Palazzo Post Acute

Based on observation, interview, and record review, the facility failed to ensure to follow safe and sanitary food storage and food preparation practices in the kitchen by failing to: 1.Ensure to keep the ice scooper holder clean. 2.Ensure the kitchen staff (in general) did not keep their personal perishable food in the facility's refrigerator and did not place their personal belongings anywhere in the kitchen other than the designated area for staff. These failures had potential for residents at risk for foodborne illnesses (refers to illness caused by the ingestion of contaminated food or beverages). Findings: 1.During an initial kitchen observation on 6/2/2025 at 7:45 AM and a concurrent interview with the Dietary Food Nutrition Supervisor (DFNS), the DFNS stated the ice scooper holder was dirty. The DFNS stated the facility's Ice Scoop and Container Cleaning Log dated 6/1/2025 and 6/2/2025, indicated the ice scooper and container were cleaned, but the ice scooper holder was dirty. The DFNs stated the ice scooper holder should always be kept clean to prevent contamination. 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 follow infection control practices by failing to: 1. Develop a sufficient water management plan (a program that identifies hazardous conditions and steps to take to minimize the growth and spread of waterborne pathogens in building water systems) to reduce the growth and spread of Legionella (bacteria that causes Legionnaires Disease, a severe lung infection. Legionella is often found in water systems and is spread by breathing in mist or swallowing water that is contaminated by the bacteria) amongst 97 out of 97 facility residents. 2.Ensure the nursing staff (Licensed Vocational Nurse 3 [LVN3]) followed its enhanced barriers precautions (EBP, an infection prevention protocol) policy during the medication administration observation for one of five sampled residents (Resident 69). 3. Ensure Registered Nurse2 (RN2) would disinfect the injection ports during the preparation of an intravenous (IV, into the vein) vancomycin (an antibiotic to treat certain infections) for one of one sampled resident (Resident 32). These failures…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 one sampled resident (Resident 9) who did not have the capacity to understand and make decisions had a legal representative to assist in making medical decisions. This failure violated Resident 9's right to make an informed decision (choice that individuals make once they have all the information related to the decision topic) in the resident' care. Findings: During a review of Resident 9's admission Record, the admission Record indicated the facility readmitted Resident 9 on 5/10/2018, with diagnoses that included major depressive disorder (persistent feelings of sadness, low mood, and loss of interest in activities that were once pleasurable), schizophrenia (a mental illness that is characterized by disturbances in thought), age-related incipient cataract (in its early stages, where the lens of the eye is starting to become cloudy but vision is not yet significantly affected), and anxiety disorder (a mental health…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 update the care plan (a plan of care that summarizes a resident's health conditions, specific care and services facility staff need to provide a resident to promote healing and prevent a worsening of a condition, and current treatments) for one of five sampled residents (Resident 47) related to the risk for falls after Resident 47 had a fall on 12/26/2024. This failure had the potential for Resident 47 to receive inadequate care. Findings: During a review of Resident 47's admission Record, the admission Record indicated the facility admitted the resident on 8/3/2023 with diagnoses that included Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow imprecise movements), encephalopathy (a group of conditions that cause brain dysfunction), unsteadiness on feet (difficulty maintaining balance while walking or standing), lack of coordination (an inability to control and synchronize movements smoothly…

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

Based on observation, interview, and record review the facility failed to ensure to provide effective oral hygiene care for one of five sampled residents (Resident 39). This failure resulted in Resident 39 having a tan substance on her teeth, dry lips, and a substance on her reddened, tongue. Findings: During a review of Resident 39's admission Record, the admission Record indicated the facility admitted the resident on 10/19/2022 with diagnoses that included dysphagia (difficulty swallowing), gastrostomy (g-tube - a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems), and malnutrition (lack of proper nutrition). During a review of the Resident 39's Care Plan Report dated 1/3/2025, the Care Plan Report indicated the resident was at risk for decline in range of motion (ROM, the full movement potential of a joint), and required assistance with oral care. The Care Plan Report indicated the nursing interventions were to provide oral care three times a day. During a review of Resident 39'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.

