St Andrews

Based on observation, interview and records review, the facility failed to ensure one of four sampled residents (Resident 24) was free from unnecessary medications when:1. There were two physician orders for Acetaminophen ([Tylenol] used to relieve mild to moderate pain) with the same indication.2. Tramadol (prescription painkiller used to treat moderate to severe pain) was administered routinely without a clinical indication.This deficient practice had the potential to result in medication errors, overdose, and unnecessary use of opioid (prescription drugs used to treat moderate to severe pain and carry significant risks of addiction, dependence, and overdose.Findings:During a review of Resident 24's admission Record, the admission Record indicated the facility admitted the resident on 2/7/2025 with diagnoses including severe protein calorie malnutrition (body lacks both enough energy calories and protein), anxiety disorder (mental health condition characterized by excessive worry about everyday situations), and major depressive disorder ([MDD] - a mood disorder that cause a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure an unopened Gabapentin (an anticonvulsant drug used primarily to treat nerve pain and seizure) oral solution was stored inside the medication room refrigerator for one of one sampled resident (Resident 35).This deficient practice had the potential for the loss of efficacy of the Gabapentin oral solution that would cause ineffective pain management of Resident 35.Findings:During a review of Resident 35's admission Record, the admission Record indicated Resident 35 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 35's diagnoses included neuralgia (sharp and burning nerve pain), malignant neoplasm of the kidney (kidney cancer), Diabetes Mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing) and gastrostomy tube placement (GT, a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with…

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

Based on observation, interview, and record review, the facility failed to ensure one of one resident's (Resident 15) dislikes on the dietary card reflected the resident's preference.This deficient practice had the potential to result in dissatisfaction with meals leading to decreased intake and weight loss.Findings:During an observation in the kitchen on 6/3/2026 at 12:00 p.m., Resident 15's plastic dietary card indicated dislikes included rice. The resident's lunch tray was observed including chicken, bread, green vegetables and rice.During an interview with Resident 15 on 6/3/2026 at 12:05 p.m., Resident 15 stated that his lunch appeared fine, but he does not dislike rice. During an interview with Dietetic Services Supervisor (DSS) on 6/3/2026 at 12:15 p.m., the DSS stated he was responsible for updating dietary cards per physician orders and resident preferences. The DSS stated Resident 15's dietary card was not updated. The DSS stated that discrepancies in dietary cards may result in residents receiving meals inconsistent with physician orders and/or individual preferences. 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 properly store, label and monitor food items for use when: Ravioli was kept in the freezer beyond use by date of 6/1/2026.Tamales was taken out of its original packaging and placed in a zip lock bag without use by date label.These deficient practices had the potential to place residents at risk for foodborne illness (an illness caused by food contaminated with bacteria, viruses, and other toxins).Findings:1.During an observation on 6/2/20206 at 8:19 a.m., reach-in freezer (Freezer 1) contained frozen ravioli stored in a zip lock bag labeled use by: 6/1/2026.During an interview on 6/2/26 at 2:37 p.m. with Dietary Service Supervisor (DSS), the DSS stated all food items removed from the original container must be labeled with use by date. The DSS stated the use by date was the last day residents can consume food items and food past the use by date was expired and must be discarded. The DSS stated consuming expired foods had the potential to cause residents to have stomach ache and illness. During an interview on…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 Arbitration Agreement form (a legally binding contract where parties agree to resolve future disputes through a private, out-of-court arbitration process instead of suing in a traditional courtroom) was not signed by one of eight residents, (Resident 1), who had a responsible party (the individual designated to pay a patient's medical bills, manage their care decisions, or supervise daily support services), had cognitive impairment, did not have the capacity to understand and make decisions and who was legally blind (a government classification for significant vision impairment used to determine eligibility for disability benefits, tax exemptions, and rehabilitation services).This deficient practice had the potential that Resident 1 did not understand what he was signing and resulted in the arbitration agreement not explained to the resident's responsible party.Findings:During a review of Resident 1's admission Record, the admission Record…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of 