Sunnyview Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based upon observation and interview, the facility failed to: 1. Ensure the room's curtains and curtain rod was not broken for one of 5 sampled residents (Resident 79). This deficient practice resulted in a violation of Resident 79's right to privacy and a potential to result in a safety hazard. Findings: During a review of Resident 79's face sheet (front page of the chart that contains a summary of basic information about the resident), the face sheet indicated Resident 79 was admitted to the facility on [DATE] with diagnoses which included cerebral ischemia (insufficient blood flow to the brain), gastro-esophageal reflux disease (a digestive disease in which stomach acid or bile irritates the food pipe lining), neuropathy (disease or dysfunction of one or more nerves, typically causing numbness or weakness in the hands and feet) and adult failure to thrive (an inability to sustain weight due to poor nutrition, leading to progressive decline). During a review of Resident 79's Minimum Data Set (MDS- a federally…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide appropriate services to prevent a decline in joint range of motion ([ROM] - full movement potential of a joint) for two out of two sampled residents (Resident 24 and 76) who had limited ROM by failing to: 1. Ensure 24 received timely quarterly (every three months) Joint Mobility Screening/Assessment to monitor changes in joint range of motion. 2. Ensure one of seven sampled residents (Resident 76) received passive range of motion ([PROM]- movement of a joint through its full range of motion without any effort from the individual) exercises seven days a week by the Restorative Nurse Assistant ([RNA]- a healthcare worker who helps residents improve and maintain function in physical abilities) as ordered by the physician. These deficient practices had the potential to cause further decline in Resident 24 and Resident 76's ROM and overall quality of life. Findings: 1. During a review of Resident 24's admission Record (front page of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to: 1. Ensure a peripheral catheter ([IV] - a thin tube inserted into a vein for therapeutic purposes such as administration of medications, fluids and/or blood products) was removed after IV antibiotic (a drug used to treat infections caused by bacteria) was completed for one of one sampled resident (Resident 57). This deficient practice had the potential for the IV insertion site to develop infection and/or hospitalization for Resident 57. Findings: During a review of Resident 57's admission Record (front page of the chart that contains a summary of basic information about the resident), the admission Record indicated, Resident 57 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 57's diagnoses included urinary tract infection ([UTI] - an infection in the bladder/urinary tract), dementia (a progressive state of decline in mental abilities), and type 2 Diabetes Mellitus ([DM] - a disorder characterized by…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 accurate accounting/documentation of a controlled drug ([Lyrica]- medication used for nerve pain) for one out of seven sampled residents (Resident 21). This deficient practice had the potential to result in drug diversion. Findings: During a review of Resident 21's admission Record, the admission Record indicated Resident 21 was admitted to the facility on [DATE]. Resident 21's diagnoses included hypertension (HTN-high blood pressure), seizure (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness), and hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body). During a review of Resident 21's History and Physical (H&P), dated 6/20/2025, the H&P indicated Resident 21 had the capacity to understand and make decisions. During a review of Resident 21's Minimum Data Set ([MDS]- a resident assessment tool), dated 6/4/2025,…

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: 1. Ensure a pharmacy consultant (a professional responsible for reviewing each resident's medication profile monthly to identify and report changes) recommendation to consider ordering valproic acid level (test that measures the concentration of valproic acid, an anticonvulsant medication, in the blood) and ammonia level (test that measures the amount of ammonia level in the blood) was acknowledged and acted upon for one of five sampled residents (Resident 72). This deficient practice had the potential for Resident 72 to experience a delay in treatment. Findings: During a review of Resident 72's admission Record (front page of the chart that contains a summary of basic information about the resident), the admission Record indicated, Resident 72 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 72's diagnoses included congestive heart failure ([CHF] - a heart disorder which causes the heart to not pump the 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 interview and record review, the facility failed to: 1. Ensure laboratory test (a medical procedure that analyzes a sample of blood, urine, or other bodily fluid or tissue) to check ammonia level (test that measures the amount of ammonia level in the blood) was completed monthly as ordered by the physician for one of 19 sampled residents (Resident 24). This deficient practice had the potential for Resident 24 not receiving necessary medical treatment. Findings: During a review of Resident 24's admission Record (front page of the chart that contains a summary of basic information about the resident), the admission Record indicated, Resident 24 was admitted to the facility on [DATE]. Resident 24's diagnoses included bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), dementia (a progressive state of decline in mental abilities), and other abnormalities of gait and mobility. 