Based on observation, interview, and record review, the facility failed to ensure to implement safety measures for one of one sampled residents (Resident 63) by failing to: -Ensure Certified Nursing Assistants (CNA2 and CNA3) locked Resident 63's bed and the Hoyer lift (a specialized lifting device to weigh or safely transfer a patient with limited mobility) prior to placing the sling (a specialized fabric support, acts as a harness) under Resident 63 on 6/2/2025 at 10:58 AM. This failure had the potential to cause physical injury to Resident 63. Findings: During a review of Resident 63's admission Record, the admission Record indicated the facility admitted the resident on 10/3/2024 with diagnoses including hemiplegia (paralysis that affects one side of the body) and hemiparesis (weakness or the inability to move on one side of the body, making it hard to perform everyday activities like eating or dressing) following cerebral infarction affecting right non-dominant side, other sequelae of cerebral infarction (a loss of blood flow to part of the brain, which damages brain tissues),…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 perform a bowel and bladder assessment (a process to evaluate a person's bowel and bladder function) quarterly as indicated in the care plan for one of one sampled residents (Resident 66). This failure had the potential for Resident 66 to not receive the appropriate care for her bowel and bladder function. Findings: During a review of Resident 66's admission Record, the admission Record indicated the facility admitted the resident on 11/8/2024 with diagnoses that included congestive heart failure (CHF, a heart disorder which causes the heart to not pump blood efficiently, sometimes resulting in leg swelling), cirrhosis of the liver (a disease where healthy liver tissue is replaced by scar tissue), reduced mobility (an impairment that impacts a person's ability to move or perform tasks), and adult failure to thrive (a condition characterized by a decline in physical, cognitive (ability to understand, think, and reason), and social functioning in adults). During a review of Resident 66's Nursing Bowel and Bladder Evaluation…

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

Based on observation, interview, and record review the facility failed to ensure one of one sampled residents (Resident 1) had a labeled flush bag for the gastrostomy tube (g-tube - a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems). This failure had the potential for Resident 1 to be exposed to infection. Findings: During a review of Resident 1's admission Record, the admission Record indicated the facility admitted the resident on 05/13/2020 with diagnoses that included aphasia (a communication disorder that impairs a person's ability to process language, affecting their ability to speak, understand, read, or write), dysphagia (difficulty swallowing), and malnutrition (lack of proper nutrition). During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 5/18/2025, the MDS indicated the resident had short and long-term memory problems and severely impaired cognitive (ability to think and process information) skills for daily decision making. During a review…

