St. John Of God Retirement

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to:1. Perform hand hygiene (cleansing hands with soap or an alcohol-based rub) before assisting two of two sampled residents (Resident 68 and 144).2. Ensure one of one sampled residents (Resident 1) gastronomy tube ending was capped off to prevent contamination.This failure had the potential to expose Resident 68 and Resident 1 to potentially infectious organisms. Findings: a. During a review of Resident 68's admission Record (AR), dated 7/18/2023, the AR indicated that Resident 68 has a diagnosis of interstitial pulmonary disease (swelling and scarring in the lung tissue), cirrhosis of the liver (severe scarring of the liver tissue), and moderate protein-calorie malnutrition (a severe nutritional deficiency from a lack of protein). During a review of Resident 68's Minimum Data Set (MDS), dated [DATE], the MDS indicated that Resident 68's has limited vision, used a wheelchair, and required substantial/maximal assistance with personal…

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 temperature in the residents' rooms were within range for two of two sampled residents (Resident 63 and Resident 120).This failure had the potential to negatively affect the residents' quality of life.Findings:During a review of Resident 63's admission Record (undated), the admission Record indicated the facility admitted the resident on 2/15/2024, with diagnoses including but not limited to arthropathy (abnormal condition affecting a joint), iron deficiency anemia (condition where the body does not have enough healthy red blood cells), hypotension (abnormally low blood pressure), and dementia (a progressive state of decline in mental abilities).During a review of Resident 63's History and Physical (H&P) Examination, dated 2/23/2025, the H&P indicated the resident does not have the capacity to understand and make decisions.During a review of Resident 63's Minimum Data Set (MDS, a standardized assessment and care screening tool),…

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 26 sampled residents (Resident 5 and Resident 130) by failing to: 1. Ensure Resident 5 and Resident 130's Gabapentin (medication used to treat seizure and nerve pain) was encoded as anticonvulsant medication. This failure had the potential to negatively affect the plan of care and services for Resident 5 and Resident 130. Findings:A. During a review of Resident 5's admission Record, the admission Record indicated, Resident 5 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 5's diagnoses included gastrostomy tube ([GT] - a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems) placement, cerebral infarction (also known as stroke, the death of brain tissue due to a lack of blood flow), and Diabetes Mellitus ([DM] - 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 interview and record review, the facility failed to: 1. Develop a comprehensive person-centered care plan for anti-fungal (a drug that kills or stops the growth of harmful fungi causing infections in humans) medication for one of one sampled resident (Resident 143). This deficient practice had the potential not able to monitor the side-effect (undesired effects of a drug) of antifungal medication that could possibly harm Resident 143. Findings: During a review of Resident 143's admission record, the admission Record indicated, Resident 143 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 143's diagnoses included, urinary tract infection ([UTI] - an infection in the bladder/urinary tract), cerebral infarction (also known as stroke, the death of brain tissue due to a lack of blood flow), and Diabetes Mellitus ([DM] - a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 143's History and Physical (H&P), 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 observation, interview and record review, the facility failed to review and revise one of two sampled residents (Resident 76) when her condition changed. This failure had the potential to result in inappropriate plan of care, outdated treatments, and patient centered goals not being met. Findings: During a review of Resident 76's admission Record, it indicated Resident 76 was admitted to the facility on [DATE] with diagnoses that included but not limited to: Alzheimer's disease (a disease characterized by a progressive decline in mental abilities), anxiety disorder, adult failure to thrive and osteoporosis (weak and brittle bones due to lack of calcium and Vitamin D). During a review of Resident 76's Minimum Data Set (MDS-a comprehensive assessment and screening tool) dated 10/25/2025, the MDS indicated Resident 76 has severely impaired cognitive skills for daily decision making. Resident 76 requires a helper to do all of the effort for oral hygiene, toileting hygiene, shower/bathe, dressing, rolling…

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 low air loss mattress settings were accurate for two of 16 sampled residents (Resident 1 and Resident 3). Findings: During a review of Resident 1's face sheet (front page of the chart that contains a summary of basic information about the resident), the face sheet indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted to the facility on [DATE]. Resident 1's diagnoses included a stage 4 pressure ulcer (full thickness tissue loss with exposed bone, tendon, or muscle), dysphagia (difficulty swallowing), type 2 diabetes (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) and bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs). During a review of Resident 1's Minimum Data Set (MDS- a federally mandated resident assessment tool), dated 9/1/2025, the MDS indicated Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to: 1. Ensure continuous supervision was provided for one of eight sampled residents (Resident 32).This deficient practice had the potential to result in injuries and accidents.Findings:During a review of Resident 32's face sheet (front page of the chart that contains a summary of basic information about the patient), the face sheet indicated Resident 32 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 32's diagnoses included dementia (a progressive state of decline in mental abilities), type 2 diabetes (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), cardiomyopathy (chronic disease of the heart muscle) and benign prostatic hyperplasia (a common, non-cancerous enlargement of the prostate gland).During a review of Resident 32's Minimum Data Sheet (MDS- a federally mandated resident assessment tool), dated 11/26/2025, the MDS indicated Resident 32's cognitive (thinking) skills was…

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. Ensure one of one sampled resident (Resident 13) was provided with Bladder training (type of training that will help a person manage urinary incontinence).This deficient practice had the potential for decline in bladder function for Resident 13.Findings:During a review of Resident 13's admission Record, the admission Record indicated, Resident 13 was admitted to the facility on [DATE]. Resident 13's diagnoses included osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage) of both hips, hyperlipidemia (too many fats like cholesterol and triglycerides in your blood), and hypertension ([HTN] - high blood pressure). During a review of Resident 13's History and Physical (H&P), dated 11/5/2025, the H&P indicated, Resident 13 had the capacity to understand and make decisions.During a review of Resident 13's Minimum Data Set ([MDS] - a resident assessment tool), dated 9/16/2025, the MDS indicated, Resident 13's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record review, the facility failed to ensure the oxygen tubing (flexible tube that delivers oxygen-rich air) was not kinked (bent) for one of one sampled resident (Resident 109).This failure had the potential to result in decreased oxygen flow (to move continuously) to Resident 109.Findings:During a review of Resident's 109 admission Record, the admission Record indicated Resident 109 was admitted to the facility on [DATE] with the diagnoses but not limited to chronic respiratory failure with hypoxia (a condition when the body's respiratory system cannot absorb enough oxygen and has low oxygen levels), emphysema (a condition when the air sacs in the lungs become damaged), and cerebral ischemia (when the blood flow to the brain is decreased). During a review of Resident 109's Minimum Data Set (MDS- a comprehensive resident assessment tool), dated 4/29/2025, the MDS indicated Resident 109 is currently receiving oxygen therapy.During a review of Resident 109's 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.

