New Vista Post-Acute Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 8) who was identified as at risk for falls did not experience a fall by failing to: Ensure Resident 8 was properly assessed and monitored after Resident 1 slipped out of the wheelchair on 1/16/2026 according to facility's policy and procedures (P&P) titled, Falls by a Resident, reviewed on 7/11/2025. Ensure Resident 8's Fall Risk Assessments were accurately documented by licensed nurse according to facility's P&P titled, Fall Risk & Prevention of Injury to include pathological Fractures, reviewed on 7/11/2025, and P&P titled Falls by a Resident reviewed on 7/11/2025. These deficient practices placed Resident 8 at risk for further falls and/or injuries. Findings: During a review of the admission Record indicated Resident 8 was admitted to the facility on [DATE] with diagnoses including hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis following cerebral…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow its policy and procedures (P&P) titled Change of Condition - SBAR [situation, background, assessment, recommendation-a communication tool used by healthcare workers when there is a change of condition among the residents] -Assessment reviewed by the facility on 7/11//2025, for one of three sampled residents (Resident 1). By failing to notify Resident 1's physician on 2/10/2026, when the resident was assessed as a high risk for elopement (the act of leaving a facility unsupervised and without prior authorization). This deficient practice resulted in Resident 1 not receiving orders for a wander guard (an electronic safety technology used in care facilities to prevent residents with dementia or cognitive impairment from wandering off or eloping [leaving]) and eloping from the facility without staff knowledge on 2/11/2026. Placing Resident 1 at risk for serious injury, harm, or death.Findings: During a review of Resident 1's admission record, 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 to develop and implement and individualized and comprehensive care plan to meet the individual needs for one out of three sampled residents (Resident 1), who was identified to be at high risk for elopement (the act of leaving a facility unsupervised and without prior authorization) risk. As a result, on 2/11/2026 Resident 1 eloped (left) from the facility unsupervised without staff knowledge and the resident's whereabouts unknown for 17 hours. Placing Resident 1 at risk for serious injury, harm, or death.Findings:A review of Resident 1's admission record indicated the facility admitted the resident on 2/10/2026, with diagnoses that included dementia (a progressive state of decline in mental abilities) with other behavioral disturbance, depression (a common, serious mood disorder characterized by a persistent, intense, and long-lasting feeling of sadness or a loss of interest in activities), and psychoactive substance (is a chemical that enters 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 two of21 sampled residents (Resident 75 and Resident 115), received care, treatment, and services in accordance with the physician's order and policy and procedure by failing to:Follow doctor's orders to perform oral care with Chlorhexidine Gluconate Mouth/Throat Solution 0.12% (a solution used to treat gingivitis (inflammation of the gum), reduce gum swelling, redness, and bleeding by decreasing mouth bacteria (germs) and provide 5 milliliters (ml - unit of measurement) of water every shift; per doctor's orders.Initiate a Situation, Background, Assessment, Request (SBAR-a formal written communication tool used to provide essential, concise information during crucial medical situations) Form when Resident 115 complained of abdominal pain. As a result, on 11/26/2025 Residen115 was transferred to a General Acute Care Hospital (GACH), due to lethargy (extreme weakness), nausea and poor appetite. This deficient practice had the potential to delay…

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 competent Restorative Nursing Assistant (RNA, nursing assistant program that help residents to maintain their function and joint mobility) nursing staff when:1. The facility failed to complete annual competencies for putting on and taking off splints (rigid material or apparatus used to support and immobilize a broken bone or impaired joint) and braces (an external device to support, align, or correct a movable part of the body) for two sampled RNAs.2. Restorative Nursing Assistant (RNA) 1 did not follow and perform RNA treatment as ordered by a physician during an RNA treatment session on 2/4/2026 with Resident 74. These deficient practices had the potential to cause injury and harm to residents who require splints during RNA and to Resident 74 during the RNA program.Findings: 1. During a concurrent interview and record review on 2/4/2026 at 3:08 p.m. with the Director of Staff Development (DSD), RNA 1 and Restorative Nursing…

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 accurate and complete medical records and documentation based on professional standards for three of 22 sampled residents (Residents 23, 32, and 8) when:1. For Resident 23, Restorative Nursing Assistant program (RNA, nursing assistant program that help residents to maintain their function and joint mobility) documentation indicated Resident 23 received RNA treatment on 2/4/2026 when Resident 23 did not receive RNA treatment.2. For Resident 32, a Certified Occupational Therapy Assistant (COTA) 2 signed on behalf of the Physical Therapist (PT) 1 on a physical therapy (PT, a rehabilitation profession that restores, maintains, and promotes optimal physical function) treatment encounter note.3. For Resident 8, a Certified Occupational Therapy Assistant (DOR/COTA) 1 signed on behalf of PT 1 on a PT treatment encounter note. These deficient practices caused inaccurate medical records and had the potential for inadequate care planning and physical…

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 infection control procedures to help prevent the development and transmission of communicable diseases (illnesses caused by organisms that can be passed from person to person) and infections by failing to ensure:1. Provide hand soap and hand sanitizer supplies in Resident 56 and 74's room.2. Properly sanitize and disinfect a cloth gait belt (an assistive device that is secured around a person's waist to assist in moving a person) between multiple resident use. 3. Staff handled soiled linen in a sanitary manner per facility's policy and procedures titled, Infection Control Policy - Laundry Services. These deficient practices had the potential to spread infections and illnesses between residents, staff, and visitors. Findings: 1. During a review of Resident 74's admission Record (AR) dated 1/26/2026, the AR indicated Resident 74 admitted to the facility on [DATE] with diagnoses including, but not limited to spinal stenosis (spaces…

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 licensed nursing staff failed to offer the pneumonia vaccine as required or appropriate to one of five sampled residents (Resident 13 and Resident 32). This deficient practice placed Resident 13 and Resident 32 at increased risk of acquiring and transmitting pneumonia to other residents in the facility. Findings: a. A review of Resident 13's admission Record indicated the facility readmitted the resident on 3/5/2025, with diagnoses of cerebral infarction (also known as a stroke in which blood flow stops to part of the brain) respiratory failure (a condition in which there's not enough oxygen in the body) and high blood pressure. A review of Resident 13's Minimum Data Set (MDS- a resident assessment tool) dated 1/16/2026, indicated the resident had severely impaired cognition (never/rarely made decisions). The MDS also indicated the resident was totally dependent on staff for transfer, dressing, eating, toilet use and personal hygiene. A review of Resident 13's Immunization Report, dated 2/6/2026, indicated Resident 13 had never received 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 that the resident or their representative was notified timely in writing the reason for the transfer/discharge to the hospital for one of eight sampled residents, (Resident 38). This deficient practice resulted in resident 38 and/or their representatives not being provided with their options and rights by the facility staff.Findings: A review of Resident 38's admission Record indicated the facility admitted Resident 38 on 9/30/2011, and readmitted Resident 38 on 2/27/2025 with diagnoses including dementia (a progressive state of decline in mental abilities), dysphagia (difficulty swallowing), and gastrostomy tube (a small, flexible feeding tube inserted directly into the stomach through a small hole in the belly). A review of resident 38's physician order dated 12/14/2025, at 11:17 A.M., indicated . may transfer the patient to general acute care hospital (GACH) . A review of resident 38's notice of transfer/discharge date d 12/14/2025 indicated person notified was resident 38. A review of Resident 38's 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 interview and record review, the facility failed to ensure residents' Minimum Data Set (MDS- a resident assessment tool) assessments were transmitted to Centers for Medicare and Medicaid Services (CMS - is a federal agency within the U.S. Department of health and Human Services (HHS) that provides health coverage to over 160 million people through Medicare, Medicaid, the children's Health Insurance Program (CHIP), and the Health Insurance Marketplace) within 14 days after completion for one-of-one sampled residents (Resident 75). This deficient practice resulted in the delay to transmit MDS report to CMS for 61 days or Resident 75.Findings: A review of Resident 75's admission Record indicated Resident 75 was admitted to the facility on [DATE], with medical diagnoses that included: Hypertension (high or raised blood pressure), Acute Kidney Failure (A condition in which the kidneys suddenly can't filter waste from the blood), and depression (a constant feeling of sadness and loss of interest). A review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to ensure the assessment entries on the Minimum Data Set (MDS- a resident assessment tool) related to antipsychotic use was accurately documented to reflect the resident's use of antipsychotic medication for one of five sampled residents (Resident 2). This deficient practice had the potential to result in resulted in lack of or delay in fully addressing in the care plan Resident 2's potential for elopement risk. Findings: A review of the admission record indicated the facility re-admitted Resident 2 on 5/7/2025, with diagnoses that included cerebral infarction (also known as a stroke in which blood flow stops to part of the brain), respiratory failure (a condition in which there's not enough oxygen in the body) and dementia (a progressive state of decline in mental abilities). A review of Resident 2's, Order Summary Report (list of active orders) for 11/25/2025 indicated Resident 2 was not prescribed an antipsychotic. A review of Resident 2's most recent…

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 complete a Preadmission Screening and Resident Review (PASRR-a tool used to help ensure that individuals are not inappropriately placed in nursing homes for long term) for one of 33 sampled residents (Resident 29). This deficient practice had the potential to result in inappropriate placement of Resident 33 in the facility by failing to: Evaluate the Resident for serious mental illness (SMI) and/or intellectual disability (ID)Offering the Resident the most appropriate setting for their needs (in the community, a nursing facility, or acute care settings).Provide the Resident with the services they need in those settingsFindings: A review of the Resident 29's admission record indicated Resident 29 was originally admitted to the facility on [DATE], with diagnoses that include epilepsy (neurological disorder characterized by recurrent, unprovoked seizures [a temporary, sudden change in brain activity that may result in involuntary movements, convulsions,…

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 Restorative Nursing Assistant program (RNA, nursing assistant program that help residents to maintain their function and joint mobility) treatments as ordered by a physician for one of 22 sampled residents (Resident 74) when Resident 74 had missed RNA treatments in November 2025, December 2025, and January 2026. This deficient practice had the potential to cause a functional decline in Resident 74. Findings: During a review of Resident 74's admission Record (AR) dated 1/26/2026, the AR indicated Resident 74 admitted to the facility on [DATE] with diagnoses including, but not limited to spinal stenosis (spaces inside bones of the spine get too small), polyneuropathy (damage of the nerves that can cause weakness, numbness, and burning pain), and unsteadiness on feet. During a review of Resident 74's Minimum Data Set (MDS, resident assessment tool) dated 1/13/2026, the MDS indicated Resident 74 was cognitively intact (sufficient…

