for Resident 67. 2.Ensure the MDS assessment for bowel and bladder was accurately documented for Resident 48. This failure had the potential to result in inadequate care for Resident 67 and Resident 48. Findings: 1.During a review of Resident 67's admission Record, the admission Record indicated the facility admitted the resident on 3/13/2025 with diagnoses that included dementia (a progressive state of decline in mental abilities), difficulty in walking, and muscle weakness. During a review of Resident 67's MDS dated [DATE], the MDS…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop a complete baseline care plan for one of one sampled resident (Resident 23) by failing to address Resident 23's dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney[s] have failed) access site. This failure had the potential for Resident 23 not to receive the appropriate care and treatment. Findings: During a review of Resident 23's admission Record, the admission Record indicated the facility admitted the resident on 3/17/2025, with diagnoses including end stage renal disease (ESRD, irreversible kidney failure), hypertension (HTN, high blood pressure), and acquired absence of left leg below knee and lack of coordination. During a review of Resident 23`s History and Physical (H&P) dated 3/17/2025, the H&P indicated the resident had the capacity to understand and make decisions. During a review of Resident 23's physician Order Summary Report dated 3/18/2025, the Order Summary Report…

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

Based on interview and record review, the facility failed to develop an individualized person-centered care plan (a plan of care that summarizes a resident's health conditions, specific care and services facility staff need to provide a resident to promote healing and prevent a worsening of a condition, and current treatments) to meet the resident's needs for two of six sampled residents (Resident 64 and Resident 38) by failing to: 1.Ensure to create an appropriate care plan for Resident 64's incontinence (the involuntary leakage of bodily fluids, specifically urine or stool). 2. Ensure to create a care plan to address Resident 38's oxygen use. This failures had the potential to result in Resident 64 and Resident 38 not to have their needs met. Findings: 1.During a review of Resident 64's admission Record, the admission Record indicated the facility admitted the resident on 9/9/2024 with diagnoses that included hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (mild or partial weakness or loss of strength on one side of 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.

Based on observation, interview, and record review, the facility failed to follow the physician's order for one of four sampled residents (Resident 36) who was at risk for developing pressure injuries/sores (PI, injuries to the skin and underlying tissue resulting from prolonged pressure on the skin) by failing to: 1. Ensure to provide Resident 36 with bilateral (both) heel protectors (a device used to prevent and treat heel pressure sores) while Resident 36 was in bed. This failure placed Resident 36 at risk for developing PIs. Findings: During a review of Resident 36's admission Record, the admission Record indicated the facility admitted Resident 36 on 1/8/2025 and readmitted Resident 36 on 4/6/2025 with diagnoses including Diabetes Mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing), failure to thrive (a decline caused by chronic diseases and functional impairments which can cause weight loss, decreased appetite, poor nutrition, and inactivity) and paraplegia (loss of movement and/or sensation, to some degree, of the legs). During…

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

Based on observation, interview, and record review, the facility failed to follow the physician orders for one of four sampled residents (Residents 36) by failing to provide Resident 36 with bilateral (both) padded siderails (are adjustable metal or rigid plastic bars that attach to the bed) for safety. This failure had the potential to place Resident 36 at risk for injury. Findings: During a review of Resident 36's admission Record, the admission Record indicated the facility admitted Resident 36 on 1/8/2025 and readmitted the resident on 4/6/2025 with diagnoses including diabetes mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing), failure to thrive (a decline caused by chronic diseases and functional impairments which can cause weight loss, decreased appetite, poor nutrition, and inactivity) and paraplegia (loss of movement and/or sensation, to some degree, of the legs). During a review of Resident 36's seizure disorder (a sudden, uncontrolled electrical disturbance in the brain) care plan, initiated 1/8/2025, the care plan…