Based on observation, interview and record review, the facility failed to assess the pain for one sampled resident (Resident 112), in accordance with the facility policy and procedure for pain management. This failure had the potential to negatively impact Resident 112's quality of life.Findings: During a review of Resident 112's History and Physical (H&P), dated 3/11/2025, the H&P indicated Resident 112 was admitted with the diagnosis, but not limited to dementia (a significant decline in memory , thinking, problem-solving and other cognitive skills that interferes with daily life) and chronic kidney disease (a long term condition where kidneys are damaged and can't filter waste and extra fluid from the body effectively leading to build up that can harm the body).During a review of Resident 112's physician order dated 12/1/2025, it indicated Resident 112 had an order for acetaminophen (a medication to treat mild pain) 325 milligrams, 2 tablets by mouth every 6 hours as needed for mild pain.During a review of Resident 112's Pain Level Summary dated 12/4 /2025, the summary 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 ensure the weekly nursing assessment for one of three sampled residents (Resident 56) was accurate.This failure resulted in inaccurate medical documentation with the potential to cause delayed or incorrect treatments, missed diagnoses or even medication errors for Resident 56. Finding:During a review of Resident 56's admission Record, the admission Record indicated Resident 56 was admitted to the facility on [DATE]. Resident 56 had the following diagnosis but not limited to chronic respiratory failure (a condition person's lungs can't get enough oxygen into their body or can't remove enough carbon dioxide from it - and this problem lasts for a long time.), obesity (a condition that having too much body fat.), dementia (a condition that affects the brain and makes it hard for someone to remember things, think clearly, or make decisions.), diabetes (a condition where the body has trouble controlling the amount of sugar (called glucose) in the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that the hospice (compassionate care for people who are near the end of life provided at the person's home or within a health care setting) services meet professional standards for one of four sampled residents (Resident 15) by failing to: 1. Ensure a hospice calendar with the scheduled visits for the hospice team was available. This deficient practice had the potential to result in a delay or lack of coordination in delivery of hospice care and services to Resident 15.Findings:During a review of Resident 15's admission Record, the admission Record indicated, Resident 15 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 15's diagnoses included chronic obstructive pulmonary disease ([COPD] - a chronic lung disease causing difficulty in breathing), cerebral infarction (also known as stroke, the death of brain tissue due to a lack of blood flow), and dysphagia (difficulty of swallowing).During a review of Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of one sampled resident (Resident 81) call light was within reach.This failure had the potential to result in Resident inability to access the call light for assistance or emergency.Findings:During a review of Resident 81's admission Record (AR), dated 3/7/2022, indicated Resident 81 has hemiplegia (partial paralysis), hemiparesis (weakness or inability to move on one side of the body), and aphasia (difficulty understanding and speaking).During a review of Resident 81's History & Physical (H&P), dated 8/13/2024, indicated Resident 81 has left sided weakness and does not have the capacity to understand and make decisions.During a review of Resident 81's Minimum Data Set (MDS), dated [DATE], the MDS indicated that Resident 81 has short- and long-term memory problems and severely impaired cognitive skills for daily decision making and is dependent on staff for toileting, personal hygiene, and getting dressed.During an observation…

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 a pack of cigarettes was not left unattended on the bench in the facility's patio (the designated smoking area).This failure had the potential to pose a risk of fire or a serious incident to residents due to unattended cigarettes.Findings:During an observation on 12/03/2025 at 12:38 PM in the designated smoking area behind the chapel, a pack of cigarettes was left unattended on a wooden bench, inside a crocheted pouch.During an interview on 12/03/2025 at 12:43 PM with the Director of Nursing (DON), DON stated the staff store cigarettes in a locked area and provide residents with designated smoking times. DON stated the facility does not permit residents to have cigarettes or lighters in their possession for safety reasons. DON stated there is a designated smoking area that is supervised to ensure it remains free of hazards. During a concurrent observation and interview on 12/03/2025 12:49 PM with DON in the designated smoking area, a pack of cigarettes was left unattended on a wooden bench. The DON…

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 upon observation, interview and record review, the facility failed to: 1. Report to the California Department of Public Health [CDPH]- the state department responsible for public health in California) an injury of unknown origin for one of three sampled residents (Resident 1). This deficient practice resulted in a delay of an onsite investigation by CDPH and had potential to place all residents at risk for abuse. Findings: During a review of Resident 1 ' s face sheet (front page of the chart that contains a summary of basic information about the resident), the face sheet indicated Resident 1 was admitted on [DATE] with diagnoses which included age-related physical debility (a decline in physical function that can occur with aging), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), difficulty in walking and lack of coordination. During a review of Resident 1 ' s Minimum Data Set (MDS- a federally mandated resident assessment tool), dated 2/14/2025,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop a comprehensive Care Plan for one of four sampled residents (Resident 1) who was receiving heparin (an injected medication given that prevent the formation of blood clots). This deficient practice had the potential for unidentified interventions for Resident 1 and placed the resident at risk for side effects and complications from the medication such as bleeding. Findings: During a review of Resident 1 ' s admission Record, the admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 1 ' s diagnoses included Atrial Fibrillation (an irregular heart rhythm that can cause blood clots), subdural hemorrhage (bleeding and buildup of blood on the surface of the brain), Repeated falls and dementia (a progressive state of decline in mental abilities). During a review of Resident 1 ' s Minimum Data Set ([MDS], a resident assessment tool), dated 9/2/2024, the MDS indicated Resident 1 had…