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 label the gastric (stomach) tube feeding with a date for one of eight sampled residents (Resident 38) according to their policy and procedure (P&P) titled Closed Enteral Feeding System Policy, revised 7/11/2025. This deficient practice had the potential to cause infection and/or possible hospitalization for Resident 38.Findings: A review of Resident 38's admission Record indicated the facility admitted Resident 38 on 9/30/2011, and readmitted Resident 38 on 2/27/2025 with diagnoses including dementia (a progressive state of decline in mental abilities), dysphagia (difficulty swallowing), and gastrostomy tube (a small, flexible feeding tube inserted directly into the stomach through a small hole in the belly). A review of Resident 38's physician order dated 1/29/2026 indicated enteral feed order, every night shift Glucerna 1.2 at 60milliliter (ML -unit of measure) per hour to provide 1200ML/1440 kilocalorie (kcal- amount of heat needed to raise the temperature) via pump . A review of Resident 38's Minimum Data Set (MDS - a…

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

Based on interview and record review, the facility failed to ensure one of eight sampled residents (Resident 45) was administered the following medications as prescribed per physician's orders dated 8/1/2023, 5/31/20, 12/12/2025, and facility's policy and procedures (P&P) titled Medication Administration, revised on 7/11/2025:Hydrocodone-Acetaminophen (a prescription combination medication used for moderate to severe pain relief) Oral (by mouth) Tablet 10-325 milligrams (mg -unit of measure in weight) give 1 tablet by mouth every 12 hours for pain management .Levothyroxine (replaces a missing hormone thyroxine in people with an underactive thyroid [a small, butterfly-shaped gland in the lower front of your neck. It releases hormones that control how quickly your body uses energy, affecting heart rate, weight, body temperature, and mood]) Sodium Tablet 100 micrograms (mcg -unit of measure in weight) give 1 tablet by mouth for low thyroid hormone These deficient practices resulted in Resident 45 not receiving Hydrocodone-Acetaminophen Tablet 10-325 mg for pain in 12/2025 and 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 that the resident's medication order included the indication for its use according to their policy and procedure (P&P) titled Physician Services and orders, revised 7/11/2025 for one of eight sampled residents (Resident 14). This deficient practice had the potential to result in a medication error and affect Resident 14's safety.Findings: A review of Resident 14's admission Record indicated the facility admitted Resident 14 on 8/15/2025, with diagnoses including lymphedema (issue swelling caused by an accumulation of protein-rich fluid that's usually drained through the body's lymphatic system[part of the immune system]), diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), and hypertension HTN-high blood pressure). A review of the physician's orders dated 10/22/2025, indicated Ketoconazole External Cream 2 % Topical (applied to a body surface, including the skin or the inside of the mouth) apply to lower extremities topically everyday shift for lower…

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 label and date food items in the patient refrigerator per facility policy. This deficient practice had the potential to result in harmful bacterial growth that could lead to foodborne illness (a disease caused by consuming food or drinks that are contaminated by germs or toxins) in 2 of 3 medically compromised residents who had food stored in the patient refrigerator.Findings: During an observation on 2/2/2026 at 8:45 AM the resident refrigerator located next to nurse's station contained one paper bag, one plastic bag, and one container of dessert labeled tiramisu. The plastic bag was tied closed with a room number written on it but no date. The dessert container had no name, room number, or date. During a concurrent interview with Assistant Director of Nursing (ADON), ADON confirmed and stated that no date was labeled. ADON inspected the contents of the bag inside which contained a plate covered with a black plastic dome lid underneath which was a slice of ham and a side of cooked greens. ADON confirmed lack…

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 full length curtains around the bed for two of 22 sampled residents (Residents 56 and 74). This deficient practice prevented Residents 56 and 74 from having full privacy in Resident 56 and Resident 74's room. Findings: During a review of Resident 74's admission Record (AR) dated 1/26/2026, the AR indicated Resident 74 admitted to the facility on [DATE] with diagnoses including, but not limited to spinal stenosis (spaces inside bones of the spine get too small), polyneuropathy (damage of the nerves that can cause weakness, numbness, and burning pain), and unsteadiness on feet. During a review of Resident 74's Minimum Data Set (MDS, resident assessment tool) dated 1/13/2026, the MDS indicated Resident 74 was cognitively intact (sufficient judgement, planning, organization to manage average demands in one's environment). The MDS indicated Resident 74 required dependent assistance with oral hygiene, toileting, dressing, and sit to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide one of 22 sampled residents (Resident 74) with an appropriate closet with doors and drawers in Resident 74's room. This deficient practice prevented Resident 74 from having a private closet with doors and furniture with enough storage in a homelike environment.Findings: During a review of Resident 74's admission Record (AR) dated 1/26/2026, the AR indicated Resident 74 admitted to the facility on [DATE] with diagnoses including, but not limited to spinal stenosis (spaces inside bones of the spine get too small), polyneuropathy (damage of the nerves that can cause weakness, numbness, and burning pain), and unsteadiness on feet. During a review of Resident 74's Minimum Data Set (MDS, resident assessment tool) dated 1/13/2026, the MDS indicated Resident 74 was cognitively intact (sufficient judgement, planning, organization to manage average demands in one's environment). The MDS indicated Resident 74 required dependent assistance…

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 call buttons were within reach for one of eight sampled residents Resident 11. This deficient practice had the potential to result in delay of necessary care including emergency response for Resident 11.Findings: A review of Resident 11's admission Record indicated Resident 11 was admitted to the facility on [DATE], with medical diagnoses that included: Muscle weakness (a lack of physical or muscle strength, throughout the body). Dementia, (a condition characterized by progressive or persistent loss of intellectual functioning especially with loss of memory). Depression, (a constant feeling of sadness and loss of interest). A review of Resident 11's Minimum Data Set (MDS - a resident assessment tool), dated 12/21/2025 indicated Resident 11's cognition (the mental ability to make decisions of daily living) was intact. Resident 11 required moderate to maximal assistance from staff for toileting, hygiene, bathing, upper and lower…

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 22 sampled residents (Resident 74) when there was a large patch of paint peeling next to Resident 74's window and there were a brown circular stain and bubbling paint on the ceiling to the right of Resident 74's window. This deficient practice caused Resident 74 to reside in an uncomfortable environment.Findings: During a review of Resident 74's admission Record (AR) dated 1/26/2026, the AR indicated Resident 74 admitted to the facility on [DATE] with diagnoses including, but not limited to spinal stenosis (spaces inside bones of the spine get too small), polyneuropathy (damage of the nerves that can cause weakness, numbness, and burning pain), and unsteadiness on feet. During a review of Resident 74's Minimum Data Set (MDS, resident assessment tool) dated 1/13/2026, the MDS indicated Resident 74 was cognitively intact (sufficient judgement, planning, organization to manage average…

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 reviews, the facility failed to meet professional standards of quality for two of five sample residents (Resident 1, Resident 2) by failing to:Ensure Resident 1 was not allowed to self-administer medications and treatment as indicated in Resident 1's Self Administration of Drugs Assessment which indicated that Resident 1 was not safe to self-administer drugs.Ensure the physician's orders for skin treatments were carried through and documented properly for Resident 1 and Resident 2.These deficient practices placed residents at risk of infection and failure in the delivery of necessary care and services for Resident 1 and Resident 2.Findings:During a review of the admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including neuromuscular dysfunction of bladder (refers to bladder control problems caused by damage to the nerves, spinal cord, or brain), hypertension (HTN-high blood pressure) and atrial…

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, facility failed to ensure staff obtained consent (communication process between the clinician and the patient that's ensures that the patient is fully informed about the nature of the procedure or intervention, the potential risks and benefits, and the alternative treatments available) to COVID -19 and influenza informed consents were properly obtained from a resident with cognitive impairment according to the facility policy and procedures (P&P) titled, Coronavirus Vaccine Policy (COVID-19 Vaccine Policy) reviewed on 7/11/2025, for one of four sampled residents (Resident 8).This deficient practice resulted in the facility violating the rights for Resident 8.Findings: A review of Resident 8's admission Record indicated that Resident 8 was admitted to the facility on [DATE] and was readmitted to the facility on [DATE] with diagnoses that included schizophrenia (a serious mental illness that is characterized by disturbances in thought), hyperlipidemia, and hypertension (HTN).…

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 review, facility failed to ensure staff adhered to infection control practices by failing to:1. Ensure four of five sampled residents (Residents 5, 6, 7, and 8) received Coronavirus disease 2019 (COVID-19 - an illness caused by a virus which causes severe acute respiratory syndrome), pneumonia (an infection in one or both lungs that may be caused by bacteria, viruses, or fungi) and influenza (an infection of the nose, throat and lungs, which are part of the respiratory system) vaccines2. Ensure certified nursing assistant (CNA) 1, CNA 2, and licensed vocational nurse (LVN) 1 were fit tested (confirm that a respirator forms a tight seal to your face before you use it in the workplace) for N95 mask (a personal protective equipment [PPE] used to protect the wearer from particles or from liquid contaminating the face) according to the facility P&P titled, Fit Test and Respirator Seal Check Policy reviewed [DATE].3. Ensure facility staff performed hand hygiene and donned…

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 staff followed proper infection prevention and control practices when attempting to provide care to one of three sampled residents, Resident 2. A Certified Nursing Assistant (CNA) 2 was observed dropping a clean towel onto the floor and then mixing the towel with clean linen and gown attempting to use the same towel on a resident. This deficient practice had the potential to place Resident 2 at risk of cross contamination and exposure to infectious agents from environmental surfaces. Findings:A review of Resident 2's admission record indicated, Resident 2 was admitted to the facility on [DATE] with a diagnosis including acute respiratory failure with hypoxia ((a condition in which your blood doesn't have enough oxygen causing shortness of breath and difficulty breathing, often caused by a disease or injury), benign neoplasm of meninges (a slow growing, non-cancerous tumor that develops around the brain and spinal cord), acute kidney…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to:1. Notify a physician that one of two sample residents (Resident 1) was experiencing itching in both eyes since 2023.2. Develop a policy and procedures for eye/vision care.These failures resulted in Resident 1 to continue rubbing and experience itching in both eyes and develop dark discoloration (change in the color or pigmentation of the skin) in both eyes.Finding: During a record review, Resident 1's admission record indicated Resident 1 was admitted to the facility on [DATE] and re-admitted to the facility on [DATE] with a diagnoses of type 2 diabetes (a condition where your body either doesn't make enough insulin or can't use the insulin it makes to get energy from food), and essential hypertension (high blood pressure with no identifiable medical cause). During a record review, Resident 1's Minimum Data Set (MDS- a resident assessment and screening tool) dated 6/19/2025, indicated the resident's cognition (mental ability to make…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to notify Resident 1's Family Member 1 (FM 1) when Resident 1's room was changed on 5/7/2025 and 5/8/2025. This deficient practice violated the residents' rights of notification according to facility's policy and procedure titled, Transfer Room to Room and Resident's Rights. Findings: During a review of the admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis including atherosclerotic heart disease (build-up of fats, cholesterol, and other substance in and on the arterial walls), endocarditis (an infection of the heart's inner lining, including the heart valves), and depression (a mood disorder that causes persistent feeling of sadness and loss of interest). During a review of the Minimum Data Set (MDS - resident assessment tool) dated 4/30/2025, indicated Resident 1's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to protect one of four sampled residents (Resident 1) from misappropriation (the unauthorized, improper, or unlawful use of funds or other property for purposes other than that for which intended) of property and personal belongings. This deficient practice resulted in Resident 1's missing cochlear hearing aid (a small electronic device that can provide a sense of sound to people who are deaf or hard-of-hearing) and significantly impacted Resident 1's ability to hear, potentially leading to social isolation and safety concerns. Findings: During a review of the admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis including atherosclerotic heart disease (build-up of fats, cholesterol, and other substance in and on the arterial walls), endocarditis (an infection of the heart's inner lining, including the heart valves), and depression (a mood disorder that causes persistent feeling 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 develop a comprehensive care plan (CP) that met the care/services based on the resident's individual assessed needs for one of six sampled residents (Resident 1) behavior of removing mittens and pulling on tracheostomy (a surgical procedure where a hole, called a stoma, is made in the neck to access the windpipe [trachea]) and gastrostomy tube (g-tube - a tube surgically inserted through the skin and directly into the stomach). This deficient practice had the potential to result negative impact on residents ' health and safety, as well as the quality of care and services received. Findings: During a review of the admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis including respiratory failure (condition in which your blood does not get enough oxygen or has too much carbon dioxide), dependence on respiratory [ventilator] status (means that a person needs a machine to breathe…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure resident received treatment and care in accordance with professional standards of practice for one of three sampled residents, Resident 1 by failing to: A. Implement Resident 1 ' s blood sugar check (BSS - measures the glucose levels in the blood) according to physician ' s order and care plan (CP). B. Implement facility ' s policy and procedure (P&P) titled, Death of a Resident, Documentation when Resident 1 expired on [DATE]. These deficient practices placed Resident 1 in incomplete assessment and documentation required per facility ' s policy and procedure upon death. Findings: A. During a review of the admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis including respiratory failure (condition in which your blood does not get enough oxygen or has too much carbon dioxide), dependence on respiratory [ventilator] status (means that a person needs a machine to breathe…