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

Based on interview and record review the facility failed to administer medication as ordered by the physician for one of five sampled residents (Resident 1). For Resident 1, the facility failed to administer the Benadryl (medication that treats the symptoms of allergies and allergic reaction) 25 milligrams (mg., metric unit of measurement, used for medication dosage and/or amount) on 3/28/25 when Resident 1 complained of facial itching due to possible allergic reaction. This deficient practice had the potential for Resident1 to continue experiencing allergic reaction and discomfort. Findings: During a review of the admission Record indicated the facility admitted Resident 1 on 1/6/25 with diagnoses including fibromyalgia (chronic long-lasting disorder that causes pain and tenderness throughout the body, as well as fatigue and trouble sleeping) and other disturbances of skin sensation. During a review of the Minimum Data Set (MDS, a resident assessment tool) dated 1/13/25 indicated Resident 1 was cognitively intact. Resident 1 needed substantial assistance (helper does more than half…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 post the federally required daily actual hours worked by the staff in an area accessible to the public for one of one sampled day (11/12/2024). As a result, the actual hours worked by the staff was not readily accessible to residents, family, or visitors. Findings: During an observation of the facility on 11/12/2024 at 10:46 a.m , no Direct Care Services Hours Per Patient Day (DHPPD) actual hours were posted in the DHPPD posting, there was no DHPPD posted for the previous day (11/11/2024). During an interview with Director of Staff and Development (DSD) on 11/12/2024 at 11:20 a.m., DSD stated, the NHPPD posting were on the wall with only the projected hours. The DSD stated, she was not sure if the DHPPD posting had to include the actual hours and if the DHPPD posting for the previous day also had to be posted. During a follow-up observation of the facility on 11/12/2024 at 11:22 a.m., DHPPD were observed posted on the wall with the projection hours information. No actual hours were posted in the DHPPD posting.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 system to consistently and accurately reconcile Pomalyst (pomalidomide- is an oral chemotherapeutic (a drug used to treat cancer) capsule treatment for Multiple Myeloma [a blood cancer that develops in plasma cells in the bone marrow]) oral capsule (cap) 4 Milligrams (MG) for one of the three sampled residents (Resident 1). This failure resulted in Resident 1 missing a total of 2 dosages on 5/18/24 and 7/13/24. Findings: A review of Resident 1 ' s admission record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including Multiple Myeloma, type 2 diabetes mellitus (DM2 - a condition that happens because of a problem in the way the body regulates and uses sugar as a fuel), and end stage renal disease (a medical condition in which a person's kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis or a kidney transplant 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 interview, and record review, facility failed to ensure dignity and respect for two of seven sampled residents (Residents 2 and 7). This failure resulted in Residents 2 and 7 not being treated with dignity and respect and had the potential to affect the resident ' s self-esteem and self-worth. Findings: A review of Resident 2 ' s admission Record dated 6/24/24, indicated Resident 2 was admitted to the facility on [DATE], with diagnoses including, hypertension (high blood pressure), low back pain, anemia (a condition in which the body does not have enough healthy red blood cells, to transport oxygen around the body) and cellulitis (bacterial infection that enters your skin and tissue through a wound) of bilateral (both) lower extremities. A review of Resident 2 ' s Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 3/30/24 indicated Resident 2 had intact cognition (ability to think, understand and make daily decisions). The same MDS indicated Resident 2 required set up…

