Pavilion On Pico Healthcare & Wellness Centre, LP

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure one of three sampled residents (Resident 19) care was not delayed when transportation failed to pick up Resident 19 on 10/28/25 per physician's orders. This failure had the potential to place the resident at risk for delayed treatment and care.Findings: During record review of Resident 19's admission record, the admission record indicated Resident 19 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including dementia (a progressive state of decline in mental abilities), Alzheimer's disease (a disease characterized by a progressive decline in mental abilities) and history of falling. During a record review of the Resident 19's Minimum Data set (MDS-a resident assessment tool), dated 10/17/2025 indicated Resident 19's cognition (mental ability decisions of daily living) was severely impaired. The MDS indicated Resident 19 was dependent (helper does all the efforts. Resident does none of the…

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

Based on observation, interview and record review, the facility failed to follow the physician's order for fluid restriction (limits total daily liquid intake) for one of one sampled resident (Resident 4). This failure had the potential to result in inaccurate fluid intake documentation leading to fluid overload (too much fluid in the body) and hospitalization for Resident 4. Findings; During a review of Resident 4's admission Record, dated January 2026, the admission Record indicated the facility admitted the resident on 11/7/25, with diagnoses including but not limited to urinary tract infection (UTI, an infection in the bladder/urinary tract), chronic obstructive pulmonary disease (COPD, a chronic lung disease causing difficulty in breathing) and congestive heart failure (CHF, a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling). During a review of Resident 4's Minimum Data Set (MDS, a standardized care screening and an assessment tool), dated 12/22/25, the MDS indicated the resident requires maximum assistance (helper…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the following for one of five sampled residents (Resident 21): 1. Resident 21 was assessed for risk of entrapment from bed rails prior to installation.2. Nursing staff implemented physician orders to maintain resident safety for seizure precautions. 3.Resident 21's bed dimensions were appropriate for the resident's size and weight.4. Staff obtained proper consent prior to using bilateral upper and lower side rails for Resident 21. These failures had the potential to result in serious physical injury, including entrapment, restricted movement during a seizure, or falls with injury, due to the use of four side rails (a device that attaches to the side of the bed).Findings: During a record review of Resident 21's admission record indicated Resident 21 was admitted on [DATE] with a diagnoses of seizures (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and 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 that medication error rate was less than five percent (5%). Two (2) medication errors out of twenty-six (26) opportunities resulted in an overall error rate of 7.69%, affecting two of four residents (Residents 14 and 45) observed during medication administration (MedPass) when:The physician order for levofloxacin (a strong, broad-spectrum antibiotic used to treat bacterial infections) for Resident 14 in electronic medical records (EMR) did not match the medication dose and directions listed on the bubble pack label.Licensed Vocational Nurse (LVN) 2 was unable to locate the prescribed strength of Vitamin D3 (supplement that supports bone health) for Resident 45 in medication cart 1, LVN 2 failed to follow up with the physician to clarify the discrepancy and obtain further instructions.These deficient practices increased the risk that Residents 14 and 45 may experience adverse reactions, complications, that could lead to a decline in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide a sufficient preparation and orientation for one of four sampled residents, (Resident) 1 with a safe and orderly discharge planning by failing to: 1. Complete an Interdisciplinary Team (IDT - a group of dedicated healthcare professionals who work to bring knowledge together to help residents receive the care they need) meeting regarding Resident 1's discharge planning. 2. Ensure the discharge planning was necessary, not because Resident 1 demanded of wanting to get up early and requested of laundry services. 3. Honor Resident 1's rights to be treated with kindness, respect and dignity. These deficient practices resulted in incomplete and ineffective discharge planning that may lead to lack of necessary care after discharge. Findings: During a review of the Resident 1's admission Record, it indicated Resident 1 was admitted to the facility on [DATE] with diagnosis including type II diabetes mellitus (DM-a disorder characterized by difficulty in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, 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 four sampled resident (Resident 1), by failing to address behavioral health care needs and implementing a person-centered care plan when Resident 1 unrealistic demands according to facility's policy and procedure (P&P) titled, Behavior/Psychotropic Drug Management . This deficient practice had the potential to negatively affect the delivery of behavioral health care and services to Resident 1. Cross Reference F745 Findings: During a review of the Resident 1's admission Record, it indicated Resident 1 was admitted to the facility on [DATE] with diagnosis including type II diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), chronic obstructive pulmonary disease (COPD-a chronic lung…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 medically-related social services to attain or maintain the highest practicable physical, mental and psychosocial well-being to one out of four sampled residents (Resident 1), by failing to promote individualized, non-pharmacological approaches to care that meet the mental and psychosocial needs. This deficient practice placed Resident 1 in psychosocial distress. Findings: During a review of the Resident 1's admission Record, it indicated Resident 1 was admitted to the facility on [DATE] with diagnosis including type II diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing) and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). During a review of the Minimum Data Set (MDS - resident assessment tool) dated 2/7/2025, indicated Resident…