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

Based on observation, interview, and record review, the facility failed to ensure food items were discarded after the use by date. The following items were as follows: 1 Baking Soda Powder dated 12/6/2022 and use by date 12/6/2023. 2. Colander Seeds dated 6/21/2022. 3. Red Food coloring opened date 6/16/2023 with no use by date. 4. Package of breadcrumbs open date 5/14/2024 and use by date 7/14/2024. This deficient practice of having expired dry food items had the potential to result in harmful bacteria growth that could lead to foodborne illness for residents who received food and drinks from the kitchen. Findings: During a concurrent observation and interview on 10/1/2024 at 9:25 a.m. with the Dietary Procurement Personnel (DP 1), in the dry storage room, the following expired dry food items were observed: 1. Expired Baking Soda Powder dated 12/6/2022, and a use by date 12/6/2023. 2. Expired Colander Seeds dated 6/21/2022. 3. Red Food coloring container opened date 6/16/2023, with no use by date. 4. Breadcrumbs opened date 5/14/2024, and a use by date 7/14/2024. DP 1 stated when 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 implement appropriate infection control practices when: 1. The facility did not follow their policy and procedure (P&P) for washing the laundry in the correct temperature range. 2. In the rehabilitation office, two resident reusable cold modality packs and two staff food containers in the refrigerator were stored in the same combination freezer/refrigerator. 3. Restorative Nursing Aide (RNA 1) did not properly disinfect a cloth gait belt (an assistive device that is secured around a person's waist to allow a caregiver to grasp the belt and assist in lifting or moving a person) during a treatment session with Resident 63. These deficient practices have the potential to spread infections among residents, staff, and visitors. Findings: 1. During a concurrent observation and interview on 10/3/2024 at 7:15 a.m. with Laundry Aide (LA) 1, in the laundry room, LA 1 stated the laundry was washed in temperatures ranging from 140 degrees Fahrenheit…

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

Based on observation and interview, the facility failed to post the complaint investigation results by California Department of Public Health ([CDPH] state licensing and certification agency) during the three preceding years in the areas of the facility that are prominent and accessible to the residents, family members, and visitors. This deficient practice placed the residents, family members or visitors at risk of not knowing the status of the facility non-compliance outcome results and past performance history. Findings: During a concurrent observation and interview on 10/1/2024 at 2:11 p.m. with the Director of Nursing (DON) at nursing station 2, the DON stated the survey binder hanging on the wall was incomplete and did not include the complaint investigation results by the CDPH and the facility's plan of correction in the past three years. The DON stated the complaint investigation results was placed in a separate binder and kept at her office. The DON stated the complaint investigation results should also be placed in the survey binder and posted in an area accessible to all…

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 annually for four 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 10/2/2024 at 10:00 a.m. with Licensed Vocational Nurse 7 (LVN 7), five random employees file were reviewed. LVN 6 stated the Director of Nursing (DON) was responsible for completing the annual competency assessment skills for licensed nursing staff and Certified Nurse Assistant (CNA). LVN 7 verified the employee records revealed the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to indicate the opened date on the label for medications (to be administered Residents 124, 131, 98, 7, and 23) stored in two of four sampled medication carts. This deficient practice had the potential for residents to experience adverse effects from the administration of expired medication. Findings: During a review of Resident 124's admission Record, the admission Record indicated Resident 124 was admitted on [DATE] with the following diagnoses, but not limited to, epilepsy (a condition with sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness), difficulty in walking, testicular hypofunction (a condition where the testicles are unable to produce enough testosterone [a hormone that helps to develop and maintain many bodily functions including male sex characteristics]), hypopituitarism (a condition that occurs when the pituitary gland [a pea-sized organ in the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one out of eight sampled Residents (Resident 47) was properly dressed daily. This deficient practice of not dressing Resident 47 daily had the potential of leaving Resident 47 feeling low self-worth and low self-esteem. Findings: During a review of Resident 47's admission Record (Face Sheet), the Face Sheet indicated Resident 47 initially admitted to the facility on [DATE] and last readmitted on [DATE]. Resident 47's diagnoses included gastrostomy ([G-tube] a surgical opening in the stomach for nutrition, hydration, and medication), epilepsy(a chronic brain disorder that causes a person to have two or more unprovoked [seizures]-uncontrolled, abnormal electrical activity of the brain that may cause changes in the level of consciousness, behavior, memory or feelings), chronic kidney disease (a long-term condition where the kidneys are damaged and can't filter blood properly), and benign prostatic hyperplasia (BPH - non-cancerous…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the call light (a device with a button that, when pressed, alerts healthcare providers that assistance is required) was within reach for one out of 30 sampled residents (Resident 14). This deficient practice had the potential to result in Resident 14 not being able to call for assistance and a delay in necessary care and services affecting resident's well-being. Findings: During a review of Resident 14's admission Record , the admission Record indicated Resident 14 was admitted on [DATE]. Resident 14's diagnoses included displaced (out of alignment) comminuted (broken into more than two pieced) fracture (broken bone) of shaft of the left femur (long portion of thigh bone), cerebral infarction (loss of blood flow to a part of the brain) with hemiplegia (total paralysis [inability to move] of the arm, leg, and trunk on the same side of the body) and hemiparesis (weakness or the inability to move on one side of the body), 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 notify the physician of a significant weight loss (a weight loss greater than 5% in one month, greater than 7.5% in three months and greater than 10% in 6 months) of 18 pounds ([lbs.] unit for measuring weight) 11.8 percent [%] in three months (Resident 24), and failed to notify the physician of a resident's swollen ankles for two of two sampled residents (Resident 24 and Resident 39). This deficient practice had the potential to place Resident 24 at risk for further weight loss, and placed Resident 39 at risk for further complications of ankle swelling. Cross reference F656. Findings: a. During a review of Resident 24's admission Record, the admission Record indicated, Resident 24 was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses including failure to thrive (a decline caused by chronic diseases and functional impairments which can cause weight loss, decreased appetite, poor nutrition, and inactivity), urinary…