5 sampled residents, Resident 1, who was on a pureed diet (foods modified to a soft, pudding-like consistency for residents who have difficulty chewing or swallowing solid foods), was not fed by an untrained facility staff (Recepitonist).This failure placed the resident at risk for choking and aspiration (the inhalation of foreign material, like food, liquid, or stomach contents, into the airway and lungs) of food, which could lead to resident injuries and hospitalization, including death.Findings: During an observation on 7/14/2025 at 12 noon, in the front lobby, the Receptionist was observed sitting in the hallway next to Resident 1 and fed him lunch of a puree textured diet. During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses including nausea and vomiting, cirrhosis of the liver (a condition…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to implement its infection prevention and control measures for two of five sampled residents (Residents 3 and 4) by failing to perform hand hygiene (washing hands or using an alcohol-based sanitizer) before and after assisting Resident 3 and Resident 4 with their lunch meals. This failure had the potential to spread germs and increase the risk of infections among residents and staff. Findings:During an observation and concurrent interview on 7/14/2025 at 12:20 p.m. in the activity room, Restorative Nurse Assistant (RNA) 1 was observed sitting down between Resident 3 and Resident 4 during lunch. RNA 1 was observed assisting Resident 3 with using his fork while the resident was eating and feeding Resident 4 with a spoon and failed to perform hand hygiene before and after assisting the residents. RNA 1 stated he should not be assisting two residents at the same time and failing to perform hand hygiene before and after assisting each resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the staff failed to ensure the residents and/or responsible party (RP) were informed of an alleged abuse on 2/24/2025 and dentist visit on 3/10/2025 for one of three sampled residents (Resident 1). The deficient practice led Resident 1 ' s responsible party feeling ignored and uninformed about the care of Resident 1. Findings: During a review of Resident 1 ' s admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE], with diagnoses of hyperlipidemia (high cholesterol) and hypertension (high blood pressure). During a review of Resident 1 ' s History and Physical (H&P) dated 3/11/2025, H&P indicated that Resident 1 did not have the capacity to understand and make decisions. During a review of Resident 1 ' s Minimum Data Set ([MDS], a resident assessment tool), dated 1/29/2024, the MDS indicated Resident 1 was sometimes able to understand and be understood by others. The MDS indicated Resident 1 required supervision 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 observation, interview and record review, the facility failed to store food in accordance with professional standards for food service safety by failing to: 1. Ensure food items were labeled in Refrigerator 1, Refrigerator 2, Refrigerator 3 and Freezer 2 in the kitchen. 2. Ensure expired food was discarded from Refrigerator 2 in the kitchen. 3. Ensure a dented can sign was on display in the dry storage area. 4. Ensure the kitchen mixer and processer was clean. 5. Ensure the juice dispensing nozzle was clean. This deficient practice had the potential to result in in foodborne illness and contamination. Findings: During a concurrent observation and interview, of the initial kitchen tour, on 4/15/2025, at 8:44 a.m., with the Dietary Supervisor (DS), an opened bag of parmesan cheese was noted to not have a dated label in Refrigerator #1. The DS stated food items in the refrigerator are required to have an open date. The DS stated the risk of not labeling the bag of parmesan cheese could result in residents consuming expired food. During a concurrent observation and interview,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 revise and provide an updated average daily census of the Facility Assessment Tool (a process for evaluating a facility's resident population and identifying the resources needed to provide care and services). This deficient practice had the potential to place residents at risk for delay of care and treatment services. Findings: During a review of the facility census for 4/15/2025, indicated 54 residents resided in the facility. During a concurrent interview and record review on 4/16/2025 at 8:21 a.m., with the Administrator (ADM), the Facility Assessment Tool, was reviewed. The ADM stated the Facility Assessment Tool was last updated on 12/6/2024. The ADM stated the assessment provided was an average daily census of 51 residents. The ADM stated the average daily census recorded on the Facility Assessment Tool did not match with the current census. The ADM stated the Facility Assessment Tool was not accurate because of the average daily census which is below the actual census. The ADM stated there were three residents who…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 assistance to one of three sampled residents (Resident 8) who had ill-fitting clothing, exposing the resident's buttocks. This failure