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

Based on observation, interview, and record review the facility failed to promote care for residents in a manner and in an environment that maintains or enhances each resident's dignity in full recognition of his or her individuality when two (2) of 13 sampled residents (Resident 2 and Resident 42) did not get their meals at the dining table at the same time. This failure had the potential to result in psychosocial distress and frustration for Resident 2 and Resident 42. Findings: During a review of Resident 2's admission Record, the admission record indicated the facility admitted Resident 2 on 12/12/2022 with diagnoses including, but not limited to, chronic obstructive pulmonary disease ([COPD] a common lung disease that makes it difficult to breathe, dysphagia (difficulty swallowing) and type 2 diabetes (a common condition that occurs when the body does not use insulin properly, resulting in high blood sugar levels.) During a review of Resident 2's Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 9/17/2024, the MDS indicated Resident 2 was severely…

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

Based on observation, interview, and record review the facility failed to follow the menu and did not meet nutritional needs of five of 54 residents on puree texture diets (diets consisted of food with smooth and pudding like consistency) received scrambled eggs instead of Florentine torta per facility menu spreadsheet. This failure had the potential to result in decrease of nutrient intake resulting to unintended (not done on purpose) weight loss. Findings: During a review of the facility's daily spreadsheet titled Fall Menus, dated 11/16/2024, the spreadsheet indicated residents on pureed International Dysphagia Standardization Initiative ([IDDSI] global framework that provides standardized descriptors and testing methods for texture-modified foods and thickened liquids for people with difficulty in swallowing) 4 included the following foods on the tray: Grape juice four (4) ounces ([oz] unit of measurement) Puree oatmeal 3/4 cup ([c] household measurement) Puree Florentine Torta 2 ½ x 3 inches - 4 oz. Puree wheat toast 2 oz. Margarine 1 teaspoon (tsp) Milk 8 oz. During an…

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

Based on observation, interview and record review, the facility failed to prepare foods in a form designed to meet individual needs when: a. Residents on pureed International Dysphagia Standardization Initiative ([IDDSI] global framework that provides standardized descriptors and testing methods for texture-modified foods and thickened liquids for people with difficulty in swallowing) level 4 (diet consisted of food that are soft with pudding like consistency) received oatmeal with lumps. b. Residents on soft mechanical diet (diet consisted of food that are soft and chopped) received toasted bread with hard bread edges. This failure had the potential to result in coughing, choking (to keep from breathing the normal way) and death for six (6) of 54 residents on puree diet and 16 of 54 residents on soft mechanical diet. Findings: a. During a review of the facility's daily spreadsheet titled Fall Menus, dated 11/16/2024, the spreadsheet indicated residents on puree level 4 diet would include the following foods on the tray: Grape juice four (4) ounces ([oz] unit of measurement) Puree…