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: 1. Ensure one of seven sampled residents (Resident 31) had enhanced barrier precautions ([EBP]- infection control strategy aimed at reducing the transmission of bacteria resistant to antibiotics) was implemented when care was provided to his feeding tube (a flexible plastic tube placed into the stomach to help you get nutrition when you're unable to eat). This deficient practice put Resident 31 at risk for infection. Findings: During a review of Resident 31's admission Record, the admission Record indicated Resident 31 was initially admitted to the facility on [DATE], with a readmission on [DATE]. Resident 31's diagnoses included hypertension (HTN-high blood pressure), dysphagia (difficulty swallowing), and malnutrition (a condition caused by not getting enough calories or the right amount of key nutrients). During a review of Resident 31's History and Physical (H&P), dated 9/19/2024, the H&P indicated Resident 31 had the capacity to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement 1 of 3 sampled residents ' , (Resident 1) care plan titled, Resident non-compliant manifested by refusing medications, history of refusing to take medications for 2 months, which indicated to hold an Interdisciplinary Team ([IDT] group of healthcare professionals, including resident/ resident representative, working together to provide residents with needed care) to address non-compliant behavior. This failure resulted in Resident 1 ' s continued refusal of medications not addressed, and had the potential to affect in maintaining the resident ' s highest practicable physical, mental and psychosocial well-being. Findings: During a review of Resident 1 ' s admission Record, dated 2/3/2025, the admission Record indicated Resident 1 was admitted to the facility on [DATE], with diagnosis of schizophrenia (a chronic mental health condition characterized by profound disruptions in thought processes, perceptions, emotions, and behaviors), suicidal…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 implement its policy and procedure (P&P) titled, Work Practices, which indicated drinks should not be stored in areas of possible contamination. This failure had the potential to cause cross contamination. wellness. Findings: During an observation on 2/3/2025 at 11:15 a.m., the Licensed Vocational Nurse (LVN 1) was observed reviewing the computer screen on the medication (med) cart and was drinking cranberry juice. During a concurrent observation and interview on 2/3/2025 at 11:35 a.m., LVN 1 was observed again with a cup of cranberry juice and her personal cell phone was ringing on top of the med cart. LVN 1 stated the juice and cell phone belonged to her. LVN 1 stated she knew she should not be drinking cranberry juice and should not place her personal cell phone on top of the med cart because germs may spread, and she could get sick. During a review of the facility's P&P titled, Work Practices, dated 4/2023, the P&P indicated food, and drink shall not be stored in areas with possible contamination.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure one out of three sampled residents (Resident 1) had a care plan for Activities of Daily Living (ADL- routine tasks/activities such as bathing, dressing, and toileting a person of life-threatening conditions) specific to showering with interventions. These deficient practice had the potential for the resident to not receive care services specific to resident's needs which can result in Resident 1 sustaining another fall. Findings: During a review of Resident 1 ' s admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE]. Resident 1 ' s diagnoses included schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), restlessness/agitation (a sense of severe uneasiness, crankiness, or inner tension), lack of coordination ( the inability to control the muscles in your body to coordinate movements), abnormalities of gait/mobility (an unusual walking pattern that can be caused…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 exercise reasonable care for the protection of two of four sampled Resident ' s (Resident 1 and Resident 4) by failing to: 1. Ensure Resident 1 ' s ID (identification) card, Medi-Cal card and passport were documented on the resident ' s Inventory List. 2. Ensure Resident 3 ' s Compact Discs (CDs) was not lost or stolen. This deficient practice had the potential for Resident 1 ' s personal belongings to be lost or stolen without accountability and could negatively affect Resident 3 ' s psychosocial well-being. Findings: During a review of Resident 1 ' s admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] and re-admitted on [DATE]. Resident 1 ' s diagnoses included, end stage renal disease ([ESRD] irreversible kidney failure), cardiomegaly (a condition where the heart becomes larger than normal), cerebrovascular accident ([CVA] stroke, loss of blood flow to a part of the brain.) During a review of Resident 1…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, for one of three residents ' (Resident 1), the facility failed to: 1. Ensure Resident 1 had an order for oxygen administration. 2. Call the physician for Resident 1, who received oxygen without a physician ' s order and suffered a low oxygen saturation (O2 Sat- [%] measures how much oxygen is in the blood, normal range 95% to 100%) of 79%-81% on 10/2/2024. 