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 5) rights by failing to treat her with dignity and respect by leaving resident exposed while changing Resident 5 ' s incontinence diaper. This deficient practice had the potential to cause embarrassment for Resident 5 Cross reference F726, F755. Findings: During a review of the admission record for Resident 5 indicated Resident 5 was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses including dementia (a progressive state of decline in mental abilities), hypertension (HTN-high blood pressure), and dysphagia (difficulty swallowing). During a review of Resident 5 ' s Minimum Data Set (MDS – a resident assessment tool) dated 1/30/2025, indicated Resident 5 had severe cognitive impairment (a noticeable decline in thinking skills that significantly impacts daily life, making it harder to perform everyday tasks and manage finances, among other things). The same 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 interviews and record review, the facility failed to ensure: 1. Licensed Vocational Nurse (LVN) 2 had the skills and knowledge to safely prepare and administer medications for one-of-one sampled resident (Resident 4) by crushing all morning medications on 5/15/2025 without a physician ' s order. 2. Certified Nursing Assistant (CNA) 1 treated one-of-one sampled resident (Resident 5) with dignity and respect by failing to provide privacy and leaving resident exposed while changing Resident 5 ' s incontinence diaper. This failure had the potential to result in medication side effects such as low blood pressure for Resident 4 and embarrassment for Resident 5. 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 schizophrenia (a mental illness that is characterized by disturbances in thought), hypertension (HTN-high blood pressure), and dysphagia (difficulty swallowing).…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record reviews the facility failed to implement procedures to ensure safe dispensing and administration of medications for one out of one observed residents (Resident 4) by failing to: 1. Properly identify Resident 4 when preparing her (Resident 4) morning medications. 2. Crushing medications without a physician ' s order 3. administering all medications as ordered by the physician. This deficient practice had the potential to increase the risk of medication adverse reactions. Cross reference F726. 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 schizophrenia (a mental illness that is characterized by disturbances in thought), hypertension (HTN-high blood pressure), and dysphagia (difficulty swallowing). During a review of Resident 4's history and physical (a term used to describe a physician's examination of a patient) for 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 observation, interview, and record review, the licensed nursing staff failed to maintain complete and accurate medical records in accordance with the accepted professional standards for three of four sample residents (Resident 1, Resident 2, Resident 3). The facility failed to ensure Medication Administration Record (MAR) was completed with identifiable information of licensed staff initials and signature. This deficient practice had the potential to result in medication administration errors and delays in communication between staff leading to care interruptions. Findings: A review of Resident 1 ' s admission Records dated 5/7/2025 indicated, Resident 1 was initially admitted to the facility on [DATE] with a diagnosis not limited to hypertension (HTN- when the pressure in your blood vessels is too high), end stage renal disease (ESRD - The stage of renal impairment that appears irreversible and permanent, and requires a regular course of dialysis or kidney transplantation to maintain life). A review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to maintain a clean and homelike environment in room [ROOM NUMBER]. This deficient practice had the potential for accidents and resulted in the room to be cluttered and disorderly. Findings: During an initial tour of the facility on 3/10/2025 at 9:45 AM, resident room [ROOM NUMBER] was observed with the following: Ø room [ROOM NUMBER] is occupied by three beds. Ø Bed A and B in room [ROOM NUMBER] were open, bed C is occupied by Resident 1. Ø Bed B was covered with blankets to absorb a water leak from the ceiling. Ø Floor next to bed A and B were covered with blankets from ceiling water lead above bed A and B. Ø Wash basins filled with blankets to absorb water leak were on the floor next bed B, and C, and on bed B. During an interview on 3/10/2025 at 10 AM with Resident 1, Resident 1 stated, the ceiling in the room started leaking water a couple of months ago during the rain time. The facility is still looking to find and fix the hole in 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 that the Case Manager (CM) have the specific competencies and skill sets necessary to ensure that the admission process is seamless and efficient according to facility's policy and procedure (P&P) titled, Nurse admission Policy: Duties and Responsibilities. This deficient practice resulted in a negative effect to residents' plan of care and delivery of necessary care and services. Findings: During an interview with Business Office Manager (BOM) on 1/7/2025 at 10:48 a.m., BOM stated, referrals are sent from hospital regarding a potential residents' new admission. BOM stated, the referrals are first reviewed by the CM who does not work onsite and works out of state. During the on-site visit on 1/7/2025 at 10:56 a.m., surveyor tried to contact CM via telephone and CM's contact number did not ring, went straight to voicemail but the voicemail box was full. Surveyor tried to contact CM on multiple occurrences at 10:56 a.m., 11:05 a.m., 11:45 a.m., 11:53 a.m., 11:54 a.m., and 11:57 a.m. During a follow-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 interviews, and record reviews the facility failed to implement its' abuse policy and procedures (P&P) when the facility did not report to the California Department of Public Health (State Agency) of an alleged abuse of one of four sampled residents (Resident 1). This deficient practice resulted in a delay of the onsite investigation by the State Agency and the potential to place Residents 1 to be exposed to continuous sexual abuse from the alleged abuser causing mental anguish and emotional distress. Findings During a review of Resident 1's face sheet indicated the facility initially admitted the resident on 7/25/2024 and readmitted the resident on 7/31/2024 with diagnoses that included obstructive hydrocephalus (a condition that occurs when the flow of cerebrospinal fluid (CSF) is blocked in the brain), depression (a common and serious medical illness that negatively affects how you feel, the way you think and how you act), and hypertension (HTN-high blood pressure). During a review of Resident 1's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, for two of six sampled residents (Residents 21 and 101), the facility failed to ensure: 1. Residents clothes received back the exact number and color of clothes after the cclothes were washed, 2. Residents did not wear other residents clothes. These failures resulted in Resident 101, and 21 loosing their clothes, Resident 101's T-shirt was bleached from black color to biege color, and another resident wearing Resident 101's T-shirt. Findings: A review of Resident 21's admission Record indicated Resident 21 was admitted to the facility on [DATE] with diagnoses including, hypertension (high blood pressure), depression (a common but serious mood disorder that causes a persistent feeling of sadness and loss of interest), and vertigo (dizziness). A review of Resident 21's Minimum Data Set (MDS - a resident assessment tool) dated 11/20/24, indicated Resident 21 cognition (a person's mental ability to think, learn, remember, use judgement, and make decisions) 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 provide care in a manner that maintained or enhanced a resident's dignity and respect in full recognition of his/her individuality for two (2) out of the 18 sampled residents (Resident 34 and Resident 69) by: 1. Staff standing over Resident 34 while assisting her to eat a meal. 2. Failing to describe what food was on the food tray and where each food item was located on the food tray. Resident 69 is visually impaired (is a partial or total inability to see). This deficient practice had the potential to affect Resident s self-esteem, self-worth, and dignity. Findings: A review of Resident 34's admission record indicated Resident 34 was admitted to the facility on [DATE] with diagnoses that included dementia (a general term impaired thinking, remembering or reasoning that can affect a person ' s ability to function safely) arthritis (is inflammation or degeneration of one or more joints), hypertension (elevated/high blood pressure) 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, Certified Nursing Assistant (CNA) 1 failed to protect the resident's rights by not closing the privacy curtain to ensure a resident is visually exposed to the roommates while the performing personal care for one of 24 sampled residents (Resident 13). This deficient practice violated the Resident 13's right for privacy. Findings: A review of the admission record indicated Resident 13 was admitted to the facility on [DATE] and was re-admitted the resident to the facility on [DATE], with diagnoses including Stage 4 pressure ulcer (deep wound reaching the muscles, ligaments, or bones), respiratory failure (a condition in which your lungs have a hard time loading your blood with oxygen or removing carbon dioxide) and tracheostomy [an opening created at the front of the neck so a tube can be inserted into the windpipe to help you breathe]. A review of Resident 13's Minimum Data Set (MDS-a resident assessment tool) dated 11/26/2024, indicated Resident 13's cognition…

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 safe, comfortable, and clean homelike environment for one out of three sampled residents (Resident 101) by failing to: 1. Repair the window frame was broken and the window glass that had detached from the window frame was repaired. 2. Trash was not left on the floor. 3. The floor was not partially cleaned. These failures resulted in cold air to continuously enter Resident 101's room making the residnt feel uncomfortably cold at night, and was ashamed of her living area. Findings: A review of Resident 101's admission record indicated the facility admitted Resident 101 on 11/12/24 with diagnoses including, Raynaud's syndrome (A condition affecting fingers and toes, causing them to loose blood flow when exposed to cold temperatures),sSchizophrenia (a chronic (a condition or something that continues or occurs again over a long period of time) mental illness that affects how a person thinks feels, and behaves), depression (a mental health condition that involves a prolonged period of feeling sad, hopeless, and unable to…

