Sunray Healthcare Center

Based on interview and record review, the facility failed to implement the facility's policy and procedure (P&P) titled, Abuse, Neglect [s the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress], Exploitation (taking advantage of a resident for personal gain through the use of manipulation, intimidation, or threats) and Misappropriation Prevention Program, for one of three sampled residents (Resident 1) reviewed for abuse by failing to: -Ensure to provide one-on-one abuse training for Certified Nurse Assistant 3 (CNA3) prior to having direct-care responsibilities for residents following a three-day suspension after an allegation of abuse. This failure had the potential to place Resident 1 at risk for abuse, neglect, and feeling intimidated. Findings: During a review of Resident 1's admission Record dated 1/15/2026, the admission Record indicated the facility admitted Resident 1 on 10/23/2025 with diagnoses including diverticulitis (infection of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of four sampled residents (Resident 1), reviewed for behavioral health services who had a diagnosis of depression (a mood disorder that causes persistent feeling of sadness and loss of interest) received appropriate mental health services and support. On 1/1/26, R1 alleged that CNA3 abused her, and on 1/5/26, R1's physician noted that R1 had increased nighttime anxiety and was afraid to fall asleep. The facility failed to identify R1's increased anxiety and failed to implement care-planned interventions in response to R1's change in behavioral health symptoms. 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 hypertension (HTN-high blood pressure), hyperlipidemia (abnormally high levels of fats in the blood), depression, presence of colostomy (a surgical procedure that brings one end of the large intestine out…

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 specific and individualized person-centered care plan (a plan of care that summarizes a resident's health conditions, specific care and services facility staff need to provide a resident to promote healing and prevent a worsening of a condition, and current treatments) for dysphagia (difficulty swallowing) for four of four sampled Residents (Resident 1, Resident 2, Resident 3, and Resident 4) reviewed for care plans. This failure placed Resident 1, Resident 2, Resident 3, and Resident 4 at an increased risk for aspiration (when something enters the airway or lungs by accident) and choking.Cross Reference F678 and F689.Findings:a. During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 9/10/2025 with diagnoses that included dysphagia, oropharyngeal phase, dementia (a progressive state of decline in mental abilities), encounter for attention to gastrostomy (care needed for gastrostomy…

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, record review, and the facility policies and procedures (P&P) titled Controlled Medication Storage, last reviewed 8/28/2025, Controlled Medication Disposal, last reviewed 8/28/2025, the facility failed to:1. Reconcile (the process of comparing transactions and activity to supporting documentation) four (4) medication emergency kits (eKITs - kits containing medications needed to be used during emergencies) containing Controlled Substances (CM, Controlled Medications - medications which have a potential for abuse and may also lead to physical or psychological dependence) for September 2025, in one of one inspected medication storage rooms (Medication room [ROOM NUMBER].) 2. Includes the signatures of the Director of Nursing (DON) or a Registered Nurse (RN) with Licensed Vocational Nurse (LVN) on the Antibiotic or Controlled Drug Record accountability logs for seven of seven sampled records awaiting disposal (removal, destroying) in the CS locked cabinet. As a result, control and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure three of seven sampled residents (Resident 6, Resident 44, and Resident 47) were free from significant medication errors (mistakes when giving medications that can cause the resident discomfort or jeopardizes his or her health and safety) according to professional standards of practice. By failing to ensure facility staff rotated the administration site (the practice of moving the injection spot to different places on the body, like the stomach, arms, thighs, or buttocks, to allow previous spots to heal) when administering insulin (a hormone that acts like a key to let sugar (glucose) from the blood enter the body's cells for energy) as per physician's orders and the facility's policy and procedures (P&P) titled Insulin Administration dated 8/25/2025. This failure had the potential for Resident 6, Resident 44, and Resident 77 to develop lipohypertrophy (a condition where lumps of fat and scar tissue form under the skin, often at 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to properly store the insulin and albuterol when they stored it in the non-hazardous waste bin. On 9/30/2025 at 11:08 a.m. three used insulin (is a natural hormone [is chemicals that coordinate different functions in the body] that turns food into energy and manages the blood sugar level made with metacresol [m-cresol - a toxic and corrosive preservative]) pens, and; three aerosolized (having tiny particles of matter and gas or liquid that turn into a fine mist to be inhaled) inhalers (a pressurized device/canister that is inhaled to deliver medication(s) into the lungs) was found in the in the pharmaceutical (any medication/drug or dietary supplement for use by humans) waste bin (specialized container for disposing pharmaceutical waste) in one of one inspected Medication Rooms (Medication room [ROOM NUMBER].) This deficient practice violates both state regulations and the facility's own medication disposal policies, which require hazardous…

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

Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen when:a. A pack of hot dogs and three cartons of protein shake were found in the resident refrigerator with no receive dates. b. Dietary Aid 1 (DA1) was observed wearing multiple pieces of jewelry (necklace, rings and bracelets) and watches. These deficient practices have the potential to promote foodborne illness and cross- contamination due to improper food handling, storage and hygiene practices. Findings: a. During an observation on 9/29/2025 at 10:30am in the resident refrigerator located in Nurses Station, one carton of nutritional supplement was observed with no label, name, or date. And a frozen pack of hot dogs in a cellophane bag with no received date was found. During an interview on 9/29/2025 at 10:35 a.m. with the Dietary Supervisor (DS), DS stated that she checked the Resident's refrigerator and that she overlooked and forgot to open the freezer area, DS stated that it is the Nursing staff who receives the food…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to develop a resident centered comprehensive care plan (a document outlining a detailed approach to care customized to an individual resident's need) for one of two residents (Resident 7). By failing to create and implement a care plan once a physician's order was received on 7/2/2025 for a right-hand mitten (padded mitted, used prevent the individual from using their hands to inadvertently or intentionally disrupt medical treatment or cause self-harm). As a result, Resident 7 did not have a care plan in place for the right-hand mitten from 7/2/2025 until 9/29/2025. Placing the resident at risk of receiving inadequate care and monitoring, which could affect Resident 7's quality of care and could cause the resident harm.During a review of Resident 7's admission Record, the admission record indicated the facility admitted the resident on 6/12/2025 with diagnoses including traumatic subdural hemorrhage (serious condition where blood collects between 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 provide necessary respiratory care services for one out of eight sampled residents (Resident 12) by failing to label Resident 12's oxygen cannula tubing (small, flexible tube with two prongs that fit into the nostrils to deliver extra oxygen to someone who has trouble breathing) with the date changed according to of the facility's policy and procedure (P&P), titled Departmental (Respiratory Therapy) - Prevention of Infection, dated 8/28/2025 This deficient practice had the potential for Resident 12 to experience respiratory infections.During a review of Resident 12's admission Record, the admission Record indicated the facility originally admitted Resident 12 on 9/21/2020 and readmitted the resident on 10/13/2024 with diagnoses that included other chronic obstructive pulmonary disease (CPOD), unilateral (one sided) pulmonary emphysema (when the tiny air sacs in just one of the lungs are damaged and enlarged, making it hard to breathe and leading to symptoms like shortness of breath, especially with activity),…