3. Provide the treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan. This failure resulted in the resident ' s delay in receiving interventions from the physician which could have prevented resident ' s transfer to the general acute care hospital (GACH). 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 including metabolic encephalopathy (a brain disorder caused by chemical imbalance in the blood that affects brain function), sepsis (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 maintain complete and accurate clinical records for one out of three sampled residents (Resident 1). This failure resulted in incomplete resident records necessary in providing care to Resident 1. Findings: During a review of Resident 1 ' s admission Record, the admission Record indicated, Resident 1 was admitted to the facility on [DATE] with diagnoses including metabolic encephalopathy (a brain disorder caused by chemical imbalance in the blood that affects brain function), sepsis (a life-threatening emergency characterized by an extreme response to infection that can result in multi-system organ failure), pneumonitis (inflammation of the walls of the alveoli in the lungs, usually caused by a virus), diabetes mellitus (abnormal blood sugar levels), anemia (low blood count), hypertension (high blood pressure), chronic systolic heart failure (hear failure), bacteremia (presence of bacteria in the blood), kidney failure and adult failure to thrive (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 and interview the facility failed to ensure call lights were placed within reach for three of 19 sampled residents (Resident 43, 65, and 72). This deficient practice had the potential to result in a delay in or inability for the residents to obtain necessary care and services in a timely manner. Findings: a)During observation and interview on 6/4/2024, at 10:36 a.m., Resident 65 was observed in his room, lying in his bed, awake, alert and was able to respond to questions with limited words and gestures. Resident 65 was observed pressing on the television (TV) remote control and continuously shouting for help. Resident 65's call light was observed tied on the nightstand and was not within the resident's reach. A review of Resident 65's of admission Record (facesheet), the admission Record indicated Resident 65 was admitted to the facility on [DATE] with diagnosis including of cerebral infarction (a lack of adequate blood supply to the brain cells, damage to tissues in the brain due to a loss…

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

Based on interview and record review, the facility failed to: 1. Ensure 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 were performed yearly for three 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 6/6/2024 at 9:08 a.m., with the Director of Staff Development (DSD), five randomly employee files were checked. Certified Nursing Assistant (CNA 2), Certified Nursing Assistant (CNA 3), and Certified Nursing Assistant (CNA 5), did not have competency assessment skills done yearly. The DSD stated competency assessment skills check to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure: 1. A received-by and delivery dates were placed on 3 tubs of frozen ice cream in freezer # 5. 2. Dirty aprons were not placed in the dry storage area of the kitchen. This deficient practice had the potential to result in foodborne illnesses. Findings: During an observation, on 6/4/2024 at 8:50 a.m., at Freezer # 5 in the kitchen, Freezer # 5 was observed to have had three ice cream tubs (3 gallons each) with no received-by and delivery date labeled on the items. During a concurrent observation and interview, on 6/4/2024 at 9:15 a.m., a dirty apron bin was observed sitting in the dry storage area. Dietary [NAME] 1 (DC 1) stated the dirty apron bin was not supposed to be in the dry storage area. DC 1 stated the risk of having a dirty apron bin in the dry storage care could result in contaminating the food. During a concurrent observation and interview, on 6/5/2024 at 9:05 a.m., with DC 1 at Freezer # 5, DC 1 stated the 3 tubs of ice…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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. Implement infection control measures for two of two sampled residents (Residents 15 and 24) by failing to wear Personal Protective Equipment ([PPE] gown - specialized clothing or equipment worn by an employee for protection against infectious materials) prior to entering and administering medication via g-tube to Resident 15 and Resident 24 on Enhanced Standard Precautions ([ESP] a resident-centered and activity-based approach for preventing Multiple Drug Resistant Organism ([MDRO]-are bacteria that have become resistant to certain antibiotics) transmission in skilled nursing facilities). This deficient practice had the potential to result in cross contamination (physical movement or transfer of harmful bacteria from one person, object, or place to another), spread of infections and placed other residents at risk for infection. Findings: A review of Resident 15's admission Record, the admission Record indicated, Resident 15 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 observation, interview, and record review, the facility failed to: 1. Ensure residents who had physical restraint (any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body) were evaluated regularly and less restrictive measures were attempted for one of one sampled resident (Resident 69). This deficient practice had the potential to place Resident 69 at risk for unnecessary prolonged use of restraint that could lead to decline in physical functioning and not being treated with respect and