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

Based on observation, interview, and record review, the facility failed to ensure two of two sampled residents (Resident 48 and Resident 278) received appropriate urinary and bowel care services by failing to: 1.Ensure Resident 48 who was continent (able to verbalize/control bladder and bowel movements) on admission, received services and assistance to maintain continence. 2. Ensure Resident 278's urinary catheter (a hollow tube inserted into the bladder to drain or collect urine) did not have a dependent loop (restricts urine flow from the bladder and can lead to improper bladder emptying), and urine did not backflow to the urine drainage port. These failures had the potential to negatively affect Resident 48 and Resident 278 from receiving the proper care necessary to prevent urinary tract infection (UTI, an infection in any part of the urinary system), and skin breakdown. Findings: 1.During a review of Resident 48's admission Record, the admission Record indicated the facility admitted Resident 48 on 3/28/2025 with diagnoses including resistance to multiple antimicrobial drugs…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 respiratory care services for two of four sampled residents (Resident 7 and Resident 10) by failing to: 1.Ensure to label Resident 7's nasal cannula (flexible plastic tubing used to deliver oxygen through nostrils [nose] and the tubing is fitted over the patient's ears) as indicated in the facility's Oxygen Therapy policy and procedure. 2. Ensure to change Resident 10's humidifier bottle (a medical device used to humidify oxygen) when empty. These failures had the potential to place Resident 7 at risk for respiratory infections and for Resident 10 not to receive effective respiratory therapy care. Findings: 1. During a review of Resident 7's admission Record, the admission Record indicated the facility admitted Resident 7 on 3/20/2025 with diagnoses including displaced fracture (the broken pieces of bone have moved out of their normal alignment [straight line], creating a gap or misalignment between the fracture ends) 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 observation, interview, and record review, the facility failed to ensure one of one sampled resident (Resident 23) who was on dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney[s] have failed) received dialysis care and treatment by failing to: 1. Ensure to assess Resident 23's dialysis access sites (a way to reach the blood for dialysis). 2. Ensure to assess Resident 23 before and after (pre and post) dialysis treatment on 4/7/2025, 4/14/2025, 4/23/2025, and 4/30/2025. These failures had the potential to result in undetected complications of a dialysis access site and could lead to the delay of necessary care for Resident 23. Findings: During a review of Resident 23's admission Record, the admission Record indicated the facility admitted the resident on 3/17/2025, with diagnoses including end stage renal disease (ESRD, irreversible kidney failure), hypertension (HTN, high blood pressure), and acquired absence of left leg below knee and lack of coordination. During a review of Resident 23`s History and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure the assistive signaling devices used to prevent falls were monitored for placement and function for one of two sampled residents (Resident 1). For Resident 1, the facility failed to: 1.Monitor the placement and functioning of the bed alarm when initially applied on12/23/24. 2.Monitor the placement and functioning of the wheelchair alarm when initially applied on 1/3/25. Monitoring for the placement and function for the bed and wheelchair alarms started on 3/18/25. These deficient practices had the potential for the assistive devices to malfunction without the facility's knowledge and had the potential for Resident 1 to leave the bed and/or the wheelchair without the facility's knowledge and may lead to accident. Findings: During a review of Resident 1's admission Record indicated the facility admitted Resident 1 on 1/28/23 and readmitted on [DATE] with diagnoses including dementia (a progressive state of decline in mental abilities), difficulty…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 administer adequate supplemental oxygen in accordance with professional standards of practice for one of three sampled residents (Resident 1). For Resident 1 who was found on 9/20/24 at 7:40 p.m. with altered level of consciousness (ALOC, state of reduced alertness or inability to arouse) and with oxygen saturation (O2 sat – measurement of how much oxygen the blood is carrying as a percentage) of 64% (normal range is between 95% to 100%), the facility failed to administer oxygen by non-rebreather mask (oxygen mask that delivers high concentration of oxygen) immediately while waiting for the arrival of the paramedics. This deficient practice had the potential for Resident 1 to continue to deteriorate and not receive enough oxygen to sustain life. Findings: During a review of the admission Record indicated the facility admitted Resident 1 on 5/29/24 with diagnoses including congestive heart failure (CHF, a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling) 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 residents and their family member/next of kin were given the opportunity to discuss and review the documents the residents signed for two of two sampled residents (Resident 1 and Resident 2). For Resident 1 and Resident 2, the facility failed to ensure the Assisted Living Waiver (ALW, program that provides specified benefits to eligible residents to remain in their community as an alternative to residing in a licensed health facility) forms and consents signed by Resident 1 and Resident 2 on 7/26/24 were in the language Resident 1 and Resident 2 could understand. These deficient practices resulted in Resident 1, Resident 2 and their families not being aware of what forms and consents Resident 1 and Resident 2 signed. Findings: 1. During a review of the admission Record indicated the facility originally admitted Resident 1 on 9/1/21 and was readmitted on [DATE] with diagnoses including Parkinson ' s Disease (brain condition that causes problems…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 a Notice of Proposed Transfer and Discharge to one of two sampled residents (Resident 2). For Resident 2, the facility failed to provide the Notice on 8/29/24 when Resident 2 had a planned discharged to a lower level of care on 9/4/24. This deficient practice had the potential for Resident 2 not be given her right to know in writing the date and reasons for her discharge. Findings: During a review of the admission Record indicated the facility originally