had the potential to negatively affect Resident 8's sense of self-worth and self- esteem. Findings: During a review of Resident 8's admission Record, the admission Record indicated the facility admitted Resident 8 on 5/15/2017 and was readmitted on [DATE] with diagnoses including Parkinson's disease (a progressive of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), idiopathic peripheral autonomic neuropathy (nerve damage in hands and feet) restless leg syndrome (an overwhelming urge to move legs often, accompanied by uncomfortable sensations in the legs), right hand, right elbow, left hand contractures (a stiffening/shortening at any joint, that reduces joint's range of motion), and polyosteoarthritis (arthritis that affects five or more joints…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 honor snack preferences for one of five sampled residents (Resident 34). This deficient practice resulted in Resident 34 not being able to make choices about his preference for food. Findings: During a review of Resident 34's face sheet (front page of the chart that contains a summary of basic information about the resident), the face sheet indicated Resident 34 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included obesity (the state or condition of being very fat or overweight), chronic pulmonary edema (a condition where there is a persistent buildup of fluid in the lungs, leading to difficulty breathing), type 2 diabetes (a disorder characterized by difficulty in blood sugar control and poor wound healing) and hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body). During a review of Resident 34's physician orders, dated 12/7/2023, the physician order…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 notify the physician for one of three sampled resident (Resident 11) who was refusing range of motion (ROM- full movement potential of a joint where two bones meet) therapy. This failure had the potential for Resident 11 to decline in physical functioning and resulted in delayed continuity of care due to the physician not being notified in a timely manner. Findings: During a review of Resident 11's admission Record, the admission Record indicated the facility admitted Resident 11 on 10/19/2011 and was readmitted on [DATE] with diagnoses including cerebral vascular accident (stroke), right hemiplegia(total paralysis of the arm, leg, and trunk on the same side of the body) left hip contracture (a stiffening/shortening at any joint, that reduces the joint's range of motion), and right hip contracture. During a review of Resident 11's Minimum Data Set (MDS- a resident assessment tool), dated 3/18/2025, the MDS indicated Resident 11 had severe…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation interview and record review, the facility failed to ensure the responsible party/Power of Attorney was notified of Medi-Cal approval for one of five sampled residents (Resident 46). This deficient practice had the potential to result in the responsible party not being able to make medical decisions for the resident. Findings: During a review of Resident 46's face sheet (front page of the chart that contains a summary of basic information about the resident), the face sheet indicated Resident 46 was admitted to the facility on [DATE], with diagnoses that included myalgia (pain in a muscle or group of muscle), unspecified dementia (a progressive state of decline in mental abilities), unspecified psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality) and toxic encephalopathy (brain dysfunction caused by toxic exposure). During a review of Resident 46's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to: 1. Transmit the Minimum Data Set ([MDS]- a resident assessment tool) within 14 days after completion to the Center of Medicare and Medicaid Services (CMS) for one of 20 sampled residents (Resident 53). This deficient practice had the potential to result in a billing error and inaccurate data on resident care needs. Findings: During a review of Resident 53's admission Record (front page of the chart that contains a summary of basic information about the resident), the admission Record indicated, Resident 53 was admitted to the facility on [DATE]. Resident 53's diagnoses included urinary tract infection ([UTI] - an infection in the bladder/urinary tract), diabetes mellitus ([DM] - a disorder characterized by difficulty in blood sugar control and poor wound healing), and cerebrovascular accident ([CVA] - stroke, loss of blood flow to a part of the brain). During a review of Resident 53's History and Physical (H&P), dated 11/28/2024, the H&P indicated,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record, the facility failed to ensure an accurate Minimum Data Set ([MDS] - a resident assessment tool) assessment was completed accurately for two of 20 sampled residents (Resident 3 and 27) by failing to: 1. Esure Resident 3's Trazodone (medication used to treat depression) was not encoded as a hypnotic (a class of psychoactive drugs that treat insomnia and help people fall asleep) under MDS Section N (N0415 High-Risk Drug Classes) for medication. 