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

Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen when: a. Trash can in the handwashing sink room was not covered when it was not actively used. b. Staff did not perform hand hygiene. 1. Staff did not wash their hands after touching the lids of the garbage can then touched the clean resident's tray. 2. Staff loaded the dirty dishes in the dishmachine then proceeded to putting away the clean plates without washing their hands nor changing their gloves. c. Frozen raw chicken was stored on top of ground beef and cooked chicken was stored on the bottom of the raw fish. d. [NAME] racks had dust and rust in Refrigerator 2. 2. Freezer 3's gasket had dirt debris and buildup. 3. Freezer 4's gasket was torn and had dust buildup. 4. Preparation table roof had food dried buildup. 5. Ice machine spout had calcium buildup. e. There were chipped, cracked, and rusted kitchen utensils and equipment. 1. Refrigerator 5's shelves were chipped. 2. Eight (8) of 12 resident's trays were cracked. f.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 dispose garbage and refuse properly by a. Not maintaining the garbage area free from dirty, plastics, mask on the floor and surroundings. b. Not maintaining one (1) of the dumpster's (a large trash metal container designed to be emptied into a truck) lid close and not overflowing with trashes. This failure had the potential to result in attracting birds, flies, insects, pest and possibly spread infection to 53 of 54 facility residents. Findings: a. During a concurrent observation and interview on 11/16/2024 at 8:22 a.m. at the dumpster area with the Dietary Supervisor (DS), there were masks, dog poop bags, boxes and dirt on the floor and surroundings of the dumpster. DS stated the trash area should be cleaned from trash on the floor for infection control purposes. During a concurrent observation and interview on 11/16/2024 at 10:36 a.m. with Maintenance Director (MD), MD stated there were boxes, poop bags, mask on the floor and it was coming from the people walking by. MD stated dumpster area should always be…

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

Based on observation, interview, and record review, the facility failed to maintain sanitary conditions in the food services department when six (6) flies (a type of insect) were observed in the kitchen. This deficient practice had a potential to result in 53 of 54 residents, who received food from the kitchen, to acquire food borne illnesses (illness caused by consuming contaminated foods or beverages) by consuming potentially contaminated food. Findings: During an observation on 11/15/2024 at 5:43 p.m. one (1) fly was flying around the preparation area. During an observation on 11/16/2024 at 6:15 a.m. 1 fly was flying around the preparation table. During an observation on 11/16/2024 at 6:54 a.m. 1 fly was flying round the trayline (area where food was assembled) and the preparation area During a concurrent observation and interview on 11/16/2024 at 7:42 a.m. with [NAME] 1, there was two (2) flies flying around the preparation area. [NAME] 1 stated there was a fly in trayline. During a concurrent observation and interview on 11/16/2024 at 8:17 a.m. with Dietary Supervisor (DS), DS…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to document in the resident's medical record a change in the resident's condition in accordance with the facility's policy and procedure (P&P) titled Change of condition Notification revised 6/28/2024 for one of ten sampled residents (Resident 2). This deficient practice resulted in Resident 2's attending physician and resident representative not being promptly notified of Resident 2's change of condition. Findings: During a review of Resident 2's admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses including hypothyroidism (when the thyroid gland [a small butterfly shaped gland in front of the neck that produces hormones that regulate many of the body's functions] does not produce enough thyroid hormone), generalized muscle weakness (a decrease in muscle strength), and hypertension (HTN -blood pumping with more force than normal through your arteries). During a review of Resident 2'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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Bases on interview and record review, the facility failed to notify the physician of the laboratory testing finding in accordance with the facility's policy and procedure (P&P) titled Laboratory Services revised 6/28/2024 for one of ten sampled residents when: 1. Resident 2's lab results report dated 8/23/2024, indicated thyroid stimulating hormone (TSH -a hormone that is produced by the pituitary gland [small pea size gland found at the base of the brain] releases to trigger the thyroid to produce and release its own hormone) 27.71 micro-internation units (uIU -metric unit of measurement for volume) per milliliter (ml -metric unit of measurement for volume, normal range is 0.45 % to 5.33 %) 2. Resident 2's refused to have the TSH laboratory draw done on 10/10/2024 that was ordered on 8/29/2024. Findings: During a review of Resident 2's admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses including hypothyroidism (when the thyroid gland [a small butterfly shaped gland in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure that the Low air loss (LAL -a pressure relieving mattress for the management or prevention of pressure sores) Mattress setting was appropriately set for one of ten sampled residents (Resident 205). This deficient practice had the potential to result in the redevelopment of pressure ulcers (a localized injury to the skin and/or underlying tissue usually over a bony prominence due to pressure, or pressure in combination with shear) and possible hospitalization. Findings; During a review of Resident 205's admission Record indicated the resident was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including diabetes (DM - a disorder characterized by difficulty in blood sugar control and poor wound healing), hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body), and generalized muscle weakness (a decrease in muscle strength). During a review of Resident 205'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 observation, interview and record review, the facility staff failed to ensure one of three sampled residents (Resident 16) received appropriate treatment and services to prevent urinary tract infections (UTI-an infection in any part of your urinary system your kidneys, ureters, bladder, and urethra) by failing to: 1. Place a securement device/anchor on Resident 16's indwelling urinary catheter (a flexible plastic tube inserted into the bladder that remains there to always provide continuous urinary drainage) to secure the catheter below the level of the bladder at all times. 2. Assess and monitor the catheter for proper placement and drainage, and to ensure no leaking was present as per the resident's care plan (a plan of care that summarizes a resident's health conditions, specific care needs, and current treatments) titled Assess urinary drainage created on 4/28/2024. These deficient practices had the potential to result in urine backflowing up into Resident 16's bladder and blood stream resulting in…