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

Based on observation, interview, and record review the facility failed to ensure one of one resident's (Resident 62) food preferences were honored as documented in Resident 62's Dietary Profile/Preferences, dated 11/12/2025. This Deficient practice had the potential to result in decreased meal satisfaction, decrease caloric intake, dehydration (a condition where your body loses more fluids than it takes in, meaning it doesn't have enough water to perform its normal functions), and malnutrition (when your body doesn't get enough of the right nutrients to stay healthy). During a review of Resident 62's admission Record, the facility admitted Resident 62 on 1/5/2005 with diagnoses including Guillain-Barre Syndrome (the immune system mistakenly attacks the he nerves that carry messages from the brain and spinal cord to the rest of the body), gastro-esophageal reflux (stomach acid backflows into the canal that connects the throat to the stomach), and peptic ulcer (lesion in the lining of the digestive tract). During a review of Resident 62's Care Plan Report, dated 2/18/2025, the 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 perform required staff competency evaluations (an evaluation of the skills, knowledge, and abilities of a staff member) for two of three sampled staff (Certified Nursing Assistant 1 [CNA1] and CNA3) in accordance with the facility's Performance Evaluations policy and procedure.This deficient practice had the potential for residents not to receive the appropriate care and services needed, which could affect the quality of care received, and potentially lead to resident harm.During a concurrent interview and record review on 7/28/2025 at 12:11 PM with the Director of Staff Development (DSD), CNA1 and CNA3 files were reviewed. The DSD stated CNA 1 did not have a performance skills checklist (is a tool used to assess and record the proficiency level of an individual in performing specific tasks or demonstrating certain abilities) in the employee file and CNA 3 (hired on 11/26/2024) did not have a performance evaluation. The DSD stated she (DSD) was hired shortly after CNA 1 was hired (6/27/24) and was new to the system…

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 a clean, odor free, homelike environment for one of four sampled residents (Resident 1), by failing to maintain an urine odor free environment and maintain the gray fall mat at the right side of Resident 1's bed clean, dry and odor free. This deficient practice resulted in a strong odor of urine lingering around the resident's bed and room entrance, and a dirty, wet, smelly fall mat, leading to an unkempt, un-homelike environment. During a review Resident 1's admission Record dated 7/8/25 indicated Resident 1 was admitted to the facility on [DATE] with diagnosis including diabetes mellitus (DM-a condition where your body has trouble controlling the level of sugar in the blood), chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), cerebrovascular disease (stroke, loss of blood flow to a part of the brain), gastrostomy (Gtube-a surgical opening fitted with a device to allow feedings…

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 infuse the proper amount enteral feeding (a method of providing nutrition directly into the gastrointestinal (GI) tract, typically through a feeding tube) of diabetic source 1.2 calories per milliliter (ml) at 80 ml an hour for 20 hours with a total volume of 1600 ml or 1920 calories, continue until dose is met as ordered by the physician for one of four sampled residents (Resident 1). This failure resulted in the resident not receiving the ordered nutrition had the potential to cause a low caloric intake that could result in malnutrition, dehydration, unexpected weight loss, and decline in overall health. During a review Resident 1's admission Record dated 7/8/25, the admission record indicated Resident 1 was admitted to the facility on [DATE] with diagnosis including diabetes mellitus (DM-a condition where your body has trouble controlling the level of sugar in the blood), chronic obstructive pulmonary disease (COPD-a chronic lung…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure safe medication administration and accurate accountability of controlled medications (high potential for abuse) as indicated in the facility's policy and procedures (P&P) for four of four sampled residents (Resident 6, Resident 18, Resident 73, and Resident 80) observed during the medication administration by failing to: -Ensure Resident 80's blood pressure (BP) medication, Amlodipine 5 milligram ([mg] - a unit of measure for weight) was administered as ordered and the physician was notified when administered over an hour later than the 9 AM scheduled administration six times, between 4/7 to 4/21/2025. (Cross Reference F759) -Ensure the Controlled Drug Record form (CDR, an accountability record of medications that are considered to have a strong potential for abuse) coincided with the Medication Administration Record (MAR, a log initialed and/or signed by the nurse with the date and time each time a medication is administered to a…

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

Based on observation, interview, and record review, the facility failed to ensure staff followed the Reduced Concentrated Sweets (RCS) diet for blood sugar control, according to the facility's food portioning and serving guide spreadsheet instructions. By failing to ensure residents on RCS diets did not receive garlic bread for lunch on 4/21/2025. This deficient practice could result in increased blood sugar levels for 13 of 64 residents who were on RCS diet. Findings: A review of the facility lunch menu for regular and RCS diets on 4/21/2025 indicated the following items were to be served: Regular diet: Spaghetti with meat sauce 1 cup, tossed salad with dressing 1 cup, garlic bread 1 each, Strawberry poke cake 1 square, and water. RCS diet: Spaghetti with meat sauce 1 cup, tossed salad with dressing 1 cup, strawberry poke cake ½ square, and water. During an observation of the tray line service for lunch (a system of food preparation, in which trays move along an assembly line) on 4/21/2025 at 11:45 AM, both regular and RCS diets were observed receiving garlic bread. During a review…