2. Ensure Resident 27's weight loss was not encoded as significant weight loss (loss of 5 percent ([%] - out of each 100) or more in the last month or loss of 10% or more in last 6 months) under MDS Section K (K0300 Weight Loss). This deficient practice resulted in incorrect data being transmitted to the Center for Medicare and Medicaid Services (CMS) and had the potential to negatively affect the plan of care and delivery of care and services for Resident 3 and 27. Findings: a). During a review of Resident 3's admission Record, the admission…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to complete and re-submit the Preadmission Screening and Resident Review ([PASARR - a tool to determine if the person had, or was suspected of having a mental illness, intellectual disability, or related condition) Level one (I) screening and refer one of three sampled residents (Resident 33) who had a diagnoses of anxiety disorder (a condition that involves excessive and persistent feelings of fear, dread, and worry that can interfere with daily life) and major depressive disorder ([MDD] - a mood disorder that causes a persistent feelings of sadness and loss of interest) to the appropriate state-designated authority for PASARR Level two (II) evaluation and determination. This deficient practice had the potential to result in Resident 33 to not receive the appropriate medical treatments for mental illness diagnoses. Findings: During a review of Resident 33's admission Record (front page of the chart that contains a summary of basic information about 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 properly obtain an accurate orthostatic blood pressure (a form of low blood pressure that happens when standing after sitting or lying down) readings for one of one sampled resident (Resident 10). This deficient practice had the potential to result in Residents 10 experiencing a delay in interventions if they were positive for orthostatic hypotension (low blood pressure). Findings: During a review of Resident 10's Face Sheet (front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated Resident 10 was admitted on [DATE] with diagnoses that included bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), muscle weakness, and lack of coordination. During a review of Resident 10's History and Physical (H&P), dated 2/8/2025, the H&P indicated Resident 10 had the ability to understand and make decisions.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure the low air loss mattress settings were correct for one of five sampled residents (Resident 5). This deficient practice had the potential to result in further skin breakdown. Findings: During a review of Resident 5's face sheet (front page of the chart that contains a summary of basic information about the resident), the face sheet indicated Resident 5 was admitted to the facility on [DATE] with diagnoses which included an unstageable pressure ulcer of the back (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence), pressure induced deep tissue damage (damage to the deeper layers of the skin and underlying tissues, like muscle and fat, caused by pressure), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest) and nausea (a feeling of sickness with an inclination to vomit). During a review of Resident 5'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 failed to provide appropriate services to prevent a decline in joint range of motion ([ROM] - full movement potential of a joint) for one of four sampled residents (Resident 50) who had limited range of motion by failing to: 1. Provide a left-hand roll (a device that prevents fingers from curling up tightly). This deficient practice had the potential to result in further decline in Resident 50's ROM and overall quality of life. Findings: During a review of Resident 50's admission Record (front page of the chart that contains a summary of basic information about the resident), the admission Record indicated, Resident 50 was admitted to the facility on [DATE]. Resident 50's diagnoses included a contracture (a stiffening/shortening at any joint, that reduces the joint's range of motion) of the muscle of the left forearm, cerebrovascular accident ([CVA] - stroke, loss of blood flow to a part of the brain), and hypertension ([HTN] - high blood…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 driver's license was renewed in a timely manner for one of five sampled residents (Resident 46). This deficient practice had the potential to result in a delay in the delivery of care and services. Findings: During a review of Resident 46's face sheet (front page of the chart that contains a summary of basic information about the resident), the face sheet indicated Resident 46 was admitted to the facility on [DATE] with diagnoses that included myalgia (pain in a muscle or group of muscle), unspecified dementia (a progressive state of decline in mental abilities), unspecified psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality) and toxic encephalopathy (brain dysfunction caused by toxic exposure). During a review of Resident 46's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 2/11/2025, the MDS indicated Resident 46's cognitive…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of four sampled residents (Resident 3) did