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

Based on interview and record review the facility failed to develop a comprehensive care plan (a document outlining a detailed approach to care customized to an individual resident's need) for physical restraints one of 24 sampled residents (Resident 30). This deficient practice had the potential for Resident 30 to not be provided with effective personalized care. Findings: A review of Resident 30's admission Record indicated the facility originally admitted the resident on 10/11/2022 and re-admitted the resident on 9/18/2024 with diagnoses that included respiratory failure ( a condition in which your lungs have a hard time loading your blood with oxygen or removing carbon dioxide) epilepsy (a brain condition that causes recurring seizures[a sudden, uncontrolled burst of electrical activity in the brain]), tracheostomy [an opening created at the front of the neck so a tube can be inserted into the windpipe to help you breathe] and ventilator dependence (a person requires a machine called a ventilator to breathe for them). A review Resident 30'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 interview and record review, the facility failed to provide restorative nursing assistance program (RNA -a program/person that helps patient regain their ability to perform daily activities after an illness or injury) according to the physician's orders for one of five sampled residents (Resident 38). This deficient practice resulted in Resident 38 not receiving therapy for two out of 31 days in 11/2024 placing Resident 38 at increased risk for decline in physical function and possibly contractures. Findings: A review of Resident 38's admission Record indicated the facility admitted Resident 38 on 5/2/2019 and readmitted Resident 38 on 10/19/2024 with diagnoses including hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body), Diabetes mellitus (DM - a disorder characterized by difficulty in blood sugar control and poor wound healing), and hypertension (HTN -high blood pressure). A review of Resident 38's physician orders, dated 10/28/2024, indicated, Restorative Nurse Assistant (RNA -a healthcare professional who helps patients regain 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 to fully identify, evaluate, and implement accident risks and hazard interventions for one out of 18 sampled residents (Resident 51) to prevent Resident 51 from falling. These deficient practices resulted in Resident 51 falling on 5/9/2024. Resident 51 was transferred a general acute care hospital (GACH) on 5/9/2024 where the resident was diagnosed with acute on chronic right frontal convexity subdural hematoma measuring approximately 11 millimeters (mm-unit of measurement) in depth with associated 4mm of leftward midline shift. On 5/10/2024, Resident 51 developed for altered mental status (AMS- a change in mental function that stems from illnesses0, was intubated (a process where a healthcare provider inserts a tube through a person's mouth or nose, then down into their trachea [airway/windpipe] so that air can get through) disorders and injuries affecting the brain), and then transferred to Intensive Care Unit (ICU-a unit in a hospital that provides 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 label tube feeding (nutrition in a liquid form) according to facility policy and procedure for one of ten sampled residents (Resident 44). This deficient practice had the potential to cause infection. Findings: A review of Resident 44's admission Record indicated the facility admitted Resident 44 on 1/10/2020 and readmitted Resident 44 on 11/8/2024 with diagnoses including Dependent on respiratory ventilator (a medical device to help support or replace breathing), dysphagia (difficulty swallowing), and hypertension (HTN -high blood pressure). A review of Resident 44's Minimum Data Set (MDS - a resident assessment tool) dated 11/29/2024, indicated Resident 44 had cognitive impairment (when a person has trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life). The MDS indicated Resident 44 was dependent on staff for activities of daily living. During an observation on 12/2/2024, at 9:12 A.M., in Resident 44's room, the tube feeding bottle was observed hanging…

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 outside staff food was not stored in the kitchen refrigerator #3. This deficient practice placed the residents at increased risk to suffer foodborne illness (food poisoning). Findings: During an observation in the kitchen on 12/2/2024 at 7:32 AM, a half filled 20 ounce (oz) cup from an outside coffee shop, a can of carbonated soda, an open undated bag of tortillas, and an unlabeled plastic container of an unknown substance was stored in the kitchen top freezer refrigerator #3. During a concurrent interview and observation on 12/2/2024 at 7:36 AM, with [NAME] (CK) 1 the tortillas, soda, coffee drink and plastic container were not foods for the residents. CK 1 stated those items should not be stored in the kitchen refrigerator and CK 1 asked another kitchen staff member to remove the items. stated During an interview on 12/2/2024 at 7:46 AM, with the Dietary Supervisor (DS), the DS stated those were staff food items and should not have been stored in the kitchen refrigerator. The DS further stated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, for two of 18 residents (Residents 69 and 44), the facility failed to: 1. Provide hand hygiene to Resident 69 prior to meals. 2. Label tube feeding (nutrition in a liquid form) according to facility policy and procedures for Resident 44. These deficient practices had the potential to cause infection and cross contamination with infectious agents such as blood, body fluids, secretions and excressions (visible and invisible) for Residents 69 and 44. Findings: 1. A review of Resident 69s admission record indicated Resident 69 was originally admitted to the facility on [DATE] and re-admitted on [DATE], with diagnoses that included hyperlipidemia (a condition where there are high levels of lipids, or fats, in the blood), lack of coordination, encephalopathy (is a disturbance of brain function), hypertension (HTN-High blood pressure) and blindness to the left and right eye. A review of the History and Physical report completed on 9/13/2024, indicated Resident 69 did…

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 (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered) before administering an influenza vaccine (flu vaccine -an injection that helps prevent the flu and its complications) for one of five sampled residents (Resident 41). Resident 41 received the Influenza vaccine on 11/4/2024 and the consent for Influenza vaccine was obtained on 11/8/2024. This deficient practice violated the responsible party's (RP) right to be notified in order to make an informed choices for Resident 41 to receive or not to receive the influenza vaccine. Finding: A review of Resident 41's admission Record indicated the facility admitted Resident 41 on 6/30/2022 and readmitted Resident 41 on 4/1/2024 with diagnoses including Alzheimer's disease (a disease characterized by a progressive decline in mental abilities), pressure ulcer (localized, pressure-related damage to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to protect the resident's right to be free from resident to resident physical abuse for one of two sampled residents (Resident 1). The facility was aware for a couple of months, that Resident 2 had been asking Resident 1 to marry Resident 2. As a result, on 10/20/2024 at 1:50 PM, Resident 1 got upset with Resident 2 after Resident 2 sneezed on Resident 1's shoulder. Also, Resident 2 hit Resident 1. Findings: During a review of Resident 1's face sheet (admission Record -front page of the chart that contains a summary of basic information about the resident), indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including: hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body), dementia (a progressive state of decline in mental abilities), lack of coordination (loss of muscle control in the arms and legs), and glaucoma (a group of eye diseases that can cause vision loss and blindness). During…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to thoroughly investigate resident to resident physical abuse and harassment for one of two sampled residents (Resident 1). The facility was aware that for a couple of months, Resident 2 had been asking Resident 1 to marry Resident 2. This deficient practice resulted in two months continuous verbal abuse and harassment to Resident 1 by Resident 2 which resulted in Resident 1 and Resident 2 hitting each other on 10/20/2024. Cross Reference F600 Findings: During a review of Resident 1's face sheet (admission Record -front page of the chart that contains a summary of basic information about the resident), indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including: hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body), dementia (a progressive state of decline in mental abilities), lack of coordination (loss of muscle control in the arms and legs), and glaucoma (a group of eye diseases 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.

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 1), had an order for Rehabilitation Services evaluation carried out. This failure had the potential to result in Resident 1 ' s functional decline. Findings: During a review of Resident 1's Face Sheet (FS, first page of resident medical record with summary of the resident ' s information including diagnosis), dated 10/24/24, the FS indicated, Resident 1 was readmitted to the facility on [DATE] with diagnoses acute respiratory failure (disease of injury that affects one ' s ability to breath) with hypoxia (low level of oxygen in body tissues), metabolic encephalopathy (problem with the brain cause by chemical imbalance in the blood), tracheostomy (an alternate way breathing via a surgical hole in the windpipe), dependence on ventilator (mechanical device that helps you breath, moves air in and out of lungs). During a review of Resident 1 ' s Minimum Data Set (MDS, a standardized assessment and screening…

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 staff provided adequate supervision and monitoring to prevent elopement (the act of leaving a facility unsupervised and without prior authorization) for one of three sampled residents (Resident 1). This deficient practice resulted in Resident 1 eloping from the facility on 10/04/2024 at 9:36 AM., placing the resident at increased risk to suffer accidents, falls with injuries, physiological (referring to the body and its systems) harm, hospitalization, and death. Resident 1 went to family member 1's (FM 1) residence and never returned back to the facility. Findings: During 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] with the following diagnoses: metabolic encephalopathy (brain dysfunction caused by an underlying condition), end stage renal disease (ESRD- when the kidneys stop functioning on a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to monitor residents' personal foods that were placed in a residents' refrigerator and ensure the refrigerator was unaccessible by other residents and/or family member per facility ' s policy and procedure. This deficient practices had the potential to result in missing residents ' own food and food-borne illness and compromised infection control for all residents who received food from outside sources. Findings: A review of Resident 1's Face Sheet indicated Resident 1 was admitted originally to the facility on 4/30/2022 and readmitted on [DATE] with diagnoses including atrial fibrillation (afib- an irregular and very rapid heart rhythm that and can lead blood clots in the heart) and paraplegia (loss of movement and/or sensation, to some degree, of the legs). A review of Resident 1's History and Physical (H&P) dated 2/16/2024 indicated, Resident 1 has the capacity for medical decision making. A review of Resident 1's Minimum Data Set (MDS -…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the Resident Council Meetings were conducted regularly at least monthly for per facility's policy and procedure titled, Resident Council. This deficient practice resulted in unresolved residents' grievances related to residents' care needs. Findings: 1. A review of Resident 1's Face Sheet indicated Resident 1 was admitted originally to the facility on 4/30/2022 and readmitted on [DATE] with diagnoses including atrial fibrillation (afib- an irregular and very rapid heart rhythm that and can lead blood clots in the heart) and paraplegia (loss of movement and/or sensation, to some degree, of the legs). A review of Resident 1's History and Physical (H&P) dated 2/16/2024 indicated, Resident 1 has the capacity for medical decision making. A review of Resident 1's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 7/30/2024, indicated Resident 1's cognitive skill (mental action or process of acquiring knowledge 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 one of one sampled resident, (Resident 2)'s clinical record was updated per facility's policy and procedure by failing to: 1. ensure Resident 2's clinical records were updated regarding Physician Orders for Life-Sustaining Treatment (POLST - is a form designed to improve patient care by creating a portable medical order form that records patients' treatment wishes so that emergency personnel know what treatments the patient wants in the event of a medical emergency). This deficient practice had the potential to cause conflict with resident's wishes regarding health care. Cross Reference F656. Findings: A review of Resident 2's Face Sheet indicated Resident 2 was admitted to the facility on [DATE] with diagnoses including heart failure (a condition in which the heart does not pump blood as well as it should), atherosclerotic heart disease of the native coronary artery, also known as coronary artery disease (CAD - a common heart condition 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement a comprehensive care plan that met the care/services based on the resident's individual assessed needs for one of three sampled residents (Resident 2) by failing to ensure that a comprehensive (CP) was implemented, This deficient practice had the potential to result negative impact on residents' health and safety, as well as the quality of care and services received. Findings: A review of Resident 2's Face Sheet indicated Resident 2 was admitted to the facility on [DATE] with diagnoses including heart failure (a condition in which the heart does not pump blood as well as it should), atherosclerotic heart disease of the native coronary artery, also known as coronary artery disease (CAD - a common heart condition that occurs when plaque builds up in the coronary arteries) and muscle weakness. A review of Resident 2's History and Physical (H&P) dated [DATE] indicated, Resident 2 has the capacity to understand and make decisions. A review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, facility failed to ensure two of five sampled residents (Resident 3 and Resident 4) was free from significant medication error by failing to ensure Resident 3 and Resident 4's medications were given on time and as ordered by the physician and according to facility's policy and procedure. These deficient practices have the potential to result in residents' unintended complications related to the management of medications. Cross Reference: F656 Findings: 1. A review of Resident 3's admission Record indicated the facility originally admitted the resident on 11/10/2023 and readmitted on [DATE] with diagnoses including hypertension (HTN - elevated blood pressure), diabetes mellitus (DM-a chronic condition that affects the way the body processes blood sugar [glucose]), and respiratory failure (condition in which your blood does not get enough oxygen or has too much carbon dioxide). A review of Resident 3's Minimum Data Set (MDS-standardized assessment and screening…