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

Based on interview and record review, the facility failed to provide appropriate treatment and services for the resident's change in condition of loose stools for one of two sampled residents (Resident 74). Resident 74 continued to receive a laxative (medication used to treat constipation) and experience frequent loose stools without appropriate intervention. This deficient practice had the potential for Resident 74 to become dehydrated (a condition that occurs when you lose more fluid than you take in, not having enough water to carry out its normal functions) and potentially cause kidney damage, brain damage, and/or death. Findings: A review of Resident 74's admission Record indicated the facility admitted the resident on 3/16/2024 with diagnoses that included multiple myeloma (a rare blood cancer), moderate protein-calorie malnutrition (occurs when an individual does not eat enough protein and energy to meet their nutritional needs), Type II diabetes (a long-term condition in which the body has trouble controlling blood sugar and using it for energy), dependence on renal dialysis…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 transfer records from the general acute hospital (GACH 1) were reviewed thoroughly for one of two sampled residents (Resident 1). For Resident 1, who had appointments arranged by the general acute hospital (GACH 1) for vascular diagnostic (a test used to determine possible circulation problems of the blood vessels), chemotherapy (use of drugs to destroy cancer cells), hematologist (medical doctor who had special training in diagnosis and treating blood disorders) and pulmonologist (medical doctor who had special training in diagnosing and treating diseases of the lungs (body organ that helps with breathing) prior to Resident 1's transfer and admission to the facility on 3/16/24, the facility failed to: 1. Thoroughly review Resident 1's GACH 1 transfer record when the facility admitted Resident 1 on 3/16/24. 2. Notify Resident 1's physician about Resident 1's appointments arranged by the GACH 1 to make decisions whether to continue with 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 safeguard personal funds for one of three sampled residents (Resident 1). The Licensed Vocational Nurse (LVN) 1 retrieved $800 from Resident 1 and placed the money in the narcotic box. This failure had the potential to result in Resident 1's personal funds becoming stolen or misused. Findings: A review of Resident 1's admission Record indicated the resident was originally admitted to the facility on [DATE] with diagnoses including heart failure, unspecified (occurs when the heart muscle does not pump blood as well as it should), Type II diabetes mellitus with other skin ulcer (a complication caused by poor circulation and nerve damage from high blood sugar levels), and essential hypertension (elevated blood pressure without a known cause). A review of Resident 1's Minimum Data Set (MDS - a standardized assessment and care screening tool) dated 3/18/2024, indicated Resident 1 was cognitively intact, was dependent and or required maximum assistance from…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 one of three sampled residents (Resident 1) from verbal abuse. This failure had the potential to result in mental anguish, depression, anxiety and has the potential to result in physical abuse. Findings: A review of Resident 1 ' s admission record, indicated Resident 1 was admitted to the facility on [DATE] with a diagnoses including assault by unspecified firearm discharge, essential hypertension (high blood pressure that is multifactorial and doesn ' t have one distinct cause), and unsteadiness on feet (not walking in a steady way). A review of Resident 1 ' s history and physical dated 3/2/2023 indicated Resident 1 had the capacity to understand and to make decisions. A review of Resident 1 ' s Minimum Data Set [MDS- a comprehensive assessment and care screening tool] dated 9/9/2023, indicated the resident was cognitively intact, and required limited assistance with activities of daily Living [ADL ' s- activities related 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 observe infection control measures as isolation gowns were disposed of in unlidded disposal bins in resident rooms 41, 43, 45, and 47, and Certified Nursing Assistant 5 (CNA 5) was observed feeding one of 35 sampled residents (Resident 57) in a designated yellow zone room (area in the facility designated for residents that are under observation for COVID-19, a respiratory disease caused by coronavirus) without wearing gloves. These deficient practices had the potential to result in the possible spread of COVID-19 to residents and staff. Findings: a. During an observation on 10/18/2021, at 10:25 AM, resident room [ROOM NUMBER] had signage posted on the door indicating contact precautions (area where gloves and an isolation gown was required before entering), droplet precautions (area where a mask and eye protection was required before entering), and airborne precautions (area where a N95 respirator mask, a respiratory protective device…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 accommodate the needs of one of 35 sampled residents (Resident 45) when Resident 45's call light (device used to call for assistance from the facility staff) was observed hanging off the resident's bed. This deficient practice had the potential for Resident 45 to have the inability to call the facility staff for help when needed. Findings: A review of Resident 45's Facesheet indicated, Resident 45 was admitted to the facility on [DATE], with diagnoses including osteoarthritis (a disease caused by aging joints which results in pain, swelling, and reduced motion in the joints), contractures (a condition of shortening and hardening of muscles, tendons, or other tissues, often leading to deformity and rigidity of joints) in both the left and right knee. A review of Resident 45's Care Plan, dated 7/8/2021, indicated Resident 45 was at risk for spontaneous fracture due to Vitamin D (a vitamin that is essential for absorption of calcium 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.