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

Based on observation, interview and record review the Licensed Vocational Nurse (LVN) 4 failed to hold a Amlodipine (blood pressure medication) per the physician's order for one of two sampled residents (Resident 32). This deficient practice placed Resident 1 at risk for a further decrease in heart rate. Findings: During a review of Resident 32's admission Record indicated the facility originally admitted Resdent 32 on 5/19/2022 and more recently on 12/21/2022 with diagnoses including diabetes mellitus (a disease in which the body does not control the amount of hglucose/sugar in the blood and the kidneys make a large amount of urine), essential hypertension (HTN-high blood pressure), anemia (a condition where the body does not have enough healthy red blood cells), hyperlipidemia (high fat in the blood), morbid obesity (severely overweight), and epilepsy (seizures). During a review of Resident 32's Minimum Data Set (MDS- a federally mandated resident assessment tool) dated 9/25/2024 indicated Resident 32's cognition (mental ability to make decisions for daily living) was intact.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 the correct temperature in one of two medication storage rooms, Medication storage room [ROOM NUMBER]. This deficient practice put the medications at risk of losing their efficacy before they expire. Findings: During a concurrent observation and interview on 11/16/2024 at 2:43 p.m. with Registered Nurse Supervisor (RNS), inside of the Medication Storage room [ROOM NUMBER] the thermostat indicated 90 degrees. The RNS stated, I think it's supposed to be 68°F-77°F (degrees Fahrenheit-Unit of measurement). During a concurrent observation and interview on 11/16/2024 at 3:59 p.m. with the [NAME] President of Operations (VPO), the Medication Storage room [ROOM NUMBER] door was open with a large fan on the floor blowing air into the room. The VPO stated the light switch in the room also controls the fan located in the ceiling; when the light is turned off so is the fan and that is the cause of the elevated temperature inside the room.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 staff monitored, supervised, and were aware of the location of one of two residents with wandering behaviors for safety and prevent elopement (leaving the facility unsupervised and without staff knowledge). This deficient practices resulted in Resident 1, eloping (an unauthorized departure of a patient from an around-the-clock care setting) via the facility ' s front reception area doors during the afternoon on 7/3/2024 at 2 pm. Resident 1 was located the same day (7/3/24) at the resident's previous address 3.5 miles away from the facility and Resident 2 leaving the facility, increasing the risk for injury and harm related to accidents. 2. Ensure the wander-guard alarm (a device used as an additional layer of security that allows sensors on doors/exits to alarm if patients at high risk of elopement leave through them) failing to notify staff Resident 2 was leaving facility. This deficient practice had the potential 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 interview and record review, the facility failed to ensure one of three sampled residents (Resident 4), had a wound care consultation follow up for pressure injury (refers to localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device) prevention initiated in a timely manner. This failure resulted Resident 4 ' s wound care treatments to be ordered 10 days after admission to the facility which, had the potential to result in Resident 4 ' s pressure injury on the sacrum (bony structure at the base of the spine) and bilateral (both sides) lateral (outer) ankle arterial ulcers (wound located on lower leg or foot due to poor circulation) to worsen. Findings: During a review of Resident 4's admission Record, dated 1/31/24, indicated, the resident was admitted to the facility on [DATE] with diagnoses including essential (primary) hypertension (high blood pressure), hemiplegia (muscle weakness on one side of the body) and hemiparesis (muscle…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 