not receive an opened capsule of Duloxetine (a medication used for depression and nerve pain). This deficient practice had the potential to result in Resident 3 to experience adverse effects due to the nurse not following the medication manufacturer's directions. Findings: During an observation on 4/17/2025 at 8:59 a.m., Licensed Vocational Nurse (LVN) 2 opened the Duloxetine Delayed Release (DR- allows the medication to bypass certain areas of the digestive system) 30 milligrams (mg- unit of measurement) Capsule, poured the contents into a medication cup, mixed it with apple sauce, and gave it to Resident 3 to take. A sticker on the Duloxetine Capsule indicated Do Not Crush. During a review of Resident 3's Face Sheet (front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated Resident 3 was admitted to the facility on [DATE] with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow the physicians orders to draw monthly labs for a Complete Blood Count (CBC), Comprehensive Metabolic Panel (CMP) and Keppra level for one of two sampled residents (Resident 25). This deficient practice had the potential to result in a delay in care and services due to missing laboratory results. Findings: During a review of Resident 25's Face Sheet (front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated Resident 25 was admitted to the facility on [DATE] with diagnoses that included seizures (a sudden, uncontrolled electrical disturbance in the brain which could cause uncontrolled jerking, blank stares, and loss of consciousness), chronic kidney disease (a condition where the kidneys lose their ability to filter waste and excess fluid from the blood), and diabetes mellitus type 2 (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing). 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one out of four sampled residents (Resident 2) had a Care Plan (a documentation that outlines a patient's care and is created by a nurse as part of the nursing process) for physical aggression (behavior causing or threatening physical harm towards others). This deficient practice of not having a Care Plan for physical aggression had the potential for Resident 2 to be physical aggressive again. Findings: During a review of Resident 2's admission Record (Face Sheet), the Face Sheet indicated Resident 2 was initially admitted to the facility on [DATE]. Resident 2's diagnoses included schizophrenia (a serious mental illness that affects a person's thoughts feelings, and behaviors), bipolar disorder (a mental illness that causes extreme mood swings), major depressive disorder (a mental health disorder persistently sad mood or loss of interest in activities). During a review of Resident 2's History and Physical (H&P), dated 8/21/2024, the H&P…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 physician order was followed for one out of four sampled Residents (Resident 1). This deficient practice of not following physician orders placed the Resident 1 at risk for continuing aggressive behavior after an altercation (a noisy argument or quarrel between people which could include fighting). Findings: During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 1's diagnoses included moderate intellectual disabilities (a level of intellectual disability that is characterized by an average mental age of six to nine years), osteomyelitis (inflammation or swelling that occurs in the bone), functional quadriplegia (a mental health disorder persistently sad mood or loss of interest in activities). During a review of Resident 1's History and Physical (H&P), dated 8/21/2024, the H&P indicated Resident 1 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop a resident-centered care plan for the use of foley catheter (flexible tube that drains urine from the bladder into a collection bag) for one of three residents (Resident 1). This deficient practice had the potential to result in poor quality care on a resident with foley catheter, placing the resident at risk for urine infection and other catheter usage complications (blockage, sediments). Findings: During a review of Resident 1 ' s admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE]. Resident 1 ' s diagnoses included end stage renal disease (medical condition where the kidneys permanently stop functioning and require dialysis or a kidney transplant to stay alive) and muscle weakness. During a review of Resident 1 ' s History and Physical (H&P), the H&P indicated Resident 1 had the capacity to understand and make decisions. During a review of Resident 1 ' 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, the facility failed to ensure staff implemented the fall prevention care plan for one of two sampled residents (Resident 2). This deficient practice increased the potential for avoidable physical harm to Resident 2 related to a repeat fall with possible injury. Findings: During a review of Resident 2 ' s admission Record, the record indicated Resident 2 was admitted to the facility on [DATE]. Resident 2 ' s admitting diagnoses included hemiplegia and hemiparesis (muscle weakness or partial paralysis on one side of the body that can affect the arms, legs, and facial muscles), lack of coordination, and age-related