dignity. Findings: A review of Resident 69's admission Record, the admission Record indicated, Resident 69 was admitted to the facility on [DATE] with diagnoses of Alzheimer's disease (a progressive disease that destroys memory and other important mental functions) and seizure disorder (sudden change in movement or awareness due to a change 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: 1. Ensure one of eight sampled residents (Resident 2), Preadmission Screening and Resident Review ([PASRR] a tool to determine if the person had, or was suspected of having a mental illness, intellectual disability [a term used when a person has certain limitations in cognitive functioning and skills, including communication, social and self-care skills], or related condition) level one (I) screening was re-submitted after a hospital exemption and Resident 2 had stayed in the facility for more than 30 days the appropriate state-designated authority for a PASRR level two (II) evaluation and determination. This deficient practice had the potential for Resident 2 not receiving the necessary and appropriate psychiatric level of treatment and evaluation in the facility. Findings: A review of Resident 2's admission Record, the admission Record indicated, Resident 2 was initially admitted to the facility on [DATE] and last readmitted on [DATE]. Resident 2's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to: 1. 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 eight sampled residents (Resident 15) who had a diagnoses of schizophrenia (a serious mental illness that affects how a person thinks, feels, and behave) to the appropriate state-designated authority for PASRR level two evaluation and determination. This deficient practice had the potential to result in Resident 15 not receiving appropriate treatment recommendations for schizophrenia. Findings: A review of Resident 15's admission Record, the admission Record indicated, Resident 15 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 15's diagnoses included schizophrenia and dementia (loss of cognitive functioning, thinking, remembering, and reasoning). A review of Resident 15's History…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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. Implement care plan intervention of placing a bed alarm while in bed for one of three sampled residents (Resident 69) who was identified at risk for fall. This failure had the potential to cause further fall for Resident 69. Findings: A review of Resident 69's admission Record, the admission Record indicated, Resident 69 was admitted to the facility on [DATE] with diagnoses of Alzheimer's disease (a progressive disease that destroys memory and other important mental functions) and seizure disorder (sudden change in movement or awareness due to a change in the electrical function of the brain). A review of Resident 69's Minimum Data Set ([MDS] resident assessment and care screening tool) under Section C (Cognitive Patterns), dated 4/6/2024, the MDS indicated, Resident 69's cognitive (ability to reason, understand, remember, judge, and learn) skills for daily decision making was severely impaired. The MDS under Section GG (Functional…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, interview and record review, the facility failed to ensure: 1. A nasal cannula for oxygen use was dated and properly stored to prevent contamination for one out of 5 residents (Resident 41). This deficient practice had the potential to result in complications associated with oxygen therapy, negatively impacting the health and well-being of the resident. Findings: A review of Resident 41's admission record (face sheet) indicated Resident 41 was initially admitted on [DATE] with a readmission date of [DATE]. Resident 41's face sheet indicated diagnoses that included Klebsiella Pneumoniae (a type of bacteria that is resistant to antibiotics), peripheral vascular disease (a slow and progressive blockage disorder of the blood vessels), dementia (a mental condition resulting in the loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life) and schizophrenia (a serious mental illness that affects how a person thinks, feels, 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. Document one of one sampled resident (Resident 65)'s refusing splints (an external device used to support and immobilize an injury or joint) on the left hand and left knee. This failure had the potential to result in Resident 65's existing contractures (tightening of the muscles and tendons that causes the joints to shorten and become very stiff) to worsen. Findings: A review of Resident 65's of admission Record (face sheet), the admission Record indicated, Resident 65 was admitted to the facility on [DATE] with diagnosis including cerebral infarction (a lack of adequate blood supply to the brain cells, damage to tissues in the brain due to a loss oxygen to the area), contracture of the left hand, major depression (a mood disorder that causes a persistent feeling of sadness and loss of interest and can interfere with daily living). A review of Resident 65's History and Physical (H&P), dated 4/18/2024, the H&P indicated, Resident 65 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 develop a comprehensive and person-centered plan of care for one of three sample residents (Resident 1) to address the following Resident's noncompliance related to care and treatment: 1. Refusal to keep the wound dressing on both feet after treatment was performed, and while going outside into the smoking patio with gangrene (dead tissues caused by infection) wounds on his feet. 2. Refusal to refrain from