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 an accurate Minimum Data Set ([MDS] a federally mandated resident assessment tool) was completed accurately for two of 30 sampled residents (Resident 14 and Resident 81) by failing to: 1. Ensure Resident 14's mental illness diagnosis was reflected in the MDS assessment under Section A (Level II Preadmission Screening and Resident Review [PASRR] a tool to determine if the person had or was suspected of having a mental illness or intellectual disability) conditions. 2. Ensure Resident 81's Minimum Data Set [MDS] a federally mandated assessment tool) was updated quarterly. These deficient practices resulted in incorrect data transmitted to Center for Medicare and Medicaid Services (CMS) and had the potential to result inaccurate care and services for Residents 14 and 81. Findings: a. During a review of Resident 14's admission Record, the admission Record indicated, Resident 14 was initially admitted to the facility on [DATE] and was readmitted 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 correctly fill out the Preadmission Screening and Resident Review ([PASRR] a tool to determine if the person had, or was suspected of having a mental illness, intellectual disability or related condition) level one screening and refer one of three sampled residents (Resident 14) who had a diagnosis of schizophrenia (a mental illness that can affect thoughts, mood, and behavior) to the appropriate state-designated authority for PASSR level two evaluation and determination. This deficient practice had the potential to result in Resident 14 not receiving appropriate treatment recommendations for schizophrenia. Cross Reference F641. Findings: During a review of Resident 14's admission Record, the admission Record indicated, Resident 14 was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses including schizophrenia (a mental illness that can affect thoughts, mood, and behavior) and dementia (a progressive state of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop an individualized person-centered plan of care with measurable objectives, timeframe, and interventions to meet the resident's needs for three out of four sampled residents (Residents 19, 24, and 39) by failing to: 1. Address Resident 19's need for a one to one (1:1, close supervision) sitter. This deficient practice had the potential to result in a lack of meeting necessary care goals and addressing medical needs for Resident 19. 2. Develop a care plan for significant weight loss for Resident 24. This deficient practice had the potential to place Resident 24 at risk for further weight loss related to not having nutritional interventions. 3. Ensure a care plan with interventions for swollen ankles was in place for Resident 39. This deficient practice of not having a care plan with interventions for swollen ankles for Resident 39 had the potential for worsening condition. Findings: 1. During a concurrent observation and interview on 10/2/2024 at…

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 eight sampled Residents (Resident 47) was taken outside for a garden stroll. This deficient practice of not taking Resident 47 outside for a garden stroll had the potential to negatively affect the resident's mental and emotional well-being. Findings: During a review of Resident 47's admission Record (Face Sheet), the Face Sheet indicated Resident 47 initially admitted to the facility on [DATE] and last readmitted on [DATE]. Resident 47's diagnoses included gastrostomy ([G-tube] a surgical opening in the stomach for nutrition, hydration, and medication), epilepsy (a chronic brain disorder that causes a person to have two or more unprovoked [seizures]-uncontrolled, abnormal electrical activity of the brain that may cause changes in the level of consciousness, behavior, memory or feelings), chronic kidney disease (a long-term condition where the kidneys are damaged and can't filter blood properly), and benign prostatic hyperplasia (BPH…

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 received treatment and care in accordance with professional standards of practice, by failing to check pacemaker (a small battery-powered device that monitors and regulates the heart's rhythm and rate) for one of one sampled resident (Resident 63). This deficient practice had the potential to result in pacemaker failure possibly leading to medical complications requiring hospitalization. Findings: During a review of Resident 63's admission Record, the admission Record indicated, Resident 63 was admitted to the facility on [DATE] with diagnoses including acute on chronic congestive heart failure (a type of heart failure that occurs when the heart tries to compensate for a loss of function that has developed over time) and hypertensive heart disease (group of heart conditions that develop over time due to chronic high blood pressure). During a review of Resident 63's History and Physical (H&P), dated 8/19/2023, 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 observation, interview, and record review, the facility failed to provide appropriate services to decline in joint range of motion (ROM, full movement potential of a joint) for three out of 12 sampled residents (Residents 64, 14, and 15) who had limited ROM or were assessed at risk for decline in joint ROM, as indicated in the resident's care plans. The facility failed to: 1. Ensure Resident 64 received timely quarterly rehabilitation joint mobility screens to monitor changes in joint range of motion. 2. Ensure Resident 14 received timely quarterly rehabilitation joint mobility screens to monitor changes in joint range of motion. 3. Ensure Resident 15 received timely quarterly rehabilitation joint mobility screens to monitor changes in joint range of motion. These deficient practices had the potential to cause further decline in Residents 64, 14, and 15's ROM and overall quality of life. Findings: 1. During a concurrent observation and interview on 10/2/2024 at 8:24 AM in Resident 64's room, Resident 64…

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: 1. Ensure Resident 81 had floor mats at bedside to prevent injury from a fall. This deficient practice of not placing floor mats at the Resident 81's bedside had the potential for injury if Resident 81 was to have a fall. 2. The sharps container (a puncture-proof container used to contain used and discarded needles and other sharp tools for patient care) in rooms 221, 321 and 333 were replaced with a new one when it was at least 75 percent (%) full. This deficient practice had the potential for staff or resident to sustain an injury with a full sharps container. Findings: 1. During a review of Resident 81's admission Record (Face Sheet), the Face Sheet indicated Resident 81 initially admitted to the facility on [DATE] and last readmitted on [DATE]. Resident 81's diagnoses included dementia (a progressive state of decline in mental abilities), chronic obstructive pulmonary disease ([COPD] a chronic lung disease causing difficulty…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure oxygen (air) tubing and humidifier (a device that humidifies oxygen for patients undergoing oxygen therapy) were dated, labeled, and changed every seven days in accordance with facility's policy and procedure for one of five sampled residents (Resident 23). This deficient practice had the potential to cause respiratory infection for residents on oxygen therapy. Findings: During a review of Resident 23's admission Record, the admission Record indicated, Resident 23 was initially admitted to the facility on [DATE] and was readmitted on [DATE], with diagnoses including acute respiratory failure with hypoxia (a condition where the body doesn't have enough oxygen in the tissues and the respiratory system can't absorb enough oxygen) and obstructive sleep apnea (a condition where sleep is interrupted by abnormal breathing). During a review of 23s History and Physical (H&P), dated 4/19/2024, the H&P indicated, Resident 23 had the capacity…