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 a comprehensive care plan that met the care/services based on the resident's individual assessed needs for two of five sampled residents (Resident 3 and Resident 4) by failing to ensure that a comprehensive care plan (CP) was implemented for administering medications. This deficient practice had the potential to result negative impact on residents ' health and safety, as well as the quality of care and services received. Findings: 1. A review of Resident 3's admission Record indicated the facility originally admitted the resident on 11/10/2023 and readmitted on [DATE] with diagnoses including hypertension (HTN - elevated blood pressure), diabetes mellitus (DM-a chronic condition that affects the way the body processes blood sugar [glucose]), and respiratory failure (condition in which your blood does not get enough oxygen or has too much carbon dioxide). A review of Resident 3's Minimum Data Set (MDS-standardized assessment 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 provide sufficient staffing to accommodate the residents needs and request by not administering medications to one of five sampled residents (Resident 4). This deficient practice resulted in Resident 4 not receiving needed services timely and efficiently and had the potential to affect the quality of life and treatment given to the residents. Findings: A review of Resident 4 ' s admission Record indicated Resident 4 was originally admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses including respiratory failure (condition in which your blood does not get enough oxygen or has too much carbon dioxide), hypertension (HTN - elevated blood pressure), diabetes mellitus (DM-a chronic condition that affects the way the body processes blood sugar [glucose]). A review of Resident 4 ' s Minimum Data Set (MDS-standardized assessment and screening tool), dated 7/30/2024, indicated Resident 4 ' s cognition (the mental action or process 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 protect one of six sampled residents (Resident 2) from misappropriation (the unauthorized, improper, or unlawful use of funds or other property for purposes other than that for which intended) of property and personal belongings. This deficient practice resulted in Resident 2 ' s missing mobile phone and chargers. Findings: A review of Resident 2 ' s Face Sheet indicated Resident 2 was originally admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included intracranial injury (a form of acquired brain injury, occurs when a sudden trauma causes damage to the brain), cellulitis (bacterial skin infection) of right upper limb, and meningitis (inflammation of the tissues surrounding the brain and spinal cord). A review of the Resident 2's Minimum Data Set (MDS, a standardized resident assessment and care-screening tool) dated 7/27/2024, indicated Resident 2's cognition (the mental action or process of acquiring knowledge 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 implement their policy regarding reporting of residents ' allegation of physical abuse and to submit a conclusion report of investigation within five days or in accordance with state or federal law for one of six sampled residents (Resident 1). This resulted in a delay of an onsite inspection by the Department of Public Health to ensure the residents' allegation of abuse was investigated which can also lead to a delay in prevention of further physical abuse for Resident 1. Findings: A review of Resident 1 ' s Face Sheet indicated the resident was originally admitted on [DATE] and readmitted on [DATE] with diagnoses including metabolic encephalopathy (a chemical imbalance in the blood affecting the brain), hemiplegia (loss of the ability to move in one side of the body) following cerebral infarction (lack of blood flow resulting in severe damage to some of the brain tissue) affecting left non-dominant side and bipolar disorder (a disorder associated…

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 1) who are smokers was not allowed to keep and use a marijuana in their possessions according to facility ' s policy and procedure. This deficient finding placed Resident 1 at risk for smoking related accident. Findings: A review of Resident 1 ' s Face Sheet indicated the resident was originally admitted on [DATE] and readmitted on [DATE] with diagnoses including metabolic encephalopathy (a chemical imbalance in the blood affecting the brain), hemiplegia (loss of the ability to move in one side of the body) following cerebral infarction (lack of blood flow resulting in severe damage to some of the brain tissue) affecting left non-dominant side and bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs). A review of Resident 1's Minimum Data Set (MDS - a comprehensive standardized assessment and care-screening tool) dated 8/2/2024, 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, facility failed to provide necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care to one of one sampled resident (Resident 1) by failing to address behavioral health care needs and implementing a person-centered care plan when Resident 1 had episodes of aggressiveness toward staff. This deficient practice had the potential to negatively affect the delivery of behavioral health care and services to Resident 1. Findings: A review of Resident 1 ' s Face Sheet indicated the resident was originally admitted on [DATE] and readmitted on [DATE] with diagnoses including metabolic encephalopathy (a chemical imbalance in the blood affecting the brain), hemiplegia (loss of the ability to move in one side of the body) following cerebral infarction (lack of blood flow resulting in severe damage to some of the brain tissue)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to: 1. Ensure one of five sampled residents (Resident 2) who is on an airborne precaution (a set of measures used to prevent the spread of infectious agents that can be transmitted through the air) for coronavirus (COVID-19 - an infectious disease that can cause respiratory illness in humans) was placed into a private single room. 2. Ensure two of two sampled residents (Resident 3, Resident 4) who were exposed to COVID-19 infections were placed into a contact precaution room according to facility ' s policy and procedures (P&P). These deficient practices had the potential to transmit infectious diseases and increase the risk of infection to the residents, staff, and visitors. Findings: 1. A review of Resident 2 ' s admission Record indicated Resident 2 was admitted to the facility on [DATE] with diagnoses including respiratory failure (condition in which your blood does not get enough oxygen or has too much carbon dioxide) with hypoxia (low…

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 enhance a resident's dignity and respect by failing to provide personal hygiene such as showering to one of four sampled residents (Resident 1). This deficient practice had the potential to negatively affect the residents' psychosocial wellbeing. 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 diagnoses including atrial fibrillation (afib- an irregular and very rapid heart rhythm that and can lead blood clots in the heart) and paraplegia (an injury that occurs lower down the spinal cord may only affect a person's lower body and legs). A review of Resident 1 ' s Minimum Data Set (MDS - a standardized assessment and screening tool), dated 7/30/2024, indicated Resident 1's cognitive skill (mental action or process of acquiring knowledge and understanding) for daily decision-making were intact. The MDS indicated Resident 4 required maximal assistance…

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 facility ' s policy and procedures were followed for a resident leaving against medical advice (AMA) for one of six sample residents (Resident 1). This failure resulted in an incomplete AMA form and the potential for serious complications due to Resident 1's diagnoses and medical condition. Findings: During a review of Resident 1's Face Sheet (first sheet of the medical record with detailed information about the resident), dated 12/12/23, the Face Sheet indicated, the resident was admitted to the facility on [DATE], with diagnoses including End Stage Renal Disease (ESRD, a condition where your kidneys no longer work as they should), anemia (a condition where you have low levels of healthy red blood cells to carry oxygen throughout your body), and dependence on renal dialysis (kidney dialysis, is the process of removing excess water, solutes, and toxins from the blood in people whose kidneys can no longer perform these functions naturally).…

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 the door alarm on one of four exit doors in working order. This failure had the potential to result in residents that were at risk for elopement (a resident leaving a safe area or premises without authorization or necessary supervision) to leave the facility. Findings: During an observation with concurrent interview on 8/23/24 at 9:16 am with Central Supply (CS) staff, the exit door located next to the kitchen was observed to not have a functioning alarm. The CS stated it was not like that when he checked it, it needs to be reported to the maintenance supervisor. During an observation with concurrent interview on 8/23/24 at 9:35 with Maintenance Supervisor (MS), the same exit door was opened and there was not alarm that sounded, the maintenance supervisor confirmed the alarm was not working and stated he will have to fix it for the resident ' s safety. During a review of the facility ' s policy and procedures safety and supervision of residents, reviewed 7/12/24, indicated, the facility strives to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to meet professional standards of quality of care and services by failing to ensure timely medication administration was provided to one of three sampled residents (Resident 4). This failure had the potential to negatively impact the delivery of care services provided to Resident 4. Cross Reference F755. Findings: During a review of Resident 4's admission Record indicated Resident 4 was admitted to the facility on [DATE] with diagnoses including dysphagia (difficulty swallowing food or liquid), chronic respiratory failure (condition in which your blood does not get enough oxygen or has too much carbon dioxide) and tracheostomy (an opening surgically created through the neck into the trachea [windpipe] to allow direct access to the breathing tube). During a review of Resident 4's Physician Orders, dated 5/23/2024, indicated a physician's orders scheduled at 9:00 a.m. for the following medications: · Multivitamin-Minerals (supplement) 1 tablet…

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 timely administer medications per facility policy to one of three sampled resident (Resident 4). This failure had the potential to result in medication ineffectiveness and risk for unsafe, and improper medication administration use. Cross Reference F658. Findings: During a review of Resident 4's admission Record indicated Resident 4 was admitted to the facility on [DATE] with diagnoses including dysphagia (difficulty swallowing food or liquid), chronic respiratory failure (condition in which your blood does not get enough oxygen or has too much carbon dioxide) and tracheostomy (an opening surgically created through the neck into the trachea [windpipe] to allow direct access to the breathing tube). During a review of Resident 4's Physician Orders, dated 5/23/2024, indicated a physician's orders scheduled at 9:00 a.m. for the following medications: · Multivitamin-Minerals (supplement) 1 tablet via gastrostomy (GT- a flexible tube surgically…

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 sufficient nursing staff was available to provide nursing and related services to meet the resident's needs safely and in a manner that promotes each resident's rights, physical, mental, and psychosocial well-being for four of eight sampled residents (Residents 4, 6, 7 and 8) by failing to: 1. Ensure the call light was answered timely for Resident 4. 2. Ensure scheduled showers were provided to Resident 6, 7 and 8. This deficient practice resulted in Residents 4, 6, 7 and 8 not receiving assistance from staff with activities of daily living (ADLs-bed mobility, walk in room/ corridor, transfer, toilet use, bathing, personal hygiene, etc.) in a timely manner and had the potential to affect the quality of life for Residents 4, 6, 7 and 8. Findings: 1. A review of Resident 4's admission Record indicated Resident 4 was originally admitted to the facility on [DATE] with diagnosis that included respiratory failure (condition in which your…