wearing shoes on his feet for prolonged periods with gangrene wounds. This deficient practice had a potential to result in a delay or lack of care and services for Resident 1 which could worsen the resident's condition. Findings: During a review of Resident 1's admission Record (Face Sheet), dated 8/14/2023, the Face Sheet indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that include gangrene, type 2 diabetes mellitus ([DM], abnormal blood sugar), peripheral vascular disease (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 interview and record review, the facility failed to ensure wound care treatment was provided for one of three sampled residents (Resident 1) who had a diabetic mellitus ([DM], abnormal blood sugar) ulcer (open sore or wound) to the left 1st toe. This deficient practice had to potential to result in the worsening of Resident 1's wound. Findings: During a review of Resident 1's admission Record (Face Sheet), dated 8/14/2023, the Face Sheet indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that include gangrene (dead tissues caused by infection), type 2 DM, peripheral vascular disease (blood circulation disorder that causes the blood vessels outside of you heart and brain to narrow, often in legs), atherosclerosis (thickening or hardening of the arteries caused by a buildup of plaque in the inner lining of an artery) of extremities (a limb of the body, hand or foot) with gangrene to bilateral (involving two sides) legs. 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 interview and record review, the facility failed to inform and consult with the resident ' s physician when a resident had a laboratory result that fall outside of clinical reference ranges for one of one sample resident (Resident 1). This failure resulted in Resident 1 not receiving the necessary care and services and placed Resident 1 at increased risk for medical complications, hospitalizations, and death. Findings: a. A review of Resident 1 ' s admission record (Face Sheet), dated 7/27/2023 the Face Sheet indicated Resident 1 was admitted to the facility on [DATE], with a diagnoses that included dementia (impaired ability to remember, think or make decisions that interferes with doing everyday activities), psychotic disturbance (a collection of symptoms that affect the mind, where there has been some loss of contact with reality), bipolar disorder (a mental illness that causes unusual shifts in a person ' s mood, energy, activity levels, and concentration), major depressive disorder (a mood disorder…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow up on the status of three of 23 sampled residents (Resident 32, 43, and 63), Pre-admission Screening and Resident Review (PASRR) Level II and integrate the level of care into a plan of care. The deficient practice had the potential to result in Resident 32, 43 and 63 not receiving the appropriate care and management for their mental illness. Findings: During a review of the admission record for Resident 32, the admission record indicated Resident 32 was originally admitted to the facility on [DATE] and was readmitted on [DATE], with a diagnosis of schizophrenia disorder (a mental disorder characterized by disruptions in thought processes, perceptions, emotional responsiveness, and social interactions) and psychosis (a severe mental disorder in which thought, and emotions are so impaired that contact is lost with external reality). During a review of the Minimum Data Set ([MDS] a standardized assessment and care screening tool), (What date?) 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, based on a comprehensive assessment, that Resident 68 did not receive Lamictal (a mood stabilizer medication that works in the brain) and Risperdal (an antipsychotic medication used to treat mental illness), a psychotropics (medications capable of affecting the mind, emotions, and behavior) unless it was necessary to treat a specific condition. The facility also failed to perform a gradual dose reduction and implement behavioral interventions, to discontinue the psychotropic drug. As a result, Resident 68 was placed at unnecessary risk of unwanted and irreversible side effects and adverse drug reactions. Findings: During a review of Resident 68's face sheet (admission record, a document containing medical and demographic information), the face sheet indicated Resident 68 was self-responsible, and was initially admitted to the facility on [DATE], and readmitted on [DATE]. Resident 68's initial admitting diagnoses included…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 it was free of a medication error rate of five percent (%) or greater as evidenced by six medication errors out of 25 opportunities for error to yield a medication error rate of 24 %, for three of five residents (Residents 14, Resident 15, and Resident 80) observed during medication administration (med pass). a. The facility failed to administer Resident 14's prescribed over the counter (OTC) house supply medication docusate sodium (used to treat constipation) and MiraLAX (used to treat occasional constipation) as ordered by the physician. b. The facility failed to ensure Resident 15 was administered a diabetic (a disease that results in too much sugar in the blood) medication, metformin (a medication that helps control blood sugar levels) with food and administered the correct prescribed dosage of Docusate Sodium as ordered by the physician. c. The facility failed to ensure Resident 80 was administered a diabetic medication, glimepiride (a medication that helps control blood sugar levels) with food 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.