osteoporosis (a condition in which bones become weak and brittle). During a review of Resident 2 ' s Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 7/4/2024, the MDS indicated Resident 2 did not have impaired cognition (when a person has trouble remembering, learning new things, concentrating, or making decisions that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure fall prevention interventions were implemented, as indicated in the care plan, for one of two sampled residents (Resident 2). This deficient practice increased the potential for avoidable physical harm to Resident 2 related to a repeat fall with possible injury. Findings: During a review of Resident 2 ' s admission Record, the record indicated Resident 2 was admitted to the facility on [DATE]. Resident 2 ' s admitting diagnoses included hemiplegia and hemiparesis (muscle weakness or partial paralysis on one side of the body that can affect the arms, legs, and facial muscles), lack of coordination, and age-related osteoporosis (a condition in which bones become weak and brittle). During a review of Resident 2 ' s Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 7/4/2024, the MDS indicated Resident 2 did not have impaired cognition (when a person has trouble remembering, learning new things,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, Licensed Vocational Nurse (LVN) 1 failed to administer medications according to the facility ' s policy and procedure (P&P) for one of two sampled residents (Resident 2). This deficient practice created the potential for Resident 2 to take medications affecting his blood pressure and heart rate, without his blood pressure or heart rate being within the required range for safe administration. The failure also created the potential for Resident 2 ' s medications to be taken by a facility resident the medications were not ordered or intended for. Findings: During a review of Resident 2 ' s admission Record, the record indicated Resident 2 was admitted to the facility on [DATE]. Resident 2 ' s admitting diagnoses included hemiplegia and hemiparesis (muscle weakness or partial paralysis on one side of the body that can affect the arms, legs, and facial muscles), aphasia (loss of ability to understand or express speech, caused by brain damage), lack of coordination,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to notify resident representative for one of four sampled resident ' s (Resident 1, after Resident 1 was found on the floor. This deficient practice resulted in Resident 1's representative not aware of the fall incident. Findings: A review of Resident 1 ' s admission Record, dated 5/2/2024, indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 1's diagnoses included chronic obstructive pulmonary disease [(COPD), a group of lung diseases that block airflow and make it difficult to breathe], dementia (a group of conditions characterized by impairment of at least two brain functions such as memory loss and judgement), and muscle weakness. A review of Resident 1 ' s History and Physical (H&P), dated 11/2/2023, indicated Resident 1 was able to make decisions for activities of daily living and Resident 1 ' s son was the surrogate decisionmaker. A review of Resident 1 ' 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 interviews and record review, the facility failed to ensure staff supervision was provided to one of four sampled residents (Resident 1), who was left on the floor alone, after a fall, while the other staff called for assistance. This deficient practice had the potential to cause further injury to Resident 1 and Resident 2, who put Resident 1 back to bed. Findings: A review of Resident 1 ' s admission Record, dated 5/2/2024, indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses including chronic obstructive pulmonary disease [(COPD), a group of lung diseases that block airflow and make it difficult to breathe], dementia (a group of conditions characterized by impairment of at least two brain functions such as memory loss and judgement), and muscle weakness. A review of Resident 1 ' s History and Physical (H&P), dated 11/2/2023, indicated Resident 1 was able to make decisions for activities of daily living and Resident 1 ' s son was the surrogate…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to maintain accurate documentation for one of four sampled residents (Resident 1). This failure resulted to an inaccurate documentation for Resident 1 ' s incident. Findings: A review of Resident 1 ' s admission Record, dated 5/2/2024, indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including chronic obstructive pulmonary disease [(COPD), a group of lung diseases that block airflow and make it difficult to breathe], dementia (a group of conditions characterized by impairment of at least two brain functions such as memory loss and judgement), and muscle weakness. A review of Resident 1 ' s History and Physical (H&P), dated 11/2/2023, indicated Resident 1 was able to make decisions for activities of daily living and Resident 1 ' s son was the surrogate decisionmaker. A review of Resident 1 ' s Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 2/16/2024, indicated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to