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 two of 35 sampled residents (Resident 45, Resident 24) when Resident 45 stated the noise levels in the facility bothered her and Resident 24 could hear staff clock out. This deficient practice caused an increase risk to disturb the sleep schedule of the residents and not allow them to receive enough rest. Findings: A review of Resident 45's Facesheet indicated, Resident 45 was admitted to the facility on [DATE], with diagnoses including osteoarthritis (a disease caused by aging joints which results in pain, swelling, and reduced motion in the joints), contractures (a condition of shortening and hardening of muscles, tendons, or other tissues, often leading to deformity and rigidity of joints) in both the left and right knee. A review of Resident 45's Minimum Data Set (MDS - a comprehensive standardized assessment and screening tool), dated 8/19/2021, indicated Resident 45 had severe cognitive impairment…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 an accurate assessment was conducted for one of three sampled residents (Resident 3). Resident 3 did not have an accurate assessment for cognitive skills for daily decision making. This deficient practice had the potential to result in Resident 3's delay in necessary care and treatment. Findings: A review of the admission Record indicated Resident 3 was admitted to the facility on [DATE] with diagnoses including history of falling, wedge compression fracture T9-T10 Vertebra (a fracture in the front part of the thoracic vertebra), wedge compression fracture of lumbar vertebra (a fracture in the front part of the lumbar vertebra), hypertension (high blood pressure), and osteoporosis (when bones become weak and brittle). A review of the Resident 3's History and Physical dated 6/24/2021, indicated Resident 3 had the capacity to understand and make decisions. Resident 3 was alert oriented to person, place, and time. A review of Resident 3's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow professional standards of practice and implement a physician's written order for a pain management consult for one of three sampled residents (Resident 17). This deficient practice had the potential to place Resident 17 at risk for increased levels of pain and a decrease in daily function. Findings: A review of the admission Record indicated Resident 17 was admitted to the facility on [DATE] with diagnoses including polyarthritis (joint pain that affects five or more joints), chronic pain, muscle weakness, rheumatoid arthritis (an inflammatory disorder affecting many joints), spinal stenosis (narrowing of the spaces in the spine causing pressure on the nerves), and cardiomegaly (an enlarged heart). A review of the Minimum Data Set (MDS- a comprehensive assessment and care screening tool) dated 7/8/2021, indicated Resident 17 had intact cognitive skills for daily decision making. Resident 17 required extensive one person physical assistance with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a resident received proper assistive devices to maintain hearing abilities by not assisting in the arranging for an audiologist referral consult for one of three sampled residents (Resident 3). This deficient practice resulted in a delay of services and Resident 3 not being able to hear adequately. Findings: A review of Resident 3's admission Record indicated Resident 3 was admitted to the facility on [DATE] with diagnoses including history of falling, wedge compression fracture T9-T10 Vertebra (a fracture in the front part of the thoracic vertebra), wedge compression fracture of lumbar vertebra (a fracture in the front part of the lumbar vertebra), and hypertension (high blood pressure), A review of Resident 3's Order Summary Report, dated 6/22/2021, indicated an order for Ear Nose Throat (ENT) evaluation and treatment. A review of the Resident 3's History and Physical dated 6/24/2021, indicated Resident 3 had the capacity 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 meet State licensure requirements for Physical Therapy and Occupational Therapy to have a hands-free sink in the rehabilitation room as outlined in the California Code of Regulations, Title 22. This deficient practice had the potential to prevent a sanitary environment in the rehabilitation area. Findings: During an interview, on 10/19/2021, at 11 AM, in the rehabilitation gym, the Physical Therapist stated they do not have a hands-free sink inside the rehabilitation room and they have to go outside to the nurses station to wash their hands. During an interview with the Administrator (ADM) on 10/19/2021 at 11:20 AM, the ADM stated there was no hands-free sink inside the rehabilitation room. A review of California Code of Regulations, Title 22, Division 5, Chapter 3, Section 72411 and Section 72421 indicated the Physical Therapy and Occupational Therapy space requirement indicated a sink shall be provided in the treatment area and shall have controls other than hand controls.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices for three of 36 sampled residents (Resident 45, Resident 62 and Resident 85) by failing to accurately document Restorative Nursing Assistant (RNA) interventions performed on Resident 45 and Resident 62. The facility failed to document records accurately and completely when administering a narcotic medication to Resident 85. These failures had the potential to result in the lack of or delay of care services to the residents as well as the potential to result in confusion and incomplete assessment of the resident's needs. Findings: a. A review of Resident 45's Face sheet indicated, Resident 45 was admitted to the facility on [DATE], with diagnoses including osteoarthritis, (a disease caused by aging joints which results in pain, swelling, and reduced motion in the joints), contractures, (a condition of shortening and hardening of muscles, tendons, or other tissues,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 provide a safe, sanitary, comfortable, environment for one of three sampled residents (Resident 43). Resident 43 had a soiled toilet which was documented as cleaned every hour. This deficient practice may have resulted in the resident's increased level of discomfort and had the potential to negatively impact the resident's quality of life. Findings: On 10/18/2021 at 9 AM, during the initial tour observation of the facility, inside Resident 43's restroom, the toilet was left soiled. During a concurrent interview, Certified Nursing Assistant 3 (CNA 3) stated and confirmed that the toilet was soiled and that Resident 43 did not use the restroom on his own. On 10/21/2021 at 8:30 AM, during an interview with the housekeeping supervisor, when shown a picture of the soiled toilet, the housekeeping supervisor stated and confirmed the toilet was soiled. The housekeeping supervisor stated when a toilet was soiled a CNA or staff member will inform the housekeeper and the toilet would be cleaned. The housekeeping supervisor stated that…