adequate supervision for Resident 44 who was identified as exhibiting wandering behavior. As a result, Resident 44 eloped from the facility on 10/14/2023. A friend to Resident 44's Family Member (FM) found Resident 44 on unknown date and time. Findings: A record review of Resident 44's admission Record indicated the facility admitted Resident 44 on 2/23/2023 with diagnoses including hepatic failure (loss of liver function that occurs quickly), alcoholic cirrhosis of liver ( a condition caused by continued alcohol use that results in long-term inflammation in your liver)with ascites (excessive abdominal fluid), epileptic syndromes (the brain's electrical rhythms have a tendency to become imbalanced), megaloblastic anemia (a type of vitamin deficiency anemia ), homelessness (a person without a home), depression (a mood disorder characterized by sadness), anxiety (intense, excessive, and persistent worry and fear about everyday situations). A record review of Resident 44's Minimum Data Set (MDS-a standardized…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 21 sampled residents (Resident 45 and Resident 148), the facility failed to ensure the call button was within reach of Resident 45 and to ensure there was a functioning call light for Resident 148. Those deficient practices had the potential to result in the needs of residents not being met, and to cause incidents leading to injuries. Findings: A review of Resident 45's admission Record indicated the facility admitted Resident 45 on 7/5/8/2023 with diagnoses including cerebral infarction (stroke -when blood flow to a part of your brain is stopped either by a blockage or rupture of a blood vessel), transient ischemic attack (TIA - a temporary blockage of blood flow to the brain), and muscle weakness (lack of physical or muscle strength). A review of Resident 45's History and physical (H+P) dated 7/7/2023 indicated Resident 45 had the capacity to understand and make decisions. A review of Resident 45's Minimum Data Set (MDS - a standard 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 ensure residents' clinical records were updated about advance directives (written statement of a person's wishes regarding medical treatment made to ensure those wishes are carried out should the person be unable to communicate them to a doctor) for five one of five sampled residents (Resident 14) by failing to maintain documentation of the residents' advance directives in the residents' clinical records. This deficient practice had the potential to cause conflict with the residents' wishes regarding health care (Resident 14). Findings: A review of Resident 14's admission Record indicated the resident was originally admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that include encephalopathy (damage or disease that affects the brain), schizoaffective disorder (a mental condition combined with symptoms of schizophrenia [mental disorder in which people interpret reality abnormally] and mood disorder [a mental health problem…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 through with the Preadmission Screening and Resident Review (PASRR) recommendation to obtain a PASRR level II evaluation for two of two sampled residents (Resident 4 and Resident 17). This deficient practice had the potential to result in inappropriate placement and unidentified specialized services for Resident 1. Findings: A review of the Resident 4s admission record indicated Resident 4 was re-admitted to the facility on [DATE], with diagnoses that included schizophrenia (a chronic [ongoing] and severe mental disorder that affects how a person thinks, feels, and behaves), and major depressive disorder (a mental condition characterized by a persistently depressed mood and long-term loss of pleasure or interest in life) and delusional disorder (a fixed false belief based on an inaccurate interpretation of an external reality despite evidence to the contrary). A review of Resident 4's PASRR completed on 7/22/2023, indicated 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 intervention and record review the facility failed to initiate and implement a care plan