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 physician signed an order for a one to one (1:1, close supervision) sitter for one out of eight sampled residents (Resident 19). This deficient practice had the potential for poor continuity of care and follow-up on the resident's status for each physician visit. Findings: During a concurrent observation and interview on 10/2/2024 at 4:20 p.m., in Resident 19's room, Resident 19 was observed to have a staff member sitting within arm's reach off to the side of him. The staff member stated she was Resident 19's 1:1 Sitter (OS 1). OS 1 stated she was the sitter for Resident 19 due to a history of falls and her duties included staying close by to ensure the resident did not fall. During a review of Resident 19's admission Record (Face Sheet), the admission Record indicated Resident 19 was readmitted to the facility on [DATE]. Resident 19's diagnoses included muscle weakness, lack of coordination, and dementia (a progressive state…

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 physical therapy (PT, a rehabilitation profession that restores, maintains, and promotes optimal physical function) services with an active physician's order for one of 12 sampled residents (Resident 64) when no PT services were provided after a physician's order dated 4/9/2024 for PT evaluation and treatment. This deficient practice had the potential for Resident 64 to have a decline in functional mobility without PT services. Findings: During a concurrent observation and interview on 10/2/2024 at 8:24 a.m., in Resident 64's room, Resident 64 was observed sitting up on a wheelchair with a bedside table in front of the resident. Resident 64 was able to hold a drink container in the left hand to drink after set-up assist from staff. During a review of Resident 64's admission Record, the admission Record indicated Resident 64 admitted to the facility on [DATE]. Resident 64's diagnoses included dementia (a progressive state of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to maintain timely resident medical records for one of twelve sampled residents (Resident 63) when Resident 63's Joint Mobility Assessment (JMA) dated 11/20/2023 was not documented until 10/3/2024. This deficient practice had the potential for inaccurate medical documentation and cause a delay in provision of appropriate interventions for Resident 63. Findings: During a record review of Resident 63's admission Record, the admission Record indicated Resident 63 was admitted to the facility on [DATE]. Resident 63's diagnoses included Parkinson's Disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements) without dyskinesia (involuntary movements of extremities) and cerebral infarction (blockage of the flow of blood brain, causing or resulting in brain tissue death). During a record review of Resident 63's Minimum Data Set (MDS, a federally mandated resident assessment tool) dated 8/6/2024, the MDS…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of three sampled resident's (Resident 17) representative (FM 1) understood the facility's arbitration agreement (a document that settles any disputes between two parties through binding arbitration [a dispute resolution outside of the legal court system]). This deficient practice resulted in FM 1 entering into an agreement for binding arbitration without fully understanding what they were signing. Findings: During a review of Resident 17's admission Record (Face Sheet), the admission Record indicated Resident 17 was admitted to the facility on [DATE]. Resident 17's diagnoses included hypertension (high blood pressure) and a history of falling. During a review of Resident 17's Minimum Data Set ([MDS]- a federally mandated assessment tool), dated 8/15/2024, the MDS indicated Resident 17 was not cognitively intact (ability to reason, understand, remember, judge, and learn). During a review of Resident 17's Resident-Facility Arbitration…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that the hospice (compassionate care for people who are near the end of life provided at the person's home or within a health care setting) services meet professional standards for one of two sampled residents (Resident 122) by failing to: 1. Ensure hospice representative participates with facility interdisciplinary team ([IDT] team members from different disciplines who come together to discuss resident care) care conference meeting. 2. Ensure to have a hospice calendar with the scheduled visits for the hospice team. 3. Ensure current physician's certification for hospice benefit (a confirmation that a patient is terminally ill and has a prognosis of six months or less to live) was available in the resident's medical record. These deficient practices had the potential to result in a delay or lack of coordination in delivery of hospice care and services to Resident 122. Findings: During a review of Resident 122'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 observation, interview and record review, the facility failed to ensure head of bed was elevated to 30 to 45 degrees as ordered by the physician, for 1 of 4 sampled residents, Resident 2, while gastrostomy tube feeding [GT] nutrition administered via an surgical openning in the abdomen into the stomach) was ongoing. This failure had the potential to result in aspiration (occurs when food or liquid is breathed into the airways or lungs, instead of being swallowed), difficulty breathing, infections and hospitalization. Findings: During a concurrent observation and interview on 7/22/2024 at 10:15 a.m. with Treatment Nurse 1 (TN 1), Resident 2 was observed on bed with GT feeding of Jevity (feeding formula) 1.5 cal (calorically dense) at 65 cc (cubic centimeter) per hour. Resident 2's head of bed (HOB) was at a low angle of 20-degree. TN 1 stated the HOB should be elevated to 30 degrees to prevent aspiration. During a review of Resident 2's admission Record dated 7/22/2024, the admission record 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 ensure responsible party for one three residents (Resident 1), was notified of the right wrist and right elbow skin discoloration observed, physician's xray (process of taking pictures of tissues and structures inside the body for diagnosis and treatment) order and the xray result. This failure resulted to the responsible party not aware of the change in condition and intervention ordered by the physician. Findings: A review of Resident 1's admission record indicated Resident 1 was admitted to the facility on [DATE], with diagnoses that included hemiplegia and hemiparesis (paralysis on one side of the body) affecting right dominant side, aphasia (disorder that affects how you communicate), and rheumatoid arthritis (inflammatory disorder affecting joints in hands and feet). A review of Resident 1's Minimum Data Set ([MDS] a standardized care assessment and care screening tool), dated 6/24/2024, indicated Resident 1's cognitive skills (thought process)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to: 1. Ensure one of three sampled residents (Resident 1) was free from abuse when CNA 1 grabbed Resident 1's wrist. This deficient practice had the potential for Resident 1 to have psychological distress and caused Resident 1 to experience feelings of humiliation and disrespect. Findings: During an interview, on 6/12/2024 at 8:40 a.m., Resident 1 was observed sitting in her wheelchair watching tv. Resident 1 stated on 6/2/2024 at 4:00 a.m., while in bed, she had pressed the call light for assistance to the restroom. Resident 1 stated CNA 1 entered the room and appeared very angry. Resident 1 stated CNA 1 grabbed her left wrist, placed her in her wheelchair and wheeled her to the restroom. Resident 1 stated she told CNA 1 she was too rough and started crying. A review of Resident 1's admission Record (face sheet) indicated the resident was admitted to the facility on [DATE]. Resident 1's diagnoses included acute kidney failure (a condition 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: 1. Follow its policy and procedure (P&P), titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program, dated 4/2021 and revised 3/2024, which indicated the facility did not condone any form of resident abuse or neglect for one of three residents (Resident 1). As a result, this violation had the potential to place Resident 1 and other residents at risk of further abuse. Findings: A review of Resident 1's admission Record (face sheet) indicated the resident was a [AGE] year-old female, admitted to the facility on [DATE]. Resident 1's diagnosis ' included acute kidney failure (a condition in which the kidneys suddenly can't filter waste from the blood), difficulty in walking (the inability to walk properly), encephalopathy (a disease in which the brain is affected by an infection or toxins), and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). A review of Resident 1's history and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to complete the 72-hour neuro checks (assessment how resident speaks, thinks, walks, moves, or interacts with the examiner) as indicated in the facility's policy and procedure, for 1 of 3 sampled residents, (Resident 1). This failure had the potential to delay interventions if Resident 1 displayed changes in neurological status (a person's mental status, coordination, ability to walk, and how the muscles, sensory systems, and deep tendon reflexes work). Findings: A review of Resident 1's admission record, dated 5/7/2024, the indicated Resident 1 was originally admitted to the facility on [DATE] and was re-admitted on [DATE]. Resident 1's diagnoses included muscle weakness, dementia ((impaired ability to remember, think, or make decisions that interferes with doing everyday activities), cerebral infarction (stroke), and urinary tract infection (UTI, an infection in any part of your urinary system: kidneys, bladder, ureters). A review of Resident 1's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility staff failed to implement or develop resident-specific communication care plans for one of three sampled residents (Resident 1). This deficient practice created the potential for direct care staff to be unaware of Resident 1's preferred language, and the communication aids necessary to ensure Resident 1's verbalized choices and preferences for care were understood and respected. Findings: A review of Resident 1's admission Record indicated Resident 1 was admitted to the facility on [DATE]. Resident 1's admitting diagnoses included depression (mood disorder effecting the way you think, feel, and act), lack of coordination, and abnormalities of gait (way of walking) and mobility. A review of Resident 1's History and Physical (H&P), dated 6/30/2023, indicated Resident 1 had the capacity to understand and make decisions. A review of Resident 1's medical record titled, Social Service admission Assessments , dated 3/12/2021, indicated Resident 1's primary spoken…