Based on observation, interview, and record review, the facility failed to ensure residents on renal diet (type of diet prescribed for patients with kidney disease) with and soft, bite size texture were served the diet according to the menu and spreadsheet instructions (food portioning and serving guide). This deficient practice had the potential to result in increase in potassium (a chemical that is critical to the function of nerve and muscle cells, including those in your heart) levels, meal dissatisfaction and decreased food intake in 3 of 6 residents who were on renal diet. Findings: During a review of the facility's lunch menu on 3/7/22,the meal menu indicated the following items would be served for regular diet: Chicken parmesan, scalloped potatoes, garlic spinach, wheat roll, pudding, and milk. During a review of the facility's lunch menu on 3/7/22, indicated the following items would be served on renal diet: Baked chicken with gravy, brown rice, broccoli, wheat roll, apples, and beverage. During a concurrent observation, and interview, of the meal plating on 3/7/22, 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.

Based on observation, interview and record review, the facility failed to ensure safe and sanitary food storage in the kitchen when: 1.Four pieces sliced ready to eat ham were stored in the reach in refrigerator with date of 2/28/22 and a medium size plastic container of sliced ham was stored in reach in refrigerator with date of 3/2/22 exceeding storage period of ready to eat lunch meat. Fully cooked half of a ham was thawing in the reach in refrigerator with no thaw date. 2.A large bag of expired frozen cookie dough was stored in the facility reach in freezer. These failures had the potential to result in harmful bacteria growth and cross contamination (transfer of harmful bacteria from one place to another) that could lead to foodborne illness in 77 out of 83 medically compromised residents who received food from the kitchen. Findings: 1.During an observation in the kitchen on 3/7/22, at 8:45AM, a plate with four slices of ham were stored in the reach in refrigerator with a date of 2/28/22. In the same reach in refrigerator there was a medium plastic container with three open…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 interventions to prevent and control the spread of infection in accordance with its infection prevention and control program for three of 83 sampled residents (Residents 22, 81, 10, and 70) by failing to ensure: 1. Restorative Nurse Assistant (RNA) 2 performed hand hygiene before, after and between providing care for Resident 22 and 81. 2. Certified Nurse Assistant (CNA) 3 performed hand hygiene before, after and between providing care for Resident 10 and 70. This deficient practice had the potential to lead to the spread of infection among residents and staff in the facility. Findings: 1. During a review of the admission record for Resident 22, the admission record indicated Resident 22 was admitted to the facility on [DATE] with a diagnosis of conversion disorder (a mental condition in which a person has blindness, paralysis, or other nervous system symptoms that cannot be explained by a medical evaluation) with seizures or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain one of one sample resident (Resident 36's) privacy and dignity by failing to provide a privacy bag (a pouch that conceals a urinary drainage bag [bag that collects urine] from public view). This deficient practice had the potential to affect Resident 36's self-esteem and self-worth. During a review of Resident 36's admission Record (facesheet), the face sheet indicated Resident 36 was admitted to the facility on [DATE] and readmitted on [DATE]. Resident 36' s diagnoses included diabetes mellitus type 2 (abnormal blood sugar), chronic kidney disease (when the kidneys no longer work as they should to meet the body's needs) and blindness (unable to see). During a review of Resident 36's History and Physical (H&P), dated 5/17/2021, the H&P indicated Resident 36 could make his needs known but could not make medical decisions. During a review of Resident 36'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 observation, interview, and record review, the facility failed to involve the Responsible party ([RP] person who makes medical decisions for a resident, who is not able to make decisions for themselves) for one of 23 sampled residents (Resident 39), in the care planning process. This deficient practice had the potential to violate Resident 39 RP's right to be an active participant in Resident 39's care. During a review of Resident 39's admission Record (facesheet), the face sheet indicated Resident 39 was admitted to the facility on [DATE]. Resident 