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

Based on observation, interview and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen, by failing to ensure resident cups, trays, and dishes were clean prior to removing from the dish machine and storing to air dry. This deficient practice 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 64 out 69 residents who received food from the facility kitchen. Findings: During a concurrent observation and interview in the dish washing area, with Dietary Aide (DA) 1 and Dietary Supervisor (DS) on 4/21/2025 at 9:30 AM, DA 1 was observed removing resident trays, cups and bowls from the dishwashing machine and storing them away to air dry. Food particles were observed stuck on trays and plastic cereal bowls. DA 1 was observed removing dishes from the dish machine with visible solid waste on it and returning them to the dishwasher (DW) to be washed again. Trays and bowls were observed washed 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 provide reasonable accommodations for resident needs by not having the call light within reach for two of 22 sampled residents (Resident 13 and Resident 61) observed for call light placement. The deficient practice had the potential for residents not being able to call facility staff for help as needed. Findings: a. A review of Resident 13's admission Record indicated the resident was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including abnormalities of gait and mobility, muscle weakness, pressure-induced deep tissue damage (localized damage to the skin and/or underlying tissue usually over a bony prominence) of the sacral region, right and left heel, need for assistance with personal care, and history of falling. During a review of Resident 13's History and Physical (H&P) dated 3/31/2025, the H&P indicated the resident had the capacity to understand and make own medical decisions. 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 ensure one of one sampled resident (Resident 399) reviewed for Beneficiary Notification was provided with a Notice of Medicare Non-Coverage (NOMNC - a notice that is provided to beneficiaries that indicates when their Medicare covered services are ending). This deficient practice had the potential to result in the resident not being informed of their coverage end date and not being able to exercise their right to file an appeal. Findings: During a review of Resident 399's admission Record, the admission Record indicated the resident was admitted to the facility on [DATE] for an acute kidney failure (a condition where the kidneys suddenly lose their ability to filter waste products from the blood and regulate fluids and electrolytes in the body). The admission record indicated Resident 399 was discharged home on [DATE]. During a review of Resident 399's Minimum Data Set (MDS - a resident assessment tool) dated 11/17/2024, the MDS indicated Resident 399…

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 three out of ten facilitiy staff (Registered Nurse [RN 1], Licensed Vocational Nurse [LVN 6], Certified Nurse Assistant (CNA 4) reviewed for personal file had a background check prior to employment. This deficient practice caused an increased risk to the safety of the residents. Findings: a. During a review of the facility document received to the Department dated 4/14/2025, the document indicated Resident 93 alerted the Administrator that CNA 4 handled her roughly during incontinent care on the morning shift. The document indicated CNA 4 was sent home and suspended pending investigation. During a review of Resident 93's admission Record, the admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses including need for assistance with personal care, gout (a form of arthritis, when uric acid crystals accumulate in the joints causing swelling and intense pain), and toxic encephalopathy (a disease or dysfunction…

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 five sampled residents (Resident 71) with pressure ulcers received the necessary treatment and services, consistent with professional standards of practice. Resident 71 was not repositioned(turn from side to side) in her bed every two hours per the care plan. This deficient practice had the potential for Resident 71 to experience worsening of pressure ulcers (bedsores - areas of damaged skin and tissue caused by sustained pressure that reduces blood flow to vulnerable areas of the body) / injuries to the resident. Findings: A review of Resident 71's admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses including acute (short-term) and chronic (long-term) respiratory failure (a serious condition that makes it difficult to breathe on your own), non-traumatic subarachnoid hemorrhage (bleeding in the space between the brain and the thin tissues that cover it, without any prior head…

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 b. A review of Resident 63's admission Record indicated the resident was readmitted to the facility on [DATE] with diagnoses including dependence on respiratory ventilator, chronic obstructive pulmonary disease (COPD - a chronic lung disease causing difficulty in breathing), chronic respiratory failure with hypoxia or hypercapnia ,and amyotrophic lateral sclerosis (ALS - also known as Lou Gehrigsdisease is a disease that affects nerve cells in the brain and spine). A review of Resident 63's H&P dated 11/24/2024, indicated Resident 63 was on a ventilator with tracheostomy and had mental capacity (a person's ability to understand information and make decisions for themselves). During a review of Resident 63's care plan titled, Ventilator dependent related to respiratory failure dated 2/20/2025, indicated a goal for Resident 63 to be free of ventilator associated pneumonia (an infection / inflammation in the lungs). During a review of Resident 63's care plan titled, Tracheostomy related to injury, dated 2/20/2025,…

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.

Based on interview and record review, the facility failed to clarify the physician's orders for hydrocortisone cream (a topical steroid cream applied to the skin to reduce inflammation, redness, itching and swelling) as recommended by the facility's consultant pharmacist (a healthcare professional, who provides specialized expertise to healthcare facilities, typically focusing on ensuring the safe and effective use of medications) during the Monthly Medication Regimen Review (MRR, when a consultant pharmacist reviews and analyzes a resident's medication list, ensuring that the medications are appropriate, effective, and safe) dated 1/13/2025, for one of three sampled residents (Resident 49) reviewed for Unnecessary Medications and Medication Regimen Review. This deficient practice had the potential for Resident 49 to experience adverse effects (undesired and harmful effects that occur because of a medication, treatment, or procedure) from hydrocortisone cream such as skin thinning, skin irritation and/or skin infection. Findings: During a review of Resident 49's admission Record,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the facility's medication error rate (observed or identified preparation or administration of medications or biologicals which was not in accordance with the physician's order, manufacturer's specifications for the preparation and administration of the medication or biological, and professional standards of practice) was not five percent (5%) or greater. There were seven medication errors out of 28 opportunities (observations during medication administration) for error, to yield a cumulative error rate of 25 % for one of four sampled residents (Resident 80) observed during the medication administration. These deficient practices had the potential to result in harm to Resident 80 by not meeting the residents' individual medication and therapeutic needs (the specific types of treatments or interventions that are necessary to address a person's medical condition or improve their overall well-being). Findings: 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 develop a person-centered care plan for one of three sampled residents (Resident 1). Resident 1 did not have a care plan for his diagnosis of depression. This deficient practice caused an increased risk in Resident 1 experiencing sadness and a decreased quality of life. Findings: A review of the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including myopathy (disease that affects the muscles that control voluntary movement in the body), schizophrenia (a mental illness that is characterized by disturbances in thought), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). A review of the comprehensive Minimum Data Set (MDS - a resident assessment tool) dated 2/19/2025, indicated Resident 1 was free of cognitive impairment (no problems with thinking, memory or making decisions) and needed assistance with bed mobility, transfer, and personal hygiene.…