follow its policy and procedure to replace the non- antibiotic Emergency Kit (E-Kit) within 72 hours. This deficient practice had the potential for not providing medication to residents during emergency situations. Findings: During a concurrent observation and interview on 4/27/2024 at 10:10 a.m., of the medication storage room [ROOM NUMBER] with Licensed Vocational Nurse 2 (LVN 2), found one portable container non-antibiotic medication E-Kit with prescription #3187400, with red seal tag. LVN 2 stated the portable container non-antibiotic medication E-Kit indicates a fill date of 2/13/2024. LVN 2 stated red seal tag means the E-Kit had been opened. LVN 2 stated yellow seal tag means the E-Kit had not been opened. During a concurrent interview and record review on 4/27/2024 at 10:15 a.m., with LVN 2, Emergency Drug Supply Log Sheet was reviewed. LVN 2 stated the non-antibiotic medication E-Kit was opened on 4/16/2024. LVN 2 stated the…

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

Based on observation, interview and record review, the facility failed to ensure food items were labeled properly and expired food was not stored in the kitchen accessible to be used in preparing foods for 45 out of 51 residents. This practice had the potential to result in the residents ingesting expired food and can result in foodborne illnesses. Findings: During a concurrent observation and interview, on 4/27/2024 at 8:10 a.m., with Dietary Aide 2 (DA 2), in Freezer #2, DA 2 observed 1 plastic bag of seasoned potato fries with an open date of 1/10/2024. DA 2 stated the seasoned potato fries were good for 3 months and should have been discarded on 4/10/2024. DA 2 discarded the bag of fries and stated the risk of having expired food could result in foodborne illnesses for residents. During a concurrent observation and interview, on 4/27/2024 at 8:30 a.m., with DA 2, in Refrigerator #2, DA 2 observed 3 opened bags of celery and 1 opened bag of flour tortillas with no received-by, open and/or used-by date. DA 2 stated the items were received 7 days ago and he forgot to label them. DA…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 document and maintain a temperature log of two out of two clothes dryers (dryer 1 and 2). This deficient practice had the potential to result in spread of infection (the invasion of growth of germs in the body) throughout the facility. Findings: During an observation on 4/28/2024 at 7:55 a.m. at the laundry area, no temperature log was observed for the clothes dryer. During a concurrent observation and interview on 4/28/2024 at 8:00 a.m., with laundry aide 1, two commercial front-loading clothes dryers were observed in the laundry room. The temperature gauge on clothes dryer #1 indicated 180 degrees Fahrenheit ([F] unit of measurement). The temperature gauge on clothes dryer #2 indicated 180 degrees F. LA 1 stated the facility does not monitor the temperature of the clothes dryers and there was no log to document the temperature of the clothes dryers. During an interview on 4/28/2024 at 8:41 a.m., with the Maintenance Supervisor (MS), the MS stated LA 1 should monitor the temperature of the clothes dryer…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 a peripheral catheter ([IV], a thin tube inserted into a vein for therapeutic purposes such as administration of medications, fluids and/or blood products) dressing was dated for one of one sampled resident (Resident 152). This deficient practice had the potential for the IV insertion site to develop an infection and/or hospitalization for Resident 152. Findings: A review of Resident 152's admission Record, the admission Record indicated Resident 152 was initially admitted to the facility on [DATE] and last readmitted on [DATE]. Resident 152's diagnoses included urinary tract infection ([UTI], common infections that happen when bacteria, often from the skin or rectum, enter the urethra, and infect the urinary tract), chronic obstructive pulmonary disease ([COPD], lung disease that causes blocked airflow from the lungs), and heart failure (a condition that develops when your heart doesn't pump enough blood for your body's needs).…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 respiratory care was consistent with professional standards of practice when there was no physician order to administer oxygen for one of two sampled residents (Resident 152). This deficient practice had the potential to result in unsafe use of oxygen equipment, respiratory infection, unable to breathe comfortably, and/or hospitalization for Resident 152. Findings: A review of Resident 152's admission Record, the admission Record indicated Resident 152 was initially admitted to the facility on [DATE] and last readmitted on [DATE]. Resident 152's diagnoses included urinary tract infection ([UTI], common infections that happen when bacteria, often from the skin or rectum, enter the urethra, and infect the urinary tract), chronic obstructive pulmonary disease ([COPD], lung disease that causes blocked airflow from the lungs), and heart failure (a condition that develops when your heart doesn't pump enough blood for your body'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.