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 daily post in a visible and prominent place the updated actual hours worked by licensed and unlicensed nursing staffing directly responsible for resident care per shift on 7/1/2024. This deficient practice had the potential to prevent residents and visitors from knowing the accurate and final Direct Care Services Hours Per Patient Day (DHPPD) and had the potential to cause inadequate staffing. Findings: During an observation on 7/1/2024 at 10:08 a.m., in the front lobby, the nurse staffing hours information was posted and dated 6/26/2024. During an observation on 7/1/2024 at 10:16 a.m., in the subacute nurses' station, the nurse staffing hours information was posted and dated 6/26/2024. During an interview with the Director of Staff and Development (DSD) on 7/1/2024 at 12:10 p.m., the DSD stated that she (DSD) was supposed to post the nursing hours daily in the morning and update as needed. The DSD also stated it was important to update the nursing hours to make sure the facility is compliant with the staffing…

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 sufficient nursing staff was available to provide nursing and related services to meet the resident ' s needs safely and in a manner that promotes each resident ' s rights, physical, mental and psychosocial well-being for three of six sampled residents (Residents 1, 3 and 4) by failing to ensure sufficient staffing was provided to all three residents at all times. This deficient practice resulted in Residents 1, 3 and 4 not receiving assistance from staff with activities of daily living (ADLs-bed mobility, walk in room/ corridor, transfer, toilet use, bathing, personal hygiene, etc.) on a timely manner and had the potential to affect the quality of life and treatment for Resident 1, 3 and 4. Findings: 1. A review of Resident 1's admission Record indicated that Resident 1 was admitted to the facility on [DATE] with diagnosis including hemiplegia (paralysis on one side of the body), cerebral infarction (lack of blood flow resulting in severe…

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 three sampled resident (Resident 2) was treated with respect and dignity by failing to ensure Registered Nurse 3 (RN3) provided good customer service to Resident 2. RN3 stated to Resident 2 that, No one wanted to take care of you. This deficient practice has the potential to affect resident ' s sense of self-worth and self-esteem. Findings: A review of Resident 2's admission Record indicated that Resident 2 was admitted to the facility on [DATE] with diagnosis including hyperlipidemia (abnormally high levels of fats in the blood), diabetes mellitus (DM-a chronic condition that affects the way the body processes blood sugar [glucose]) and asthma (respiratory condition marked by spasms in the bronchi of the lungs, causing difficulty in breathing). A review of Resident 2's Minimum Data Set (MDS - a comprehensive standardized assessment and care-screening tool) dated 5/14/2024, MDS indicated Resident 2 has an intact cognition (mental action…

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 three sampled resident (Resident 1) was provided with a well-planned discharge planning process on a timely manner. This deficient practice has the potential for a delay of discharge to Resident 1. Findings: A review of Resident 1's admission Record indicated that Resident 1 was admitted to the facility on [DATE] with diagnosis including hemiplegia (paralysis on one side of the body), cerebral infarction (lack of blood flow resulting in severe damage to some of the brain tissue) and respiratory failure (condition in which your blood does not get enough oxygen or has too much carbon dioxide). A review of Resident 1's Minimum Data Set (MDS - a comprehensive standardized assessment and care-screening tool) dated 5/1/2024, MDS indicated Resident 1 has a severe impairment with cognition (mental action or process of acquiring knowledge and understanding) for daily decision-making and requiring total assistance from staff for activities of daily…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of three sampled resident (Resident 2) received treatment and care in accordance with professional standards of practice by failing to ensure Registered Nurse 3 (RN3) provided good customer service to Resident 2. RN3 stated to Resident 2 that, No one wanted to take care of you. This deficient practice has the potential to affect resident ' s sense of self-worth and self-esteem. Findings: A review of Resident 2's admission Record indicated that Resident 2 was admitted to the facility on [DATE] with diagnosis including hyperlipidemia (abnormally high levels of fats in the blood), diabetes mellitus (DM-a chronic condition that affects the way the body processes blood sugar [glucose]) and asthma (respiratory condition marked by spasms in the bronchi of the lungs, causing difficulty in breathing). A review of Resident 2's Minimum Data Set (MDS - a comprehensive standardized assessment and care-screening tool) dated 5/14/2024, MDS indicated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the employee file containing current/active certificate, license, background check, verification of references for six sampled staff. This deficient practice had a potential for staff not to safely and competently provide the necessary care to meet the resident's needs and prevent the residents from abuse and neglect. Findings: During a concurrent interview and record review on [DATE] at 5:45 PM with Licensed Vocational Nurse 3 (LVN 3), LVN 3 acknowledged the following documents were missing from each employee file: 1) Certified Nursing Assistant 1 (CNA 1)'s criminal, abuse and fraud background checks. 2) CNA 2's certificate, CPR (Cardiopulmonary Resuscitation) card, background check, and verification of references. 3) CNA 3's criminal background check and verification of references. 4) LVN 1's background check and verification of references. 5) Registered Nurse Supervisor 1 (RNS 1)'s criminal, fraud and abuse background checks,…

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

Based on observation, interview, and record review, the facility failed to: 1) ensure medication storage room was locked. 2) ensure key to the medication storage room was not left hanging out of the keyhole. 3) ensure medication storage room was kept in a clean, safe, and sanitary manner. 4) ensure medication storage room was not used for charting. 5) ensure medication storage room was not used by staff to store personal belongings, and food. 6) ensure medication storage room was not used to keep space heater running. These deficient practices had the potential to result in unsanitary storage room and to cause harm to residents when key to the medication storage room was not kept safe; when access to the medication storage room was not limited to specific staff; when medications were exposed to improper room temperature, when personal belongings and food were stored in the medication storage room. Findings: During a concurrent observation and interview on 5/26/2024 at 5:18 AM of medication storage room (MS room) within the west side nurse station with licensed vocational nurse 2…

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

Based on observation, interview, and record review, the facility failed to maintain an orderly and homelike interior for five of eleven sampled resident rooms by failing to: 1. Ensure the sliding screen door or window in 5 of the 11 sampled rooms were present and/or free from holes and damages. 2. Repair ceiling water damage in 1 of the 11 sampled rooms (Resident 2's room) These failures resulted in an unhomelike environment and uncomfortable interior including the potential for pest to get into the facility. Findings: During a concurrent observation and interview on 5/14/2023 between 10 am to 11 am, the Maintenance Supervisor (MS) stated and confirmed that four of the ten rooms in the subacute unit had sliding screen doors or windows that had holes, damages or were missing. The MS stated it is important for each room to have an intact sliding screen door or window to ensure pests and bugs do not enter the facility. During a concurrent observation and interview on 5/14/2024 at 11:40 am, the MS stated and confirmed the ceiling above Resident 2's side of the room needed to be repaired…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop and implement a comprehensive care plan to meet the care/services based on resident ' s individual assessed needs for one of seven sampled residents (Resident 6) by failing to ensure a care plan was developed and implemented for Resident 6 ' s inappropriate behavior. This deficient practice had the potential to result negative impact on Resident 6 ' s health and safety, as well as the quality of care and services received. Findings: A review of Resident 6 ' s face sheet, indicated that Resident 6 was admitted to the facility on [DATE], with diagnoses including metabolic encephalopathy (a disease in which the functioning of the brain is affected by some agent or condition-such as viral infection or toxins in the blood), neoplasm (a new and abnormal growth of tissues) of prostate (accessory gland of the male reproductive system) and atrial fibrillation (AF-an irregular rapid heart rate that commonly causes poor blood flow). 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 meet professional standards of care and practice for one of seven sampled residents (Resident 6) by failing to ensure that a change in condition was done when Resident 6 had an inappropriate behavior towards Physical Therapy Assistant 1 (PTA1). This deficient practice had the potential to negatively impact the delivery of care service provided to Resident 6. Findings: A review of Resident 6 ' s face sheet, indicated Resident 6 was admitted to the facility on [DATE], with diagnoses including metabolic encephalopathy (a disease in which the functioning of the brain is affected by some agent or condition-such as viral infection or toxins in the blood), neoplasm (a new and abnormal growth of tissues) of prostate (accessory gland of the male reproductive system) and atrial fibrillation (AF-an irregular rapid heart rate that commonly causes poor blood flow). A review of Resident 6's Minimum Data Set (MDS - a comprehensive standardized assessment 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 provide reasonable accommodations of resident needs and preferences for one of two sampled residents (Resident 1) by failing to: 1. Ensure facility staff followed up Resident 1 ' s transportation when Resident 1 had a surgery appointment. Resident 1 had to wait for his transportation back to the facility for almost five hours. 2. Ensure Resident 1 was assisted back to bed from the wheelchair. Resident 1 waited for almost four hours prior to getting assistance back to bed. These deficient practices had the potential not to meet Resident 1 ' s needs and preferences and had the potential to delay care for Resident 1. Findings: 1. A review of Resident 1 ' s admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and was re-admitted on [DATE], with diagnoses including sacral (area at the bottom of the spine [backbone] and the coccyx [tailbone]) pressure ulcer (injury to skin and underlying tissue resulting from prolonged…

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 meet professional standards of care and practice for one of six sampled residents (Resident 2) by failing to ensure physician (MD) order was followed when MD ordered Resident 2 to be transferred to general hospital (GACH) via GACH ' s regular transportation. Facility staff arranged a different type of transportation and failed to notify MD, Resident 2 and/or Resident 2 ' s family, change the order and document the necessary change of transportation. This deficient practice had the potential to negatively impact the delivery of care service provided to Resident 2. Findings: A review of Resident 2 ' s admission Record indicated Resident 2 was admitted to the facility on [DATE], with diagnoses including chronic obstructive pulmonary disease (COPD-group of lung diseases that block airflow and make it difficult to breathe), respiratory failure (condition in which your blood does not get enough oxygen or has too much carbon dioxide) and malnutrition (lack 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 sufficient nursing staff available at all times to provide nursing and related services to meet the resident ' s needs safely and in a manner that promotes each resident ' s rights, physical, mental and psychosocial well-being for one of two sampled residents (Resident 1) by failing to ensure Resident 1 was assisted back to bed from the wheelchair. Resident 1 waited for almost four hours prior to getting assistance back to bed. This deficient practice resulted in Resident 1 not receiving assistance from staff with activities of daily living (ADLs-bed mobility, walk in room/ corridor, transfer, toilet use, bathing, personal hygiene, etc.) on a timely manner and had the potential to affect the quality of life and treatment for Resident 1. Findings: A review of Resident 1 ' s admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and was re-admitted on [DATE], with diagnoses including sacral (area at the bottom 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 properly document albuterol sulfate/ipratropium bromide (Combivent-an inhaler medication used to treat and prevent symptoms of chronic obstructive pulmonary disease [COPD-group of lung diseases that block airflow and make it difficult to breathe] such as wheezing [whistling sound or coarse rattle sound when airway is partially blocked during inhalation] and shortness of breath) via medication administration record (MAR) after as needed (PRN) dose was administered to one of six sampled residents (Resident 2). This deficient practice had the potential to result in medication administration error and risk for unsafe, improper medication administration use. Findings: A review of Resident 2 ' s admission Record indicated Resident 2 was admitted to the facility on [DATE], with diagnoses including chronic obstructive pulmonary disease (COPD-group of lung diseases that block airflow and make it difficult to breathe), respiratory failure (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 provide professional standards of care and practice to one of three sampled residents (Resident 1) by failing to ensure proper documentation of refusals of showers and appropriate education provided to Resident 1. This deficient practice had the potential to negatively impact the delivery of care service provided to Resident 1. Findings: A review of Resident 1 ' s admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and was re-admitted on [DATE], with diagnoses including chronic obstructive pulmonary disease (COPD-group of lung diseases that block airflow and make it difficult to breathe), atrial fibrillation (AF-an irregular rapid heart rate that commonly causes poor blood flow) and polyneuropathy (weakness, numbness, and pain from nerve damage). A review of the Minimum Data Set (MDS - a comprehensive assessment and care screening tool), dated 12/22/2023, indicated Resident 1 ' s cognitive (mental action or process…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement their protocol for Antibiotic (medication that fight bacterial infection) Stewardship by ensuring completion of the Surveillance Data Collection Form (SDCF-form that facility was using to monitor antibiotic medication in the facility) for one of three sampled residents (Resident 1). This deficient practice had the potential for Resident 1 to develop antibiotic resistance (not effective to treat infection) from unnecessary or inappropriate antibiotic use. Findings: A review of Resident 1 ' s admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and was re-admitted on [DATE], with diagnoses including chronic obstructive pulmonary disease (COPD-group of lung diseases that block airflow and make it difficult to breathe), atrial fibrillation (AF-an irregular rapid heart rate that commonly causes poor blood flow) and polyneuropathy (weakness, numbness, and pain from nerve damage). A review of Resident 1's Minimum…