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 the resident's care plan intervention of weekly skin assessments for one of 15 sampled residents (Resident 1). This failure had a potential to negatively affect the delivery of care and services. Findings: During a review of Resident 1's admission Record, indicated, the resident was admitted to the facility on [DATE] with diagnoses including visual loss bilateral (both sides), hypertension (high blood pressure), morbid obesity (a severe form of obesity characterized by an excessive amount of body fat that significantly impacts health and well-being), anemia (a condition where the body does not have enough healthy red blood cells), heart failure (a condition where the heart cannot pump enough blood to meet the body's needs) and arrythmia (irregular heartbeat). During a review of Resident 1's Alteration in skin integrity related to: MASD care plan dated 11/14/24 indicated assess progress of skin weekly. During a review of Resident 1'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.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program by failing to ensure one of two mobile linen carts positioned outside of the activity room was covered while unattended. This deficient practice caused an increased risk to the facility maintaining a safe and sanitary environment to prevent the spread of infections among residents. Findings: During an observation on 1/30/2025 at 10:37 am in the hallway, in front of the facility's activity room, a mobile linen cart was observed unattended, with the flap open, and the linen inside the cart was exposed. During a concurrent observation and interview on 1/30/2025 at 10:52 am with Certified Nursing Assistant 1 (CNA 1), in the hallway in front of the facility's activity room, the mobile linen cart was observed unattended with the flap open and linen inside exposed. CNA 1 was then observed closing the flap of the linen cart. CNA 1 stated the linen cart should have been covered for infection control. During an interview on 1/30/2025 at 10:53 am, Licensed Vocational…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) care plan was developed for left trochanter (hip) pressure injury stage four (full-thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage, or bone). This failure had the potential to pose the risk of not providing appropriate, consistent, and individualized care to Resident 1. Findings: During a review of Resident 1's admission Record dated 1/3/25, it was indicated that Resident 1 was admitted to the facility on [DATE], with diagnoses including chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), dysphagia (difficulty swallowing), gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach, common for people with swallowing problems), and cerebrovascular accident…

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 the policy and procedure (P&P) titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program, to ensure a background check for staff was conducted prior to the start of employment for two of three sampled staff (Licensed Vocational Nurse [LVN 1] and Certified Nurse Assistant [CNA 2]). This deficient practice caused an increased risk in the protections for health and rights of the residents in the facility. Findings: A review of CNA 2's employee file indicated a date of hire to the facility on [DATE]. A review of LVN 1's employee file indicated the date of hire was 10/1/2024. A review of the employee files with the Director of Staff Development (DSD) was conducted on 12/19/2024 at 10:51 AM. The employee files for CNA 2 and LVN 1 did not have background checks located in the file. The DSD stated the background checks for these staff should be in the employee files but were not there. The DSD then conducted a search with the OIG…

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 sampled resident (Resident 2) had current documented diagnoses to support the administration of psychotropic medications (drugs that affect the brain and mind, altering a person's thoughts, emotions, feelings, awareness, and perceptions). This deficient practice could result in a delay of treatment without a diagnosis attached to the psychotropic medications. Findings: A review of Resident 2's admission record indicated the resident was admitted to the facility on [DATE] with a diagnosis of dementia (a progressive and chronic condition that causes a gradual decline in cognitive abilities, such as thinking, remembering, and reasoning), and muscle weakness. A review of the Anxiety Disorder care plan dated 9/4/24 indicated Resident 2 had angry outbursts and used anti-anxiety medication Ativan. A review of Resident 2's Compulsive Hoarding Disorder care plan (insistent difficulty in parting with possessions and an excessive…

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 four sampled residents (Resident 1), who was administered oxygen, received care in accordance with professional standards of practice and the comprehensive person-centered care plan. Resident 1 was found smoking in his room and the smoking care plan was not updated or revised. This deficient practice caused an increased risk in a negative outcome to Resident 1's physical and psychosocial well-being. Findings: A review of the admission record indicated Resident 1 was initially admitted to the facility on [DATE] with diagnoses including hemiplegia (severe or complete loss / paralysis of one side of the body), hemiparesis (slight muscle weakness or partial paralysis of one side of the body), depression (a mental health condition that can impact a person's thoughts, feelings, behavior, and sense of well-being), anxiety (a feeling of fear, dread, and uneasiness), and intellectual disability (a condition that affects a person's ability to…

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

Based on observation, interview, and record review, the facility failed to maintain an infection control program to ensure prevention and development of communicable diseases for five sampled staff members (Certified Nursing Assistant 1, 2, 3, and Licensed Vocational Nurse 1 and 2). Facility staff were not in compliance with the mandatory respirator (a mask or device worn over the mouth and nose to protect the respiratory system by filtering out dangerous substance) fit testing requirement. This deficient practice had the potential to expose residents, employees, and the community to health hazards and airborne transmissible infectious diseases (bacteria or viruses most commonly transmitted through small respiratory droplets). Findings: During an observation on 9/18/2024 at 8:50 a.m. during initial tour, employees were seen wearing identical, white N95 respirators in the hallways and resident rooms. During a concurrent observation and interview on 9/18/2024 at 10:58 a.m. with Certified Nurse Assistant (CNA) 1 in the facility conference room, CNA 1 was observed wearing a Medline…

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 offer influenza (flu, an infection of the nose, throat, and lungs), pneumonia (an infection that inflames the air sacs in one or both lungs), and Coronavirus (COVID-19, a contagious viral illness that causes mild to severe respiratory illness with symptoms such as fever, cough, shortness of breath, sore throat, and congestion) vaccines (a biological preparation that provides active acquired immunity to a particular infectious or malignant disease) to one of five sampled residents (Resident 1). This deficient practice placed Resident 1 at increased risk of acquiring the flu, pneumonia, and COVID-19; and had the potential for Resident 1 to transmit these viruses to other residents and staff at the facility. Findings: A review of Resident 1's admission Record indicated the the resident was admitted to the facility on [DATE] with diagnoses including acute respiratory failure (a condition when there is not enough oxygen passing from the lungs to 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 ensure one of three sampled residents (Resident 1) felt safe when another resident (Resident 2) wandered into their room in the middle of the night and kissed them on the cheek. This failure resulted in Resident 1 feeling nervous and violated. Findings: During a review of the admission record indicated Resident 1 was initially admitted on [DATE] and readmitted on [DATE], with diagnoses that included cerebrovascular disease (conditions that affect blood flow to the brain), dysphagia (difficulty swallowing), muscle weakness, and tracheostomy (a surgical opening in the neck that provides an alternate way to breath). During a review of Resident 1's Quarterly Minimum Data Set (MDS- a standardized assessment and screening tool) dated 5/28/2024, indicated Resident 1 had intact cognition and memory, was able to make needs known, and was able to understand others. The MDS also indicated Resident 1 was unable to ambulate and needed maximum assistance with their…