admitted Resident 2 on 1/31/2017 and was readmitted on [DATE] with diagnoses including diabetes (group of disease that affect how the body uses blood sugar [glucose]), reduced mobility, and difficulty in walking. During a review of the Minimum Dat Set (MDS,standardized care and health screening tool) dated 6/24/24, indicated Resident 2 was cognitively intact. Resident 2 needed supervision (helper provides cues or cleans up) with oral hygiene and set up assistance (helper sets up, 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 an observation, interview, and record review, the facility failed to post the federally required daily actual hours worked by the staff in an area accessible to the public for four of six days for the month of June 2024. As a result, the total number of staff and the actual hours worked was not readily accessible to residents, family, or visitors. Findings: During an observation in the facility lobby on 6/3/2024 at 8 AM, the Census and Direct Care Service Hours Per Patient Day (DHPPD: Refers to the actual hours of work performed per patient day by a direct caregiver) did not reflect the actual hours worked of staff and reflected the projected working hours of staff for today (6/3/2024). During an observation in the facility lobby on 6/4/2024 at 9:10 AM, the DHPPD did not reflect the actual hours worked of staff and reflected the projected working hours of staff for today (6/4/2024). During an observation in the facility lobby on 6/5/2024 at 8:36 AM, the DHPPD did not reflect the actual hours worked of staff and reflected the projected working hours of staff for today…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the call lights (an alerting device for nurses to assist a patient when in need) were within the residents' reach for two of 19 sampled residents (Resident 10 and Resident 113). These deficient practices had the potential to result in a delay in care and services and Resident 10 and 113's inability to request assistance. Findings: a. A review of Resident 10's admission Record (Face Sheet) indicated the facility admitted the resident on 7/13/2017, and readmitted on [DATE], with diagnoses including hemiplegia (an inability to move one side of body) and hemiparesis (an inability to move the arm, leg and sometimes face on one side of the body) following a cerebral infarction (lack of blood flow resulting in severe damage to some of the brain tissue) affecting the right-dominant side. A review of Resident 10's care plan dated 8/7/2023, indicated Resident 10 was at risk for falls and the interventions indicated, Be sure the resident'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 revise care plans for two of 19 sampled residents (Resident 20 and Resident 47 ) investigated for care planning. The facility failed to revise Resident 20's care plan to reflect a discontinuation of antibiotic therapy (medications that are used to treat infection by stopping bacteria from reproducing or destroying them) and failed to revise Resident 47's care plan after discontinuing a urinary indwelling catheter (a tube inserted in the bladder to drain the urine). This deficient practice placed the residents at risk for inconsistent implementation of care plans which may lead to a delay in or lack of delivery of care and services. Findings: a. A review of Resident 20's admission Record indicated the facility admitted the resident on 9/18/2023 and readmitted him on 10/1/2023, with diagnoses including encephalopathy (brain disease, damage, or malfunction of brain), hydronephrosis (a condition that occurs when a kidney swells and urine…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 residents received treatment and care in accordance with professional standards of practice for one of three sampled residents (Resident 20), by not rotating the site for administration of a subcutaneous injection (an insertion of medication beneath the skin) of Basaglar (a long-acting insulin [hormone that lowers the level of sugar in the blood]). The deficient practice had the potential to result in the resident developing a lipodystrophy (a condition when fat either break down or builds up under the skin, causing interference with insulin abortion). Findings: A review of Resident 20's admission Record indicated the facility admitted the resident on 9/18/2023 and readmitted him on 10/1/2023 with diagnoses including encephalopathy (brain disease, damage, or malfunction of brain), hydronephrosis (a condition that occurs when a kidney swells and urine cannot drain out from kidney), and Type 1 diabetes (a long-term medical condition in which the body does not use insulin [a hormone that lowers the level of sugar 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 interview and record review, the facility failed to ensure one of five sampled residents (Resident 21) was free of unnecessary medication by failing to follow the Physician's Order to discontinue Enoxaparin (a blood thinner given via injection) 40 milligrams (mg - unit of measurement) subcutaneously (SQ - injected under the skin) dated 5/30/2024. This deficient practice resulted in Resident 21 receiving Enoxaparin from 5/30/2024 to 6/5/2024 without a Physician's Order, which placed the resident at risk for internal bleeding, hemorrhage (loss of blood from damaged blood vessels), organ failure, and death. Findings: A review of Resident 21's admission Record indicated the facility initially admitted the resident on 1/23/2024 and re-admitted the resident on 3/13/2024 with diagnoses that included fracture of left femur (broken thigh bone), reduced mobility and abnormalities of gait (abnormal walking pattern). A review of Resident 21's History and Physical (H&P) dated 1/29/2024, indicated the resident had capacity to understand and make decisions. A review of the Minimum Data…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a therapeutic diet (specialized diet designed to address specific medical conditions and improve health outcomes) was served per Physician's Order for one of six sampled residents (Resident 114). This deficient practice had the potential to place Resident 114 at risk for choking and aspiration (inhaling small particles of food or drops of liquid into the lungs). Findings: A review of the admission Record (Face Sheet) indicated the facility admitted Resident 114 on 5/22/2024, with diagnoses including dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), muscle weakness, and need for assistance with personal care. A review of the Physician's Order dated 5/23/2024, indicated Resident 114 was to receive a no added salt (NAS) diet, mechanical soft texture (foods that are soft and easy to chew) and nectar thick consistency liquid (slightly more body than thin liquids, but still…