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 report an injury unknown origin to the California Department of Public Health (CDPH) within two hours for one out of three sample residents (Resident 1). This deficient practice resulted in a delay in the investigation by the CDPH. 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 that included dementia (a disorder that affected memory and other mental functions), hypothyroid (a disorder of the thyroid gland), and legal blindness. During a review of Resident 1 ' s History and Physical (H&P) dated 11/3/2023, the H&P indicated Resident 1 did not have the capacity to understand and make medical decisions. During a review of Resident 1 ' s Minimum Data Set ([MDS] a standardized care assessment and care screening tool), dated 2/1/2024, the MDS indicated Resident 1 was dependent on staff 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed ensure one out of three Residents (Resident 1) was free from falls. This deficient practice of not supervising the safety of Resident 1 placed the resident at risk for a fall. 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 to the facility on [DATE]. Resident 1 ' s diagnoses included dementia (the loss of thinking, remembering, and reasoning), metabolic encephalopathy (an alteration in consciousness caused due to brain dysfunction), Alzheimer ' s (a brain disorder that slowly destroys memory and thinking skills), and lack of coordination (uncoordinated movement is due to a muscle control problem that causes an inability to coordinate movements). During a review of Resident1 ' s History and Physical (H&P), dated 2/14/2024, the H&P indicated Resident 1 does not have the capacity to understand a make decision. During a review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to enforce their infection prevention and control program by failing to report to licensing and certification of the coronavirus disease [(COVID-19), a highly contagious viral illness) outbreak. This failure had the potential to cause the spread of the COVID-19 outbreak in the facility and cause other residents to become ill. Findings: During a review of Resident 4 ' s admission record (face sheet) dated 1/4/2024, the face sheet indicated Resident 4 was admitted to the facility on [DATE] with diagnoses including dementia (a condition characterized by progressive or persistent loss of memory), hypertension (high blood pressure), and anemia (a condition where the body does not have enough healthy red blood cells). During a review of Resident 4 ' s History and Physical (H&P) dated 9/29/2023, the H&P indicated Resident 4 did not have the capacity to understand and make decisions. During a review of Resident 4 ' 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 Based on interview and record review, the facility failed to report to the State Agency (SA) the reports of all investigations regarding staff to resident abuse allegation within five (5) working days, for one of three residents,(Resident 2). This deficient practice resulted in an incomplete investigation and overlooked areas of concern that had the potential to place Resident 2 and other residents at risk for abuse and mistreatment. Findings During a review of Resident 2 ' s admission record (Face sheet), the face sheet indicated Resident 2 was admitted to the facility on [DATE], with a diagnosis including diabetes (high blood sugar), depression (a mood disorder that causes persistent feelings of sadness and loss of interests), and hypertension (high blood pressure). During a review of Resident 2 ' s history and physical (H&P) dated 6/30/2023, the H&P indicated Resident 2 had the capacity to understand and make medical decisions. During a review of Resident 2 ' s minimum data set ([MDS] a standardized care…