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 the individualized interventions to address the resident ' s dementia (a disorder of mental processes caused by brain disease or injury and marked by memory disorder, personality changes, and impaired reasoning) care needs for one of two sampled residents (Resident 2). This deficient practice resulted in Resident 2 wandering into another resident ' s room (Resident 1) and kissing Resident 1 on the cheek. Findings: A review of the admission record indicated Resident 2 was initially admitted on [DATE] with diagnoses including dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), nicotine dependence (smoking cigarettes), and cerebral infarction (loss of blood flow to a part of the brain). A review of Resident 2 ' s Annual Minimum Data Set (MDS) dated [DATE] indicated Resident 2 had moderate cognitive impairment (trouble with thinking, understanding, and reasoning), was independent 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 maintain clean and sanitary fall mats (provide a cushioned surface to absorb the impact of a fall), while in use inside two out of four sampled resident ' s room (Resident1 and Resident 2). This failure has a potential to expose residents to germs and spread an infection in the facility. Findings: During a review of Resident 2 ' s admission Record, dated 8/7/24, indicated, the Resident 2 was admitted to the facility on [DATE], with diagnoses including, metabolic encephalopathy (chemical imbalance in the blood that affects the brain), anemia (a condition of not having enough healthy red blood cells to carry oxygen to the body's tissues), type two diabetes mellitus (a condition in which the body has trouble controlling blood sugar and using it for energy), paraplegia (the loss of muscle function in the lower half of the body, including both legs) and dysphagia (difficulty swallowing). During a review of Resident 2 ' s Minimum Data Set (MDS-…

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

Based on interview and record review the facility failed to ensure their acting Infection Preventionist ' s (IP, a professional with special training in maintaining and implementing the infection control program at a healthcare facility) certificate or training records for infection prevention and control were available and accessible. This deficient practice had a potential for the facility ' s infection prevention and control program not being maintained, placing the residents and staff at risk for healthcare-associated infections (HAIs- are infections you can get while in a healthcare facility). Findings: During a review of the Director of Staff Development ' s (DSD) employee file, there was no IP certificate or training records that were found in the file. During an interview on 7/23/24 at 2:30 p.m., the DSD stated, she was the acting infection preventionist and has an Infection Preventionist certificate, however the DSD was not able to provide a copy of certificate or training records for review. During a review of the facility ' s Infection Preventionist Job Description…

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 the facility ' s employee handbook was followed for three of three sampled Certified Nursing Assistants (CNA 1, CNA 2, and CNA 3) by failing to conduct a performance evaluation every 12 months. This failure resulted in no yearly performance evaluations done for CNAs 1, 2, and 3 and had the potential to effect resident care. Findings: During a review of CNA 1 ' s employee file indicated CNA 1 was working at the facility since 2020. During telephone interview on 7/18/24 at 10:26 am with CNA 2, the CNA stated she had been working at the facility for almost two years. During a review of CNA 3 ' s employee file, the file indicated CNA 3 was hired 11/26/13. During a concurrent interview and record review on 7/18/2024 at 11:14 am with the Director of Nursing (DON), the personnel files of CNAs 1, 2, and 3 were reviewed. The files indicated no evidence of a performance review to have been done in the last 12 months. DON stated the performance reviews were not done. DON stated yearly performance evaluations are important 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, facility failed to ensure the resident's right to be treated with dignity and respect was promoted for two of five sampled residents (Residents 1 and 5). This failure resulted in Residents 1 and 5 not being treated with dignity and respect and had the potential to affect the resident ' s self-esteem and self-worth. Cross reference with F677. Findings: A review of Resident 1 ' s admission Record dated 7/9/24, indicated Resident 1 was admitted to the facility on [DATE], with diagnoses including, monoplegia (paralysis) of the left non dominate side, muscle weakness, anxiety, diabetes mellitus type two (a condition were your body has trouble controlling the level of sugar in the blood), chronic obstructive pulmonary disease (COPD, a group of lung diseases that block airflow and make it difficult to breath), and urinary tract infection. A review of Resident 1 ' s History and Physical (H&P), dated 3/1/24, indicated, Resident 1 has the capacity to understand and make decisions. 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 ensure incontinence care was provided a timely manner for one of five sampled residents (Resident 1). This deficeint practice had the potential to result in infection, illness and effect the resident ' s self-esteem and quality of life. Cross Reference:F550. Findings: A review of Resident 1 ' s admission Record dated 7/9/24, indicated Resident 1 was admitted to the facility on [DATE], with diagnoses including, monoplegia (paralysis) of the left non dominate side, muscle weakness, anxiety, diabetes mellitus type two (a condition were your body has trouble controlling the level of sugar in the blood), chronic obstructive pulmonary disease (COPD, a group of lung diseases that block airflow and make it difficult to breath), and urinary tract infection. A review of Resident 1 ' s History and Physical (H&P), dated 3/1/24, indicated, Resident 1 has the capacity to understand and make decisions. A review of Resident 1 ' s Minimum Data Set (MDS, a standardized…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed ensure discharge orders were followed for one of four sampled residents (Resident 1). This deficient practice resulted in Resident 1 being discharged home without the ordered oxygen concentrator (device that separates nitrogen from the air around you so you can breathe up to 95% pure oxygen). Findings: A review of Resident 1's admission Record, dated 6/26/24, indicated Resident 1 was admitted to the facility on [DATE], with diagnoses including asthma (A condition in which a person's airways become inflamed, narrow and swell, and produce extra mucus, which makes it difficult to breathe), chronic obstructive pulmonary disease (COPD, a group of lung diseases that block airflow and make it difficult to breathe), and obstructive sleep apnea (OSA, is when a blockage in your airway keeps air from moving through your windpipe while you're asleep). A review of Resident 1's progress notes for case management, dated 6/18/24, indicated resident was discharged home…