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 pain management was provided consistent with professional standard of practice for two of two sampled residents (Resident 2 and 9) by failing to assess and document pain assessment per facility policy. This deficient practice had the potential to negatively affect Resident 2 and 9 ' s physical comfort and psychosocial well-being when not being assessed properly. Cross Reference F755. Findings: 1. A review of Resident 2's admission Record indicated that Resident 2 was admitted to the facility on [DATE] with diagnosis including respiratory failure (condition in which your blood does not get enough oxygen or has too much carbon dioxide), and colon (abdominal parts of the body-large intestine) and bladder cancer (a disease in which abnormal cells divide uncontrollably and destroy body tissue). A review of Resident 2's Minimum Data Set (MDS - a comprehensive standardized assessment and care-screening tool) dated 10/27/2023, indicated Resident 2…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the Controlled Drug Record (CDR-accountability record of medications that are considered to have a strong potential for abuse) coincided with the Medication Administration Record (MAR) for two of two sampled residents (Residents 2 and 9). This deficient practice had the potential to result in medication error and/or drug diversion (illegal distribution or abuse of prescription drug). Cross Reference F697. Findings: 1. A review of Resident 2's admission Record indicated that Resident 2 was admitted to the facility on [DATE] with diagnosis including respiratory failure (condition in which your blood does not get enough oxygen or has too much carbon dioxide), and colon (abdominal parts of the body-large intestine) and bladder cancer (a disease in which abnormal cells divide uncontrollably and destroy body tissue). A review of Resident 2's Minimum Data Set (MDS - a comprehensive standardized assessment and care-screening tool) dated 10/27/2023,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide a safe, comfortable, and homelike environment by failing to ensure residents ' rooms were kept clean and sanitary for two of eight sampled residents (Resident 2 and 5). This deficient practice had the potential to negatively impact the resident ' s quality of life and placing Residents 2 and 5 at risk for accident, physical discomfort, and possibly spread of infection. Findings: 1. A review of Resident 2's admission Record indicated that Resident 2 was admitted to the facility on [DATE] with diagnosis including respiratory failure (condition in which your blood does not get enough oxygen or has too much carbon dioxide), and colon (abdominal parts of the body-large intestine) and bladder cancer (a disease in which abnormal cells divide uncontrollably and destroy body tissue). A review of Resident 2's Minimum Data Set (MDS - a comprehensive standardized assessment and care-screening tool) dated 10/27/2023, indicated Resident 2 has 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.

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 and services by failing to: 1. Ensure timely medication administration was provided to one of four sampled residents (Resident 8). 2. Ensure treatment order of colostomy (opening of the large intestine [abdominal area] to the outside of the body for passing of stool and gas) care for one of one sampled resident (Resident 2) was provided and documented properly under treatment administration record (TAR). 3. Ensure Rehabilitation Department documented the plan of care or progress notes to one of one sampled resident (Resident 1) when orthosis (device to improve and encourage proper joint alignment and/or protect existing limb) was needed prior to start of a rehabilitation therapy for Resident 1. Orthosis device was ordered late, unable to be evaluated for skilled therapy. These deficient practices had the potential to negatively impact the delivery of care services provided to Residents 1, 2…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to maintain proper storage of medication for one of four sampled resident (Resident 2) when opened Polyethylene glycol (laxative medication) bottle was observed at Resident 2 ' s bedside. This deficient practice had the potential to compromise Resident 2 ' s safety when being administered inappropriately. Findings: A review of Resident 2's admission Record indicated that Resident 2 was admitted to the facility on [DATE] with diagnosis including respiratory failure (condition in which your blood does not get enough oxygen or has too much carbon dioxide), and colon (abdominal parts of the body-large intestine) and bladder cancer (a disease in which abnormal cells divide uncontrollably and destroy body tissue). A review of Resident 2's Minimum Data Set (MDS - a comprehensive standardized assessment and care-screening tool) dated 10/27/2023, indicated Resident 2 has an intact cognition (mental action or process of acquiring knowledge and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that its medication error rate was less than five (5) percent (%) due to three (3) errors observed out of 30 total opportunities (error rate of 10%). The medication errors were as follows: 1. Resident 206 received a dose of fish oil (a medication used as a dietary supplement to provide support to the heart and brain) that was different than the one ordered by Resident 206's physician, 2. Resident 206 did not receive Rena Vite (a medication used as a dietary supplement to provide essential vitamins for people with chronic kidney disease) and thiamine (a medication used to treat thiamine [vitamin B1] deficiency [lack of] in those with liver disease) as ordered by Resident 206's physician. These failures had the potential for Resident 206 to experience medication adverse effects (unwanted, uncomfortable, or dangerous effects that a medication may have) and the potential to negatively impact Residents 206's health and well-being.…

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 eight licensed vocational nurses (LVNs) did not administer expired insulin (a medication used to regular blood sugar levels) to two of five sampled residents (Resident 85 and 94) observed for medication availability. As a result, Residents 85 and 94 received a total of 14 doses of expired insulin. These practices had the potential to cause Residents 85 and 94 to experience serious health complications due to uncontrolled blood sugar levels, including possible hospitalization or death. Findings: During an observation on [DATE] at 10:56 AM, in Medication Cart [NAME] 1, in the presence of LVN 2, one open insulin Lispro (fast-acting insulin) Kwikpen (an injection device containing insulin) for Resident 94 was found stored at room temperature with a label indicating that storage at room temperature began on [DATE], and an additional label indicating to discard 28 days after opening. According to the manufacturer's product labeling,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to: 1. Remove and discard from use of one expired insulin (medication used to regulate blood sugar levels) Lispro (fast-acting insulin) Kwikpen (an injection device containing insulin) for Resident 94, in accordance with manufacturer's requirements in one of three inspected medication carts (Medication Cart [NAME] 1.) 2. Label one insulin Toujeo (long-acting insulin) Max (higher volume of insulin) Solostar (an injection device containing insulin) pen for Resident 205, in accordance with manufacturer's requirements in one of three inspected medication carts (Medication Cart [NAME] 1.) 3. Store one insulin Lispro Kwikpen for Resident 26 at room temperature, in accordance with manufacturer's requirements in one of three inspected medication carts (Medication Cart [NAME] 2.) 4. Remove and discard from use of one expired insulin Aspart (rapid-acting insulin) Flexpen (an injection device containing insulin) for Resident 85, in accordance 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.

Based on interview and record review the facility failed to maintain current food handler certifications for two of three sampled cooks (CK- Ck1 and Ck2). This deficient practice could have led to unsafe food handling related to a lack of knowledge of current food handling regulations and requirements. Findings A review of CK 1's Food Handler certificate of training indicated an issue date of 4/15/2021 and valid for three years (expired on 4/15/2023). A review of CK 2's Food Handler certificate of training indicated an issue date of 10/4/2018 and valid for three years (expired on 10/04/2021). During an interview on 11/29/2023 at 2:48 p.m. the dietary supervisor (DS) stated the certifications had to be renewed every three years. During an interview on 11/30/2023 at 9:09 a.m. the tray line assistant (TLA) stated the food handler course covered infection control techniques like hand washing and wearing protective gear such as hair nets and aprons when preparing food. The TLA stated the course covered proper temperatures of refrigerators, freezers, and cooked meats to prevent food borne…

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

Based on interview and record review the facility failed to submit payroll-based journal (PBJ) staffing data to the Center for Medicare and Medicaid Services (CMS - the federal agency that provides health coverage) timely. This deficient practice had the potential to result in inaccurate reflection of the facility's staffing data. Findings: A record review of the PBJ Staffing Data Report dated Fiscal Year (FY) Quarter 4, 2022 indicated failed to submit data for the quarter. During an interview on 11/29/23 at 3:10 p.m. the vice president of operations (VPO) stated the data for the fourth quarter should have been submitted on the deadline which was on 11/14/2022 at 12 a.m. eastern time. The VPO stated, I submitted to CMS on 11/14/ 2022 at 9:05 p.m. pacific time which made it late by five minutes. A review of the Center for Medicare and Medicaid Services (CMS) electronic staffing dated submission payroll-based journal dated 6/2022, indicated, the first mandatory reporting period began 7/1/2016. Submissions must be received by the end of the 45th calendar day (11:59 p.m. Eastern…

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 light was answered timely and within reach for 2 of 6 residents (Resident 23 and 45). This failure had the potential to delay meeting residents needs for assistance and could lead to falls and accidents. Findings: 1. A review of resident 23's admission record indicated the facility readmitted the resident on 11/16/2023, with diagnoses including acute respiratory distress (breathing becomes difficult and oxygen cannot get into the body), Hemiplegia (loss of strength in the arm, leg, and sometimes the face on one side of the body), epilepsy (a brain disease where nerve cells don't signal properly which causes seizures). A review or resident 23's Minimum Data Set (MDS- a comprehensive assessment and screening tool) dated 9/15/2023, indicated Resident 23's [cognitive skills- the core skills your brain uses to think, read, learn, remember, reason, and pay attention] for daily decision making were intact. The MDS indicated…