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

Based on interview and record review, the facility failed to develop and implement a fall risk care plan, with fall prevention interventions recommended by the interdisciplinary team (IDT, professional disciplines, as appropriate, who work together to provide the greatest benefit to the resident), for one of three sampled residents (Resident 4), following two falls sustained in the facility on 8/9/2023 and 8/27/2023. This failure increased the potential for Resident 4 to suffer from avoidable physical harm from a third fall she sustained in the facility on 1/15/2024. Findings: During a review of Resident 4's admission Record, the admission Record indicated the facility originally admitted Resident 4 on 4/4/2023, then readmitted Resident 4 on 6/19/2023. Resident 4's admitting diagnoses included difficulty walking and lack of coordination. During a review of Resident 4's History and Physical (H&P), dated 6/23/2023, the H&P indicated Resident 4 had the capacity to understand and make decisions. During a review of Resident 4's Minimum Data Set (MDS, a standardized assessment and care…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure four of 18 sampled residents (Residents 92, 134, 26, and 56) had develop a comprehensive and resident-centered care plan 1. Resident 92 did not have a care plan developed to address the use of electric appliances. 2. Resident 134 did not have a care plan developed to address the use of splints (a device to maintain hand in a functional positioning during paralysis recovery) to right hand as ordered by the physician. 3. Resident 26 did not have a care plan developed to address a prophylactic (intended to prevent disease) medication. 4. Resident 56 did not have a care plan developed to address smoking. This deficient practice had the potential to negatively affect the delivery of nursing care and medical interventions to Residents 92, 134, 26, and 56. Findings: A. During a review of Resident 92's admission Record (Face Sheet), the Face Sheet indicated Resident 92 was initially admitted to the facility on [DATE] and readmitted to the facility 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: 1) Four licensed vocational nurses (LVNs) did not administer expired pantoprazole (medication used to treat acid in the stomach) liquid suspension (mixture in which particles are dispersed throughout the fluid) to one of three residents (Residents 24) observed for medication availability. 2) Nine LVNs did not administer expired ipratropium with albuterol (a combination medication used to treat and prevent shortness of breath) inhalation solution to one of three residents (Residents 87) observed for medication availability. 3) Three LVNs did not administer expired insulin (medication used to regulate blood sugar levels) Basaglar (brand name for insulin) Kwikpen (device used to administer the insulin) to one of three residents (Resident 110) observed for medication availability. As a result, Residents 24 received total of 7 doses of expired pantoprazole between 9/21/23 and 9/27/23, Resident 87 received total of 15 doses of expired iptratropium…

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 safe and sanitary food storage and food preparation practices in te kitchen when: 1. Several food items were not dated, labeled, and sealed after opened in the reach in refrigerator, and dry storage area. Cottage cheese labeled with use by date exceeding manufacturer use by date, and raw ground beef stored in fridge with a thaw date of 9/19/23 for 7 days exceeding facility policy for storing raw ground beef. 2. Dry individually packed cereal boxes were stored inside large, corrugated packaging boxes in the dry food storage room. 3. The can opener blade was worn and nicked with the potential to harbor harmful bacteria that were not easily cleanable. 4. One dietary staff working in the dish machine area did not was hands when removing the clean and sanitized dishes from the dish machine. This failure had the potential to cross contaminate dishes and cause food borne illness to residents who eat from the facility's kitchen. 5. 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 ensure the trash stored in the dumpster area was maintained in a sanitary manner. six out of six garbage bins were uncovered and lids open, 1 out of two red biohazard bin was overfilled and lid open, there was trash milk carton and red sauce like ketchup scattered on the floor. This deficient practice had the potential for harborage and feeding of pests. Findings: During an observation on 9/26/23 at 10:00AM, 4 garbage dumpsters and 2 recycling bins outside in the parking lot were half filled and the lids were open. One red biohazard bin was overfilled, and lid was unable to close due to overfilling trash. There was trash on the floor and red sauce like ketchup was scattered on the floor by the parking lot. During an interview with DON, she said she will discuss with maintenance supervisor to make sure there would be a sign to ensure the lids of the garbage bins always remain closed. She said Trash bins that are open attract unwanted pests to facility area. A review of the 2022 U.S. Food and Drug…