39' s diagnoses included Tourette's Syndrome (disorder that involves repetitive movements or unwanted sounds [tics] that can't be easily controlled), depressive disorder (mood disorder that causes a constant feeling of sadness and loss of interest) and kidney failure (disease where kidneys [organ in the body]no longer work as they should to meet the body's needs). During a review of Resident 39's History and Physical (H&P), dated 3/31/2021, 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 promote and facilitate self-determination for one resident out of 23 sampled residents (Resident 46), by not allowing resident 46 to exercise her choice of when to take a shower. This deficient practice had the potential to cause a negative impact on the psychosocial well-being of Resident 46. Findings: During a review of the admission record (face-sheet) for Resident 46, the facesheet indicated Resident 46 was admitted to the facility on [DATE], and re-admitted on [DATE], with diagnoses that included dependence on renal dialysis (The process of removing waste products and excess fluid from the body. Dialysis is necessary when the kidneys are not able to adequately filter the blood), and chronic kidney disease stage 4 (stage 4 chronic kidney disease (CKD) has advanced kidney damage with a severe decrease in the glomerular filtration rate (GFR) to 15-30 ml/min. person with stage 4 CKD will need dialysis or a kidney transplant in the near…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 develop a baseline care plan addressing the diagnosis of major depressive disorder (a mental health disorder characterized by a persistent sad mood or loss of interest in activities, causing significant impairment in daily life) for three of 23 sampled residents (Residents 57, 47, and 68). This deficient practice had the potential for the residents not to receive individualized care and treatment to meet their psychosocial needs. Findings: 1. During a review Resident 57's, admission record, the admission record indicated Resident 57 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 57 had diagnosis including major depressive disorder and insomnia (inability to sleep). During a review of the History and Physical report (H/P), dated 10/17/2021, the H/P indicated Resident 57 was able to make decisions for activities of daily living. During a review of the Minimum Data Set ([MDS] a standardized assessment…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 develop and implement comprehensive and resident-centered care plans, for three of 23 sample residents (Resident 5,36, 83) by failing to: 1) Implement Resident 5's care plan causing a three-month delay in physical therapy (PT) and occupational therapy (OT). 2) Implement Resident 36's care interventions to monitor for signs and symptoms of urinary tract infection (UTI-infection affecting the organs [kidneys, bladder, urethra] of the urinary system) for a resident with an indwelling urinary catheter (a tube inserted into the body to empty urine from the bladder into a bag outside the body). 3) Develop a fall care plan for Resident 83, who was at high risk for falls. These deficient practices have the potential to negatively the health and the delivery of care and services to Residents 5, 36, 83. A. During a review of Resident 5's admission Record (facesheet), the face sheet indicated Resident 5 was admitted to the facility on [DATE].…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to assess and maintain an indwelling urinary catheter (a tube inserted into the body to empty urine from the bladder into a bag outside the body) for one of one sample residents (Resident 36). This deficient practice had the potential to negatively affect Resident 36's plan of care and increase the risk of a urinary tract infection ([UTI] an infection affecting the urinary system including). During a review of Resident 36's admission Record (facesheet), the face sheet indicated Resident 36 was admitted to the facility on [DATE] and readmitted on [DATE]. Resident 36' s diagnoses included Benign Prostatic Hyperplasia ([BPH] a disease that can affect the flow of urine out of the bladder causing bladder, urinary tract or kidney problems), chronic kidney disease (when the kidneys no longer work as they should to meet the body's needs) and blindness (unable to see). During a review of Resident 36's History and Physical (H&P), dated 5/17/2021, 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, interviews and record review, the facility failed to ensure two of 23 residents (Resident 21 and 47) received treatment and care in accordance with professional standards of practice by failing to ensure: 1. Resident 21 had ordered labs drawn for a Hemoglobin A1c ([HgA1c] diagnostic blood test that measures the average blood sugar levels over the past three months) and Digoxin level. (Medication that treats heart failure and heart rhythm problems). 