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

Based on observation, interview and record review, the facility failed to ensure food served was palatable and attractive as voiced by for 10 of 18 sampled residents, (Residents 1, 9, 11, 21, 26, 31, 52, 62, 72, and 88). This deficient practice had the potential to impact the residents' nutritional status and not meet the residents' desires to be served food they felt was palatable and attractive. Findings: During a concurrent observation and interview on 1/21/20 at 12:44 p.m., Resident 62 was observed eating lunch in her room. Resident 62's plate consisted of chicken breast, carrots, and white rice. Resident 62 was observed consuming half of her carrots and white rice, and took only one bite of her chicken breast. When asked why she did not finish her meal, Resident 62 stated the chicken was dry and had no flavor. During the resident council meeting (A meeting conducted by Residents to discuss concerns and refer to facility for resolution) on 1/22/20 at 11:01 a.m., Residents 1, 9, 11, 21, 26, 31, 52, 72, and 88 all stated they had been complaining about bland food a long time. They…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 pull the resident's privacy curtain 100% closed during a saccrococcyx (buttock) dressing change procedure, for one of one resident (Resident 69). The deficient practice had the potential for loss of dignity and privacy due to personal exposure. Findings: On January 23, 2020 at 9:43 a.m., Resident 69 was observed in bed, facing the window, during a wound treatment observation. However, Resident 69's privacy curtain was not 100% completely closed while the Wound Medical Doctor (Physician), removed slough from his Sacrococcyx (buttock) pressure ulcer On January 23, 2020 at 9:52 a.m., during an interview with Licensed Vocational Nurse 4 (LVN 4) the treatment nurse, stated I was washing my hands, However, Certified Nursing Aide 7 (C.N.A 7) was assisting the WMD 1 during the entire procedure. On January 23, 2020 at 10:41 a.m., during an interview the Director of Nursing (DON), stated Resident 69's privacy curtain should have been 100% closed for…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 initiate and implement a comprehensive care plan for two of 18 sampled residents (Resident 18 and 59) by failing to: 1. Ensure to develop a care plan for the use of Ativan (medication for anxiety) for Resident 18. 2. Ensure to develop a plan of care for fall that reflect the actual resident's status. 3. Ensure to develop a care plan for the use of Buspirone (medication for anxiety) for Resident 59. This deficient practice placed the residents (Resident 18 and 59) at risk for the lack of and/or delay in delivery of care and services related to fall and the use of Ativan (Resident 18), and Buspirone (Resident 59). Findings: a. A review of Resident 18 admission Record indicated an admission date of 7/11/19 with diagnoses that included history of falling and unspecified dementia with behavioral disturbance (a disorder of mental processes caused by brain disease or injury and marked by memory disorder, personality changes, and impaired reasoning). A review of Resident 18's History and Physical record indicated Resident 18 had…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a resident's discharge summary was completed per the facility's policy and procedure, within 30 days after discharge from the facility, for one out of one Resident (Resident 94). The deficient practice had the potential for poor post-discharge continuity of care, and well-being Findings: A review a Resident 94's admission Record (Face Sheet), indicated Resident 94 was originally admitted to the facility on [DATE], with diagnosis that included urinary tract infection, dementia (a chronic brain disorder) with behavioral disturbance, and major depressive disorder, single episode. A review of Resident 94's Physicians Order dated 10/30/19 at 3 p.m., indicated to discharge resident to independent living with home health for safety/medication regimen. A review of the facility's undated Policy and Procedure titled, Discharge Summary and Plan, indicated under Policy and Implementation the following: The discharge summary plan will include will include a…