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, admission orders from the General Acute Care Hospital (GACH) were accurately transcribed and reconciled, and orders per admission protocol for monitoring of vital signs (measurements of the body's most basic functions including; oxygen saturation [O2 sat, saturation by percentage of oxygen in the blood], heart rate, respiratory rate, blood pressure, and temperature) were entered for one of four sampled residents (Resident 1). This deficient practice resulted in no orders entered for oxygen therapy and vital sign monitoring upon admission and therefore were not done for Resident 1. Findings: A review of Resident 1's admission Record, dated 6/26/24, indicated Resident 1 was admitted to the facility on [DATE], with diagnoses including asthma (A condition in which a person's airways become inflamed, narrow and swell, and produce extra mucus, which makes it difficult to breathe), chronic obstructive pulmonary disease (COPD, a group of lung diseases…

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

Based on observation, interview, and record review the facility failed to post the total number and the actual hours worked by the licensed and unlicensed nursing staff directly responsible for resident care per shift with actual date. This deficient practice had a potential to cause the misinformation to the public and residents regarding the most current staffing levels which could violate the residents' rights to know staff who took of them. Findings: During an observation on 6/19/2024 at 11:30 a.m., at the nursing station, the Census and Direct Care Service Hours Per Patient Day (DHPPD) dated 6/12/2024 was posted inside of a locked glass case. During an interview on 6/19/2024 at 11:35 a.m., the director of nursing (DON) stated, the payroll clerk was responsible for posting the DHPPD after the director of staff development (DSD) left. The DON stated, It should be posted daily to show the projected staffing. A review of the facility policy and procedure titled, Staffing, Sufficient and Competent Nursing, revised 8/2022, indicated Direct care daily staffing (the number of nursing…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement its abuse policy and procedure by failing to investigate staff-to-resident alleged abuse for one of five sampled residents (Resident 4). This deficient practice had the potential to result in unidentified abuse in the facility and failure to protect residents from abuse. Findings: a. A review of Resident 4's admission Record indicated the facility admitted the resident on 6/14/2024 with diagnoses including mediastinitis (an inflammation [swelling and irritation] of the chest area between lungs). A review of the Interdisciplinary Team Review (IDT) note indicated Resident 4 felt rushed during her body assessment on 6/15/2024 by Registered Nurse 2 (RN 2), and that RN 2 was very rude, and it made her uncomfortable. A review of Resident 4 ' s Care Plan initiated on 6/15/2024 indicated Resident 4 was at risk for emotional distress related to her claim of having the nurse be rude to her and feeling disrespected. The care plan…

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 the facility failed to maintain a clean, odor-free, well-kept environment for one of five sampled residents (Resident 4), by failing to ensure the resident ' s room and adjacent hallway were odor free and Resident 4 ' s floor around the bed area was not sticky. This deficient practice resulted in foul-smelling environment and sticky floor in and around Resident 4 ' s room. Findings: A review of Resident 4 ' s admission record, dated 5/22/24, the record indicated, the resident was admitted to the facility on [DATE] with diagnoses including muscle weakness, need for assistance with personal care, hypertension (high blood pressure) and hyperlipidemia (high levels of fat particles [lipids] in the blood). A review of Resident 4 ' s Minimum Data Set (MDS, a standardized assessment and screening tool), dated 5/22/24, the MDS indicated, Resident 4 had moderate impaired cognition (ability to think, understand and make daily decisions). The same MDS indicated Resident 4 required setup 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 fingernails of one of five sampled residents (Resident 4), trimmed and free of dirt and debris ( the remains of something broken down or destroyed). This deficient practice had the potential to result to odors, infection, unkempt fingernails, poor hygiene, and embarrassment. in infection, illness and effect the resident ' s self-esteem and quality of life. A review of Resident 4 ' s admission record, dated 5/22/24, indicated, Resident 4 was admitted to the facility on [DATE] with diagnoses including muscle weakness, need for assistance with personal care, hypertension (high blood pressure) and hyperlipidemia (high levels of fat particles [lipids] in the blood). A review of Resident 4 ' s Minimum Data Set (MDS, a standardized assessment and screening tool), dated 5/22/24, the MDS indicated, Resident 4 had moderate impaired cognition (ability to think, understand and make daily decisions). The same MDS indicated Resident 4 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 observation, interviews and record review, the facility failed to develop and/or implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150 B of the Act. The facility failed to report to the state survey agency within two hours an allegation of physical abuse directed toward one of three sampled residents (Resident 1) by Certified Nursing Assistant 1 (CNA 1) on 3/16/2024. This deficient practice resulted in a delay of an onsite inspection by the California Department of Public Health to ensure Resident 1's circumstance were investigated. This deficient practice also had the potential to place Resident 1 at further risk for abuse. Findings: A review of Resident 1's admission Record indicated the facility admitted the resident was re-admitted on [DATE] with diagnoses of Parkinson's disease (brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination) 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 interview and record review, the facility failed to ensure an allegation of abuse was thoroughly investigated and immediately place effective measures in order to prevent further or potential abuse for one of three sampled residents (Resident 1). After Licensed Vocational Nurse 1 (LVN 1) reported an allegation of physical abuse to Registered Nurse 1 (RN 1) on 3/16/2024, Certified Nursing Assistant 1 (CNA 1) was not immediately removed from providing direct care and continued to have access to the resident. As a result of this deficiency, Resident 1 was not protected from the potential of further harm or retaliation from the staff after being identified. Findings: A review of Resident 1's admission Record indicated the facility re-admitted the resident on 4/21/2020 with diagnoses of Parkinson's disease (brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination) and encephalopathy (a disease damaged the functions of the brain). A review of the Progress Notes, dated 3/16/2023 at 3:40 AM,…

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 Medication Administration Record (MAR) for intravenous (IV) medication Zosyn (used to treat many different infections caused by bacteria, such as stomach infections [occurs when germs enter the body, increase in number, and cause a reaction of the body], skin infections, pneumonia, and severe uterine infections) was complete and accurate for one of eight sampled residents (Resident 7). This deficeint practice resulted in an inaccurate and incomplete documentation. Findings: A review of Resident 7 ' s admission Record dated 3/8/24, indicated Resident 7 was admitted to the facility on [DATE], with diagnoses including dementia (loss of memory judgement, language, problem-solving and thinking ability), malignant neoplasm (cancerous tumor) of the large intestine and prostate (a walnut-size gland of the male reproductive system that produces a fluid), type II diabetes mellitus (a condition where your body has trouble controlling the level of sugar…