for Continuous positive airway pressure (CPAP-is a common treatment for obstructive sleep apnea) therapy as ordered by a medical doctor (MD) for one of two sampled residents (Resident 99). This deficient practice had the potential to not provide person-centered, comprehensive, and interdisciplinary care that reflets best practice standards for meeting health, safety, psychosocial, behavioral, and environmental needs of residents in order to obtain or maintain the highest physical, mental and psychosocial well-being for Resident 99. Findings: A record review of Resident 99's admission Record indicated the facility admitted Resident 99 on 9/29/2023 with medical history including intervertebral lumbar disc degeneration (loss of cushioning and herniation related to aging), hypertensive heart disease with heart failure (a chronic condition in which the heart does not pump blood as well as it should), type 2 diabetes (the body's inability to process sugar), asthma (inflamed airways),…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 for one of six sampled residents (Resident 31), the facility failed to follow, transcribe physicians' orders for a surgical (cutting into the skin) wound care in accordance with the facility's policy and procedures (P&P) titled Physicians Orders revised on 8/21/2020, . This deficient had the potential to result in infection and hospitalization for Resident 31. Findings: A review of Resident 31's admission Record indicated Resident 31 was admitted at the facility initially admitted on [DATE]/2023 and was readmitted on [DATE] with diagnoses including left leg below the knee amputation (surgical removal of part of the body), diabetes mellitus (DM - a chronic condition that affects the way the body processes blood sugar [glucose]), and hypertension (HTN - elevated blood pressure). A review of Resident 31's Minimum Data Set (MDS - a standard assessment and care screening tool) dated 9/30/2023, indicated Resident 31 was cognitively intact. The MDS indicated Resident 31 required…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on intervention and record review the facility failed to follow up and make arrangements after a medical doctor's recommendation for cataract (clouding or loss of transparency of the lens in the eye as a result of tissue breakdown and protein clumping) surgery (a procedure to remove the lens of the eye and replaces with an artificial lens) for one of one sampled resident (Resident 39) in accordance with the facility's policy and procedures titled, Referrals to Outside Services dated 12/01/2013. As a result, Resident 39 was concerned that his vision was getting worse. Findings: A record review of Resident 39's admission Record indicated Resident 39 was admitted on [DATE] and was readmitted on [DATE] with medial history including chronic atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow), type 2 diabetes( body's inability to process sugar) with chronic kidney disease (longstanding disease of the kidneys), congestive heart failure (a chronic condition in which 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 reviewed the facility failed to ensure transportation services was provided to scheduled dialysis (a treatment to clean your blood when your kidneys are not able to) appointments for one of three sampled residents (Resident 1). This deficient practice resulted rescheduling missed dialysis on 8/9/2023, 8/11/2023, and 8/14/2023 and frustration for Resident 1 with the potential to negatively impact Resident 1's over health due to increased toxins (poisons produced by living organism) within the body causing weakness, dizziness, nausea and vomiting and potentially death. Findings: A review of Resident 1's admission record (face sheet) dated indicated Resident 1 the facility admitted from a General Acute Care Hospital (GACH) on 8/4/2023 with diagnoses that included end stage renal disease (A condition in which the kidneys lose the ability to remove waste and balance fluids), hypertension (high blood pressure), type 2 diabetes (a condition that happens because of a problem in the way the…

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