2. Resident 47 was provided proper repositioning care. These deficient practices had the potential to lead to an increased risk of hyperglycemia (high blood sugar), risk of infection, delayed wound healing, hospitalizations, diabetic coma, and death for Resident 21 and had the potential to negatively affect Residents 47's physical comfort, skin integrity, and psychosocial wellbeing. Findings: 1. During a record review of the admission record for Resident 21, the admission record indicated Resident 21 was originally admitted 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 observation, interview, and record review, the facility failed to ensure one of nine sampled residents (Resident 5), with limited range of motion (ROM - the extent of movement of a joint) received the appropriate treatment and services to maintain ROM by failing to: 1. Implement Resident 5's care plan to provide Rehab as ordered by the physician causing a three-month delay in physical therapy (PT) and occupational therapy (OT). 2. Ensure PT and OT services were provided as ordered by the physician. This deficient practice had the potential to place Resident 5 at risk for further ROM decline and contracture (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints). During a review of Resident 5's admission record (facesheet), the face sheet indicated Resident 5 was admitted to the facility on [DATE]. Resident 5' s diagnoses included left sided hemiplegia (unable to move one side of body), major depressive disorder (mood disorder that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that pain management was provided to one of 23 sampled residents (Resident 68). This deficient practice had the potential to prevent Resident 68 from attaining or maintaining her highest practicable level of well- being. Findings: During a review of the admission record (face sheet) for Resident 68, the facesheet indicated resident 68 was originally admitted to the facility on [DATE] and readmitted on [DATE], with a diagnosis of aphakia (a condition in which a person is missing the lens of one or both eyes, and blepharochalasis (a rare syndrome consisting of recurrent bouts of upper eyelid edema associated with thinning, stretching, and fine wrinkling of the involved skin). During a review of the Minimum Data Sheet (MDS, a standardized assessment and care planning tool) for resident 68 dated 2/6/2022, indicated Resident 68's cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that a licensed nurse did not crush seven (7) medications together and administer them to one of five sampled residents (Resident 14) observed. (Cross Reference F759) This deficient practice had the potential to cause harm to the resident due to receiving a medication combination not ordered by the physician. Findings: During a review of Resident 14's face sheet (admission record, a document containing medical and demographic information), the face sheet indicated Resident 14 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 14's diagnoses included dysphagia (difficulty swallowing), dementia (progressive loss of memory), gastroesophageal reflux disease ([GERD] occurs when stomach acid frequently flows back into the tube connecting your mouth and stomach) During a review of Resident 14's history and physical (H&P) dated 8/18/2021, indicated, Resident 14 did not have the capacity to understand 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.

Based on observation and interview the facility failed to: 1. Store medication at the correct temperature as required by the manufacturer's specifications for one of two medication carts (Station 2 Medication Cart 2) observed. 2. Ensure expired and discontinued medications was destroyed in accordance with the facility's policy titled, Medication Destruction. These deficient practices had the potential to negatively affect the residents' health and well-being by improperly storing medications that required refrigeration and failure to destroy expired and discontinued medications remaining in the facility for over 90 days. Findings: 1. During a concurrent observation and interview on 3/8/2022, at 7:13 a.m., of Station 2 Medication Cart 2, with Licensed Vocational Nurse (LVN) 1, inside the of Medication Cart 2 was one Insulin Glargine ([insulin glargine-yfgn] is a long-acting insulin that helps control high blood sugar levels) Injection Pen (an insulin auto-injecting pen device) which was not labeled with an open date found stored at room temperature. LVN 1 confirmed the Insulin…

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