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

Based on observation, interview, and record review, the facility failed to ensure the facility assists the resident in gaining access to vision by following-up on prescription glasses ordered for one sampled resident (Resident 40). This failure has the potential for Resident 40 to have blurred vision and to decrease the quality of life for the resident. Findings: A review of Resident 40's admission record indicated an admission date of 5/10/18, with diagnoses that included cataract (disease that affects vision by clouding the lens in the eyes). During a review of Resident 40's History and Physical record, dated 7/19, indicated Resident 40 had the capacity to understand and make decisions. During concurrent observation and interview on 1/21/20, at 10:46 a.m., Resident 40 was observed without eyeglasses. Resident 40 stated she was still waiting for the prescribed eyeglasses. During a record review of Resident 40's Consultation note, dated 6/11/19, indicated a plan for new prescription glasses for Resident 40. During an interview on 1/22/20, at 12:23 p.m., the Social Services (SS)…

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

Based on observation, interview, and record review, the facility failed to provide receives the appropriate care and services to prevent urinary tract infections for one of four sampled residents (Resident 31) by failing to 1. Ensure proper care of the suprapubic [area below the belly button] urinary catheter was provided by the licensed nurses as ordered. 2. Ensure infection control was observed during the change of the main drainage bag to a leg bag [a drainage bag to collect urinary drainage from the catheter that can be attached to the leg]. These deficient practices have the potential to cause urinary tract infection (infection of urinary passageways, bladder and or kidneys). Findings: During a concurrent observation and interview on 01/21/20 at 10:07 a.m. Resident 31 was observed in a wheelchair with a suprapubic [area below the belly button] urinary catheter. The catheter was connected to a leg bag. On further observation, the leg bag was on top of the bed and not properly sealed with a cap on the port [point of connection to catheter tubing]. The residual urine from the leg…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 completion of an orientation program for two Certified Nursing Assistant (CNA) of four CNAs (CNA 2 and 4). This failure has the potential to result in the facility staff not to have the competencies and skill sets necessary to provide nursing and related services to meet the residents' needs safely. Findings: During a record review, on 1/23/20, CNA 2's employee file titled Orientation Topic (documentation of orientation, training, and education), dated 1/19/19, indicated incomplete training and orientation. The education topics were not validated through demonstration and return demonstration. During a record review, on 1/23/20, CNA 4's employee file titled Orientation Topic, dated 12/20/18 was reviewed. The orientation record indicated that the education topics were not validated through demonstration and return demonstration. During an interview on 1/23/20, at 9:06 a.m., with Director of Staff Development (DSD), the DSD stated CNA 2's date of hire was 1/9/19 and CNA 4's date of hire was 12/20/18. During 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 staffing information posted was accurate and complete on the evening shifts (3:00 p.m. to 11:00 p.m.) for multiple dates. This failure has the potential for misinformation of staffing data to residents and resident representatives. Findings: A review of the (facility name) shift document (a form used by the facility for staff data information) dated 12/10/19, 12/11/19, 12/24/19, and 12/25/19, there were no documented evidence indicating the total number of licensed nurses and the actual hours worked for those dates. On 1/23/20, at 9:49 a.m., during an interview with the Director of Staff Development (DSD), the DSD stated the staffing assignments should be completed on a daily basis at the beginning of each shift. The DSD confirmed the staffing information for 12/10/19, 12/11/19, 12/24/29 and 12/25/19 were incomplete. The DSD further stated the total number of staff (three licensed vocational nurses an done registered nurse) including the actual hours worked by the staff each shift should have been listed on 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 1. Ensure psychotropic drugs (mild altering drugs) warranted an adequate indication for use, for two of five residents (Resident 18 and 59). 2. Ensure a resident had a diagnosis or manifested behaviors of depression (sadness, hopelessness, trouble sleeping) before prescribing an antidepressant (a medication used to treat depression) for one of five sampled residents (Resident 34). This deficient practice has the potential to place the residents at risk for receiving unnecessary medication and increased risk of adverse side effects. Findings: a. A review of Resident 18's admission record indicated an admission date of 7/11/19 with diagnoses that included history of falling and dementia with behavioral disturbance (a disorder of mental processes caused by brain disease or injury and marked by memory disorder, personality changes, and impaired reasoning). A review of Resident 18's History and Physical record indicated Resident 18 had…

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