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 policy and procedures for a change in condition (COC - a deterioration in health, mental, or psychosocial status in either life-threat- ening circumstances or clinical complications) was followed for one of four sample residents (Resident 1). This failure resulted in Resident 1 ' s COC not being assessed in a timely manner by staff. Findings: A review of Resident 1 ' s admission Record dated 1/24/24, indicated Resident 1 was admitted to the facility on [DATE], with diagnoses including type two diabetes mellitus (DMII, a condition where your body has trouble controlling the level of sugar in the blood), essential (primary) hypertension (high blood pressure), hemiplegia (muscle weakness on onside of the body) and hemiparesis (muscle paralysis on one side of the body) following cerebral infarction (stroke) of the left non-dominant side and pressure injuries (bed sores) to both heels and both sides of the buttocks. 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 observation, interview and record review, the facility failed to ensure one of four sampled residents ' (Resident 2), medications were stored safely in medication cart and not at resident ' s bedside. This failure had the potential to result in Resident 2 taking extra doses of the medications. Findings: During a review of Resident 2 ' s admission Record dated 1/24/24, indicated Resident 2 was admitted to the facility on [DATE], with diagnoses including type II diabetes mellitus (DMII, a condition where your body has trouble controlling the level of sugar in the blood), essential (primary) hypertension (high blood pressure), muscle weakness and Chronic Obstructive Pulmonary Disease (COPD, a group of lung diseases that block airflow and make it difficult to breath) with dependence on supplemental oxygen. During a review of Resident 2 ' s Minimum Data Set (MDS, a standardized assessment and screening tool), dated 12/19/2022, the MDS indicated, Resident 2 had mild memory problems, and required supervision…

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 an environment that was free of accident hazards for one of three sampled residents (Resident 2), by failing to ensure call lights were answered timely. This deficient practice resulted in Resident 2 falling on 12/11/2023 sustaining a laceration to the back of the head requiring transfer to the GACH (General Acute Care Hospital). Findings: A review of Resident 2's admission Record dated 1/3/24 indicated Resident 2 was admitted to the facility on [DATE], with diagnoses including muscle weakness (generalized), quadriplegia (paralysis of legs and arms)and type II diabetes (an impairment in the way the body regulates and uses glucose [sugar] as a fuel). A review of Resident 2 ' s History and Physical (H&P) dated 8/24/23, indicated, Resident 2 could make needs known but not able to make medical decisions. A review of Resident 2's Minimum Data Set (MDS a standardized assessment and care screening tool) dated 12/29/23 indicated Resident 2 had mildly…

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 sample residents (Resident 1) was free from medication errors. By failing to: 1. Ensure Resident 1 received the ordered medication Isosorbide Mononitrate (medication used to lower blood pressure) ER (extended release) 60 mg (milligram) oral tablet one tablet by mouth in the morning (6:30 am) on 12/6/23, 12/7/23, and 12/9/23. 2. Follow Resident 1 ' s physician ' s orders for blood sugar (BS) interventions (when resident ' s blood sugar was at 401 millimoles per liter [mmol/L] or above) were followed on: 12/15/23 at 9:00 pm when the resident ' s BS was 525 requiring the administration of 10 units of insulin (medication used to lower BS levels) and physician notification, 12/17/23 at 9:00 pm when the resident ' s BS was 425 requiring the administration of 10 units of insulin and physician notification, 12/20/23 at 4:30 pm when the resident ' s BS was 401 requiring the administration of 10 units of insulin and physician notification,…

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 three sampled residents (Resident 1), had interventions in place for medical device-related pressure sore (pressure ulcer/ injury resulting from use of a medical device, equipment, furniture, or everyday objects in direct contact with skin and because of increased external mechanical load leading to soft tissue damage) prevention. This failure had the potential to result in Resident 1 developing a pressure sore on his posterior (rear) thigh, due to a medical device -- the resident ' s foley catheter (a flexible plastic tube inserted into the bladder to provide continuous urinary drainage via drainage tubing and urine collection bag) tubing. Findings: A review of Resident 1's admission Record, dated 12/11/23, the admission Record indicated, the resident was admitted to the facility on [DATE] with diagnoses including history of endocarditis (heart infection), respiratory (breathing) failure requiring tracheostomy (surgical…

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.

This is a repeated deficiency from the Recertification Survey on 12/2/2023 with a s/s=F. Based on interview and record review the facility failed to provide adequate and sufficient nursing staff to meet the needs of one of three sampled residents (Resident 1). This repeated deficient practice caused an increased risk in the care of the total resident population (66 residents), effecting resident safety, security, and implementation of policies and procedures necessary to remain in compliance with current laws, regulations and guidelines. There was inadequate availability of nursing services on 1/9/2024 to assure resident safety and attainment of the highest practicable mental and psychosocial well-being of Resident 1. As a result, on 1/18/2024, Resident 1 stated he did not receive his 1 AM sleeping medications until 5:30 AM. Resident 1 stated, I don't feel safe. It makes me feel helpless. I feel dismissed and disregarded. Findings: A review of Resident 1's admission Record indicated the facility admitted the resident on 10/25/2013 with diagnoses including insomnia, anxiety, major…

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 four sampled staff (Licensed Vocational Nurse) 3 and Certified Nursing Assistant (CNA) 1 had valid Basic Life Support (BLS - a certification for healthcare professionals who need to know how to perform CPR, as well as other lifesaving skills, in a wide variety of in-hospital and out-of-hospital settings) certification. This deficient practice had the potential for residents to not receive appropriate emergency care during life-threatening situations. Findings: During a concurrent interview and record review on [DATE] at 9:16 AM, the employee files for Certified Nursing Assistant 1 (CNA 1) and Licensed Vocational Nurse 3 (LVN 3) were reviewed with the Director of Staff Development (DSD). The DSD stated LVN 3's date of hire was [DATE]. The DSD further stated LVN 3's BLS certification expired in [DATE]. The DSD further stated she was unable to locate proof of the BLS certification for CNA 1. The DSD stated all employees of the facility must…