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

Based on observation, interview, and record review, the facility failed to provide a dycem (non-slip mat that anchors items to the trays or tables and prevents cups and plates from slipping off trays or tables) to the resident for one of three sampled residents (Resident 39). This deficient practice had the potential to result in the resident being unable to maintain or improve his ability to eat or drink independently. Findings: A review of the admission Record indicated the facility admitted Resident 39 on 8/8/2023 with diagnoses including hemiplegia (paralysis that affects only one side of the body) and hemiparesis (weakness or the inability to move on one side of the body, making it had to perform everyday activities like eating or dressing), diabetes Type II (a long-term medical condition in which the body does not use insulin [a hormone that lowers the level of sugar in the blood] properly), and muscle weakness. A review of the History and Physical (H&P) dated 8/9/2023, indicated Resident 39 had the capacity to understand and make decisions. A review of Resident 39's Care…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the indwelling catheter bag (a transparent bag where urine was collected and connected to a tubing that was inserted in the body through the bladder) was not touching the floor for one of 19 sampled residents (Resident 29). This failure had the potential for Resident 29 to acquire a urinary tract infection (UTI - an infection caused by bacteria entering the urinary tract). Findings: A review of the admission records indicated Resident 29 was admitted to the facility on [DATE] with diagnoses including UTI, Type II diabetes mellitus (a condition where the body has trouble using sugar for energy, leading to high blood sugar) and paralysis (a loss of muscle motor function) of right side of the body. The resident had more memory or thinking problems than other people their age and required assistance with daily activities such as personal hygiene, showering, toileting, dressing, eating, and transferring from bed to wheelchair. During an…

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