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

Based on observation, interview, and record review, the facility failed to: 1. Follow their policy for monitoring temperature for three of three washing machines (washing machine 1, 2, and 3) and four of four clothes dryers (dryers 1, 2, 3, and 4). 2. Document the temperature for three of three washing machines (washing machine 1, 2, and 3) and four of four clothes dryers (dryers 1, 2, 3, and 4). These deficient practices had the potential to result in spread of infection (the invasion and growth of germs in the body) throughout the facility. Findings: During an observation on 9/28/2023 at 3: 30 p.m. at the laundry area, no temperature log was observed for the washers or dryers. The temperature gauge on washing machine 1 indicated 120 degree Fahrenheit ([°F] unit of measurement). Washing machine 2 and washing machine 3 had no temperature gauge. During a concurrent observation and interview with three Laundry Aids (LA 1, LA 2, and LA 3) on 9/28/2023 at 3:43 p.m., three commercial front-loading washing machine, and four commercial front-loading clothes dryers were observed in the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide accurate information in the Minimum Data Set (MDS), a standardized assessment and care screening tool) for two of two sampled Residents (Resident 67 and 138). This deficient practice had the potential to result inaccurate care and services for the residents due to inappropriate MDS care screening and assessment tool practices. Findings: During a review of Resident 67's admission Record, the admission Record indicated Resident 67 was admitted to the facility on [DATE] with diagnoses of other specified disorders of brain and schizophrenia (a disorder which affects a person's ability to think, feel, and behave clearly). During a review Resident 67's History and Physical (H&P), dated 8/6/2023, the H&P indicated Resident 67 does not have the capacity to understand and make decisions. During a review of Resident 67's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 8/7/2023, the MDS indicated, Resident 67 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 interview and record review, the facility failed to ensure two of 18 sampled residents (Residents 56 and 118), change of condition PASRR was submitted for review to the Department of Health Care Services (DHCS). 1. Resident 56's level one PASRR was not resubmitted after a change of condition to ensure the resident was re-evaluated for biploar disorder. 2. Resident 118's level one PASRR was not resubmitted after a change of coniditon on 5/18/2023 to include depressive disorder with psychotic symptoms. This failure placed the residens at risk for not receiving appropriate care and services to address the resident's needs. Findings: A. During a review of Resident 56's admission Record (Face Sheet), dated 9/29/2023, the face sheet indicated Resident 56 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that include bipolar disorder (a mental illness characterized by extreme mood swings), heart failure (a condition that develops when your heart doesn't pump enough 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 one out of 29 sampled residents (Resident 92) the facility failed to ensure Resident 92 had a revised Care Plan and Intradisciplinary Team (IDT) Meeting with efficient interventions to address the hoarding. This deficient practice of not developing a revised care plan with efficient interventions placed Resident 92 at risk for safety hazards. Findings: During a review of Resident 92's admission Record (Face Sheet), the Face Sheet indicated Resident 92 was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE]. Resident 92's diagnoses included dementia (the loss of thinking, remembering, and reasoning), anxiety (persistent worry and fear about everyday situations), schizophrenia (a serious mental condition involving inappropriate actions and feelings, withdrawal from reality and personal relationships into fantasy), encephalopathy (damage or disease that causes brain dysfunction). During a review of Resident 92's History and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to: 1.Indicate an updated physician's order on the medication bubble pack (a medication packaging system that contains individual doses of medication per bubble) for one of four sampled residents for medication administration (Resident 139.) 2.administer medication as ordered by the physician for one of four sampled residents for medication administration (Resident 139.) 3.transcribe (write or type) the physician medication order in the clinical chart for one of four sampled residents for medication administration (Resident 139.) 4.include the verifying signatures of either the Director of Nursing (DON) or a Registered Nurse (RN) along with a licensed vocation nurse (LVN) on the Controlled (also known as Controlled Substance [CS]- medications which have a potential for abuse and may also lead to physical or psychological dependence) or Antibiotic Drug Record forms awaiting disposition (process of returning and/or destroying unused…

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 Administrator failed to conduct proper oversight over the facility's safety hazards to ensure one out of 29 sampled residents (Resident 92) was monitored by staff before using a candle maker with wax that could reach a temperature of 315 degrees Fahrenheit. This deficient practice increased the risk for Resident 92 to suffer potential burns from using a candle maker with wax. Findings: During a review of Resident 92's admission Record (Face Sheet), the Face Sheet indicated Resident 92 was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE]. Resident 92's diagnoses included dementia (the loss of thinking, remembering, and reasoning), anxiety (persistent worry and fear about everyday situations), schizophrenia (a serious mental condition involving inappropriate actions and feelings, withdrawal from reality and personal relationships into fantasy), encephalopathy (damage or disease that causes brain dysfunction). During a review of Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to identify and address one of 29 residents' (Resident 92) unsafe room condition that was cluttered and had an electric operated candle maker in the room, at the facility's Quality Assessment and Assurance committee [QAA, a committee required to meet at least quarterly to identify issues and to develop and implement plans of action to correct identified deficiencies and to coordinate and evaluate activities under the QAPI (Quality Assurance, Performance Improvement) program, to include performance improvement projects] meetings. This failure placed the affected resident, all other residents, and staffs at a higher risk for serious harm and injuries and had the potential for insect infestations in the facility. Findings: During an observation in Resident 92's room on 9/26/2023 at 10:24 a.m., Resident 92 had a cluttered and disorganized room. A shiny aluminum candle maker was observed in the corner of the room surrounded with items resting 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 observation, interview, and record review, the facility failed to ensure one of 29 sampled residents, (Resident 92) was provided a safe and comfortable environment by failing to ensure Resident 92 was monitored and supervised for safety during the use of the electric operated candle maker in the room when making candles and the resident's room refrigerator was monitored for expired food. These failures placed Resident 92 at risk for serious harm and injuries, and the potential for food borne illnesses. Findings: During an observation on 9/26/2023 at 10:24 a.m. in Resident 92's room, Resident 92 had a cluttered and disorganized room. A shiny aluminum candle maker was observed in the corner of the room surrounded with items resting on top and against the candle maker, shelves and stored equipment blocking the window, two empty glass containers, dry food items on the floor and refrigerator with food items (cheese, olives, and green bell pepper) were also observed. During a review of Resident 92's 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 observation, interview, and record review, the nursing staff failed to revise a care plan for one of five sampled residents (Resident 4) who was at risk for contracting coronavirus (an infectious disease caused by the SARS-CoV-2 virus) after being exposed to her roommate (Resident 5) who tested positive. This deficient practice had the potential for Resident 4 to not receive the proper care required after being exposed. Findings: During a review of Resident 4 ' s admission record indicated Resident 4 was admitted to the facility on [DATE], with diagnoses that included Alzheimer ' s Disease (a progressive disease that destroys memory and other important mental functions, drug-induced polyneuropathy (damage of multiple nerves due to various drug use), dysphagia (difficulty swallowing) and depression (a group of conditions associated with the elevation or lowering of a person's mood). During a review of Resident 4 ' s history and physical report completed on 4/9/2023, indicated Resident 4 did not have the…

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

Based on observation, interview, and record review, the facility failed to ensure one of three staff housekeepers (HK) 1 performed hand hygiene after cleaning and touching items inside Room A non-isolation (a special hospital rooms that keep patients separate from other people while they receive medical care) then went inside Room B, room shared by Resident 5 and Resident 6 who were in a droplet (caused by infected agents in the air around a person) isolation (separation of an infected individual from the healthy until that individual is no longer able to transmit the disease) to clean without washing hands before leaving out. This deficient practice had the potential of transmission of infectious agents (organisms that can cause infections) and placed Resident 5 and Resident 6 at increased risk for infection. Findings: During an observation on 8/23/2023 at 3:18 p.m., inside Room A, HK 1 was observed touching and moving the table, chairs and curtains with her gloved hands while cleaning the room. HK 1 then left the room without hand hygiene and went inside Room B. A covid signage…

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.