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 an injury of unknown origin within 24 hours for one of nine sampled residents (Resident 1). This deficient practice resulted in Resident 1 ' s injury of unknown origin not being reported to state licensing/certification office and delayed the investigation to determine the cause of the injury and rule out abuse. Findings: A review of Resident 1's admission Record dated 11/17/23 indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including person injured in a motor-vehicle accident, intracranial (within the skull) injury with loss of consciousness, muscle weakness, multiple fractures of the left leg, fracture of the left jaw and fracture of the back of skull, dysphagia (trouble eating), and anxiety. A review of Resident 1's Minimum Data Set (MDS - a care planning and assessment tool), dated 9/12/23, indicated Resident 1 's cognition (ability to think, understand and make daily decisions) was unable to be assessed (resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure care plan was developed post incident for one of two sample residents (Resident 2). This deficient practice had the potential to negatively affect the delivery of care and services for Residents 2. Findings: During a review of Resident 2's admission Record (Face Sheet), dated 11/9/23, Face Sheet indicated, Resident 2 was initially admitted to the facility on [DATE] with diagnoses including schizophrenia (a serious mental disorder in which people interpret reality abnormally), muscle weakness, obesity, Crohn ' s disease (a chronic condition causing inflammation in the tissues of your digestive tract) of the small intestine, with fistula (an abnormal connection between an organ, vessel or intestine to another organ vessel or intestine, or the skin). During a review of Resident 2 ' s History and Physical (H&P) dated 7/7/23, the H&P indicated Resident 2 has the capacity to understand and make decisions. During an interview with Licensed Vocational…

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 call lights were answered and residents ' needs are attended to for two of 10 sampled residents (Resident 2 and Resident 3). The facility failed to answer the call lights timely when Resident 2 and Resident 3 called for assistance. These deficient practices resulted in Resident 2 and Resident 3 stating that they felt frustrated. Findings: 1. During a review of the admission Record indicated the facility admitted Resident 2 on 5/27/2023 with diagnoses including dysphagia (difficulty swallowing), with gastrostomy tube (tube surgically inserted to the belly that brings food and medicine directly to the stomach) and need for assistance with personal care. During a review of the MDS dated [DATE] indicated Resident 2 was cognitively intact. Resident 2 needed set-up (help only) with dressing, personal hygiene and one-person physical assistance with eating and bathing. 2. During a review of the admission Record indicated the facility admitted Resident 3…

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 physician ' s order to hold (not to administer) hydralazine hydrochloride (HCL, medicine for high blood pressure) 25 milligrams (mg., unit of measurement) for systolic blood pressure (SBP, the top blood pressure number) less than 120 millimeters of mercury (mmHg). On 8/20/2023 at 5:45 p.m., Resident 1 ' s blood pressure (BP) was 116/64 mmHg and licensed vocational nurse 2 (LVN 2) administered hydralazine HCL 25 mg by mouth to Resident 1.The facility failed to hold the hydralazine HCL on 8/20/2023, at 9 a.m., 1 p.m. and 5 p.m. when Resident 1 ' s SBP was less than 120 mmHg. As a result, , Resident 1 became weak, had syncopal episode (passed out), and was unresponsive (a state in which a person becomes unaware and does not respond to touch, light, sound). Paramedics (trained team who respond and provide emergencies medical care to people who are injured or ill, typically in a setting outside of a hospital) transported Resident 1 to general acute…

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, facility failed to ensure dignity for one of 8 residents sampled (Resident 2) by failing to ensure Resident 2 was addressed by his name during care by Licensed Vocational Nurse (LVN) 1. This failure resulted in Resident 2 not being treated with dignity and respect and had the potential to affect the resident ' s self-esteem and self-worth. Findings: During an interview on 10/4/23 at 5:10 pm with Resident 2, Resident 2 stated LVN 1 calls him pops instead of addressing him by his name. Resident 2 further stated the staff should not be using that word, we should be treated with dignity and respect it is our right. During an interview on 10/4/23 at 5:15 pm with Resident 3, Resident 3 stated I call Resident 2 pops and I have heard LVN 1 call Resident 2 pops without asking his permission. During a telephone interview on 10/5/23 at 12:06 pm with Certified Nursing Assistant (CNA) 1, CNA stated she provided dignity and respect to the residents by calling them by their names. A review of the facility ' s policy and procedure (P&P) titled, 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 a licensed administrator was onsite to manage the facility. This failure had the potential to affect resident care and management of the facility. Findings: During an observation on 10/4/23 at 10:00 am no Administrator was observed at the facility for the day. During an interview on 10/5/23 at 2:30 pm with Regional Administrator (RA), the RA stated he is the Interim Administrator for the facility. During an observation with concurrent interview 10/5/23 at 7:45 pm with Administrator ' s Assistant (AA), bulletin board to the left of the main entrance and nursing station was observed with no Administrator ' s License posted, the AA confirmed there was no Administrator ' s license posted and stated the previous Administrator ' s last day was 09/25/23. The AA further stated he was hired as the Administrator ' s Assistant, and the RA was on site a few times a week for over eight hours at a time. A review of the Administrator ' s Job Description, (undated), indicated The primary purpose of your job position is…

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 that one of three sampled residents (Resident 1 ' s) resident representative (RP) was notified of change in condition (COC - a changen a person health/condition) after Resident 1 had unwitnessed fall in the facility on . This failure resulted in the violation of rights of COC notification to Resident 1 ' s RP. Finding: A review of Resident 1 ' s admission Record indicated the facility admitted Resident 1 on 6/10/2023 with diagnoses including encephalopathy (a disease in which the functioning of the brain is affected by some agent or condition-such as viral infection or toxins in the blood), congestive heart failure (CHF-a chronic condition in which the heart does not pump blood as well as it should), dependance on oxygen and muscle weakness (when full effort does not produce a normal muscle contraction or movement). A review of Resident 1 ' s Minimum Data Set (MDS - a standard assessment and care screening tool) dated 6/14/2023, indicated Resident 1 was cognitively (in a way that relates to thinking, or conscious…

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 three sampled residents (Residents 1 and 2) received treatment and care in accordance with physician ' s orders. This failure resulted in: 1. Resident 1 did not receive supplemental oxygen for five days with the potential for complications realted to hypoxemia (low level of oxygen in the blood) that could lead to hospitalization. 2. Resident 2 did not receive insulin and did not have blood sugar checked on 8/8/2023 and 8/10/2023 with the potential for complications related to hyperglycemia (high blood glucose[sugar]) /hypoglycemia (low blood glucose). Finding: 1. A review of Resident 1 ' s admission Record indicated the facility admitted Resident 1 on 6/10/2023 with diagnoses including encephalopathy (a disease in which the functioning of the brain is affected by some agent or condition-such as viral infection or toxins in the blood), congestive heart failure (CHF-a chronic condition in which the heart does not pump blood as well as it…

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.