Based on interview and record review, the facility failed to ensure a competency assessment skill (a measurable pattern of knowledge, skills, abilities, behaviors, and other characteristics in performing that an individual need to perform work roles or occupational functions successfully) checks performed upon hire and annually for two out of five randomly selected staff. This deficient practice had the potential for the facility not be able to assess the skills necessary to provide nursing services to assure resident safety and to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident will not be performed within the acceptable standards of practice. Findings: During a concurrent interview and record review on 4/27/2024 at 10:55 a.m., with the Director of Staff Development (DSD), five random employees file were checked. The DSD stated Licensed Vocational Nurse 2 (LVN 2) did not have yearly competency assessment skills check on file. The DSD stated Licensed Vocational Nurse 3 (LVN 3) did not have a competency assessment skills check…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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: 1. Ensure the order for a psychotropic medication (drug that affects behavior, mood, thoughts, or perception) as needed (PRN), was not limited to 14 days per regulation for one out of three sampled residents (Resident 43). This deficient practice had the potential to result in the use of unnecessary medication, or non-therapeutic use of psychotropic mediation. Findings: A review of Resident 43's admission Record, the admission Record indicated the facility admitted Resident 43 on 1/21/2024. Resident 43's diagnoses included end stage heart failure (a condition that develops when your heart doesn't pump enough blood for your body's needs. End stage is a high risk of dying in the next 6 to 12 months), Acute kidney failure (sudden loss of the ability of the kidneys to function), and anxiety disorder (persistent and excessive worry that interferes with daily activities). A review of Resident 43's History and Physical (H&P), dated 1/26/2024, the H&P indicated, Resident 43 could make needs known but could not make medical…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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. Label and remove one opened expired ipratropium with albuterol (a combination medication used to treat and prevent shortness of breath) inhalation solution for Resident 40. 2. Remove expired opened ipratropium (atrovent inhaler) with albuterol solution for Resident 45. These deficient practice had the potential to result in prolonged use and loss of strength of the expired inhalation solution and can lead to ineffective treatment of respiratory symptoms and possibly can cause severe adverse reactions (an unintended effect of a medication that is harmful or unpleasant) including hospitalizations. Findings: A review of Resident 40's admission Record, indicated, Resident 40 was originally admitted to the facility on [DATE] and readmitted on [DATE] . Resident 40's diagnosis included chronic respiratory failure with hypoxia (a serious condition that makes it difficult to breathe on your own) and congestive heart failure ([CHF] a serious…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to document insulin injection location sites of administration for one out of seven residents (Resident 101). This deficient practice had the potential to result in skin and tissue damage if injection sites were not rotated. Findings: A review of Resident 101's admission record indicated Resident 101 was originally admitted on [DATE] and re-admitted on [DATE], with diagnoses that included type 2 diabetes mellitus with hyperglycemia (a disease that occurs when your blood glucose, also called blood sugar, is too high), thrombocytopenia (a low number of platelets in the blood), peripheral vascular disease (a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs) and bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs). A review of Resident 101's Minimum Data Set (Minimum Data (MDS- an assessment and care screening tool), dated 2/24/2024, indicated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement its abuse policy and procedure (P&P) by failing to ensure an allegation of physical abuse was reported to the California Department of Public Health (the Department) within two hours for one out of three sample residents (Resident 1). This deficient practice had the potential for a delay in the Department ' s investigation of the abuse allegation and placed Resident 1 at risk for further abuse. Findings: During a review of Resident 1 ' s admission Record (face sheet), the face sheet indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including metabolic encephalopathy (problem in the brain), muscle weakness and schizoaffective disorder bipolar type (a mental illness that affects thoughts and mood behavior, may present with hallucinations or delusions). During a review of Resident 1 ' s Minimum Data Set ([MDS] a standardized care assessment and care screening tool), dated 11/22/2023,…

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

Based on observation, interview, and record review, the staff failed to implement and/or maintain infection control measures for one of three sampled residents (Resident 2) when: Certified Nursing Assistant 2 (CNA 2) touched a clean linen cart with soiled gloves. CNA 2 exited Resident 2's room wearing soiled personal protective equipment (PPE, specialized clothing or equipment, including gowns and gloves, worn by an employee for protection against infectious materials). CNA 3 assisted Resident 2 with morning care (care provided in the morning that includes, but is not limited to, bathing, dressing, and linen changes) without donning (putting on) the required PPE. CNA 3 exited Resident 2's room without performing hand hygiene (cleaning one's hands to substantially reduce potential pathogens [harmful microorganisms] on the hands). These deficient practices had the potential to transmit disease-causing pathogens to vulnerable facility residents. Findings: During an observation on 5/16/2023 at 8:52 AM, directly outside of Resident 2's room, signage at the room entrance indicated…

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