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

Based on observation, interview, and record review, the facility failed to ensure 1 of 6 sampled residents (Resident 39) were treated with dignity and respect, by failing to sit next to the resident while feeding the resident. This failure had the potential to affect Resident 39's sense of self-worth and self-esteem. Findings: A review of Resident 39's admission record indicated the facility admitted the resident on April 8, 2022, with diagnoses that included atrial fibrillation (abnormal heartbeat), Gastro-esophageal reflux disease (inflammation of the esophagus), and history of falling (multiple falls in a specific time period). A review of Resident 39's Minimum Data Set (MDS- a comprehensive assessment and screening tool) dated October 25, 2023, indicated Resident 39's cognitive skills (the core skills your brain uses to think, read, learn, remember, reason, and pay attention) for daily decision making were severely impaired. The MDS indicated the resident was dependent on staff for feeding assistance. A review of Resident 39's progress notes dated November 15, 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 observation, interview and record review, the facility failed to ensure two of eight sampled residents (Resident 16 and Resident 55), who were dependent on staff for the activities of daily living (ADLs), were repositioned every two hours according to its policy. This deficient practice had the potential for the residents to develop complications including bed sores and contractures. Findings: A review of the admission Record, indicated the facility admitted Resident 16 on 9/30/2011 with diagnoses including malignant neoplasm (a disease in which abnormal cells divide uncontrollably and destroy body tissue) of cerebral ventricle (an interconnected series of cavities filled with cerebrospinal fluid [CSF] that cushions the brain), hydrocephalus (a condition in which fluid accumulates in the brain, enlarging the head and sometimes causing brain damage, muscle weakness (a lack of physical or muscle strength, throughout the body), dementia (a condition characterized by progressive or persistent loss 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 ensure the safety of 1 of 6 sampled residents (Resident 45), by failing to supervise Resident 45 while smoking cigarettes as indicated in the resident's Smoker's Risk Assessment (a tool used to identify resident's requiring staff supervision and assistance with smoking). This failure had the potential to cause harm to Resident 45 when smoking cigarettes unsupervised. Findings: A review of Resident 45's admission record indicated Resident 45 was re-admitted to the facility on [DATE], with diagnoses that included nontraumatic intracerebral hemorrhage (bleeding into the substance of the brain in the absence of trauma or surgery), abnormal posture (rigid body movements and chronic abnormal positions of the body), hemiplegia (loss of strength in the arm, left, and sometimes face on one side of the body). A review of Resident 45's history and physical (H&P- [complete physical assessment and medical history performed by a physician]) 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.

Based on interview and record review, the facility failed to ensure one (1) of eight (8) sampled residents (Resident 101) was provided pain medication as ordered. This deficient practice had the potential for Resident 101 suffering unnecessary pain. Findings: A review of the admission Record, indicated the facility admitted Resident 101 on 11/10/2023 with diagnoses including but not limited to malignant neoplasm (a disease in which abnormal cells divide uncontrollably and destroy body tissue) of the rectum (the end part of the large intestine that connects the colon to the anus). A review of Minimum Data Set (MDS - a standardized assessment care screening tool) dated 11/16/2023, indicated Resident 101's cognition (the mental ability to make decisions of daily living) was intact. Resident 101 required partial one person assistance with bathing and putting on and taking off footwear tub and shower transfer. A review of the Physician's admission Orders NVPA(new vista post-acute) dated 11/10/2023, indicated an order for pain management Fentanyl (Pain medication) transdermal (relating to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to complete a comprehensive assessment completed and developed a treatment plan for a diagnosis of post-traumatic stress disorder (PTSD- a disorder that develops in some people who have experienced a shocking, scary, or dangerous event) for ensure one of three sampled residents (Resident 86). This deficient practice had the potential for Resident 86 to have experience increased anxiety (intense, excessive, and persistent worry and fear about everyday situations disorder), depression (persistent sadness and a lack of interest or pleasure in previously rewarding or enjoyable activities) and recurrence of reliving PTSD. Findings: A review of the admission record for Resident 86, dated 11/01/2023, indicated Resident 86 was admitted to the facility on [DATE] with diagnoses that included cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply the brain) with hemiplegia (muscle weakness 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 implement the facility's policy and procedures (P&P) for psychotropic (a drug capable of affecting the mind, emotions, and behavior) medications for one of three sampled residents (Resident 86) by not monitoring Resident 86 for anxiety (intense, excessive, and persistent worry and fear about everyday situations disorder). This deficient practice had the potential for Resident 86 to have increased anxiety, increased depression (persistent sadness and a lack of interest or pleasure in previously rewarding or enjoyable activities) and inaccurate assessment of current mood. Findings: A review of the admission record for Resident 86, dated 11/01/2023, indicated Resident 86 was admitted to the facility on [DATE] with diagnoses that included cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it) with hemiplegia (muscle weakness or unable to move one side of the body) on the left side,…

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 store food in accordance with professional standards for food safety, by failing to label three boxes of ice cream in the unit freezer with open date. This deficient practice had the potential to lead to food borne illness. Findings: During an observation of the facility's kitchen on 11/28/2023 at 7:45 a.m., the unit freezer had three boxes of individual ice cream cups opened and without a label indicating the date they were opened or the date they expired. During an interview on 11/28/2023 at 7:50 a.m. the cook (CK 1) stated, I opened those yesterday, but I forgot to put the date and label. CK 1 stated Any time we open something we have to put the label and put the date it was opened. During an interview on 11/28/2023 at 8:00 a.m., the dietary supervisor, (DS 1) stated, The ice cream should have been labeled with an open date. A review of the facility's policy and procedures titled, Labeling and dating foods, dated 2020, indicated newly opened food items needed to be closed and labeled with an open date and used by date…

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 label personal food items in the facility's residents' refrigerator according to the facility policy and procedures (P&P). This deficient practice had the potential to cause food borne illness. Findings During a review of the facility's Fridge Clean Log dated 11/26/2023 indicated housekeeper 1 (HK 1) cleaned the residents refrigerator located in the activity room for residents' food brought in from outside. During an observation and inspection of the residents' refrigerator located in the activity room for residents' food brought in from outside, and concurrent interview with the dietary supervisor (DS) on 11/30/2023 at 11:13 a.m., the DS looked through the refrigerator and the following were identified: 1. One tin foil tray was covered with foil. Inside the tin foil, were disposable plates with green beans, and macaroni and cheese. 2. The pan did not have a patient name nor date. 3. Unlabeled and undated plastic grocery bag that contained three bundles of raw green and slightly wilted Asparagus. 4. Unlabeled…

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 observe infection control measures for one of three sampled residents (Resident 256) by failing to wear appropriate personal protective equipment (PPE equipment worn to minimize exposure to hazards that cause serious workplace injuries and illnesses) when entering Resident 256's room. This deficient practice had the potential to transmit microorganisms (a complex structure of elements that can only be seen under a microscope [a tool used to see very small objects]) throughout the facility and increase the risk of infection for all residents and staff members. Findings: A review of the admission record for Resident 256, dated 11/25/2023, indicated Resident 256 was admitted to the facility on [DATE] from General Acute Care Hospital (GACH) with diagnoses that included end stage renal disease (a condition in which the kidneys lose the ability to remove waste and balance fluids), dependence on renal dialysis (the process of removing excess…

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 one of the sampled residents (Resident 1) received his mail/package he had ordered himself online per their policy. This deficient practice resulted in the violation of Resident 1 ' s rights to receive his mail privately. Findings: A review of the admission record (Facesheet) indicated, Resident was admitted on [DATE] with diagnoses including diabetes type 2 (a disease in which your blood glucose, or blood sugar, levels are too high. Glucose is your main source of energy), acquired absence of both the right and left leg below the knee (is an amputation that involves removing the foot, ankle joint, distal tibia [shinbone], fibula [smaller of the two bones between the knee and the ankle], and corresponding soft tissue structures. A review of a Minimum Data Set (MDS- a comprehensive assessment and screening tool), dated 8/24/2023, indicated was cognitively intact (has sufficient judgment, planning, organization, self-control, 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 accurrately assess and document on one of four sampled residents as evidenced by Treatment Licensed Vocational 1 (Treatment LVN 1) failing to describe the foreign object that was found on Resident 1's right ear in the change of condition / SBAR form (SBAR stands for Situation, Background, Appearance/Assessment and Review; SBAR is a technique incorporated in a form that provides framework for communication between members of the health care team about a patient's condition), This deficient practice had the potential to negatively affect the provision of care and services for Resident 1 and may result to lack of clear communication among the members of the health care team. Findings: A review of the admission Record (Face Sheet) indicated Resident 1was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included persistent vegetative state (a chronic state of brain dysfunction in which a person shows no signs of awareness),…

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 quality of care was rendered to one of four sampled residents. Resident 1 was found with maggots (fly larvae) on her right ear. This deficient practioce had the potential for Resident 1 to experience discomfort and may have led to an ear infection. Findings: A review of the admission Record (Face Sheet) indicated Resident 1 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included persistent vegetative state (a chronic state of brain dysfunction in which a person shows no signs of awareness), dependence on respirator (a person who is not able to breath independently so they become ventilator dependent; a ventilator is a breathing apparatus that delivers breaths to a patient who is physically unable to breath) status, type 2 diabetes mellitus (high blood sugar) and gastrostomy (a feeding tube that is inserted through the belly that brings nutrition directly to the stomach for people who are unable to swallow…

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 homelike environment for six of eight sampled residents (Residents 2, 3, 5, 6, 7, and 8) by failing to: 1. Ensure resident's bathroom paint was properly maintained and free from peeling and cracks and free from broken wallboard for Resident 5 and Resident 6. 2. Provide a working, unclogged sink inside the room for Resident 2 and Resident 3. 3. Provide a working television (TV) for Resident 7 and Resident 8. These deficient practices had the potential to negatively impact the quality of life and increased risk for physical discomfort for Residents 2, 3, 5, 6, 7, and 8. Cross Reference F921. Findings: 1. A review of Resident 5's Face sheet indicated the resident was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis including anemia (a condition which the blood does not have enough health red blood cells), type II diabetes mellitus (DM-a chronic condition that affects the way the body processes…

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 facility are properly maintained by: 1. Ensure resident's bathroom paint was properly maintained and free from peeling and cracks and free from broken wallboard for Resident 5 and Resident 6. 2. Provide a working, unclogged sink inside the room for Resident 2 and Resident 3. 3. Provide a working television (TV) for Resident 7 and Resident 8 These deficient practices had the potential for the resident ' s physical discomfort that may affect the Resident 2, 3, 5, 6, 7, and 8 ' s quality of life. Cross References F584. Findings: 1. A review of Resident 5's Face sheet indicated the resident was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis including anemia (a condition which the blood does not have enough health red blood cells), type II diabetes mellitus (DM-a chronic condition that affects the way the body processes blood sugar [glucose]), and hypertension (HTN - elevated blood pressure). A…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of eight sampled residents (Resident 4), was transferred from the bed to a wheelchair using a two-person assist by using a Mechanical lift (sling lift, an assistive device that allows residents to be transferred between a bed and a chair, by the use of electrical or hydraulic power) . This failure had the potential to place Resident 4 at risk for falls or injury possible fracture while being transferred from the bed to a wheelchair solely by Certified Nursing Assistant (CNA 1). Findings: A review of Resident 4's Face Sheet indicated Resident 4 was admitted to the facility on [DATE], with diagnoses including multiple sclerosis (a progressive disease involving cell damage of the brain, spinal cord which will leave numbness, impairment of speech, muscular coordination, blurred vision and extreme tiredness), paraplegia (paralysis that affects the legs, but not the arms), and pulmonary edema (a condition caused by excess fluids 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.