The Rehabilitation Center Of Los Angeles

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to maintain dignity (providing care that respects a resident's self-esteem, identity, and personal choices) and respect for one of one sampled resident (Resident 83) when the resident's chest was left exposed with the privacy curtain (a fabric partition used to block the line of sight between beds) pulled open. This failure had the potential to violate Resident 83's right to personal dignity, privacy, and respect, and could negatively affect Resident 83's psychosocial well-being and have impact on Resident 83's self-esteem (sense of personal worth and value).Findings: During a review of Resident 83's admission Record, the admission Record indicated the resident was a [AGE] year old woman who was admitted to the facility on [DATE] with diagnoses that included quadriplegia (paralysis from the neck down, including legs and arms, usually due to a spinal cord injury), hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure Resident 138's privacy curtain was completely closed, and private area was exposed during morning care for one of one sampled resident.This deficient practice had the potential to result in compromised resident dignity, embarrassment, emotional distress, and loss of privacy during care.During a review of Resident 138's admission Record (Face Sheet), the admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side (paralysis and weakness on one side of the body following a stroke), functional quadriplegia (complete immobility due to severe physical disability), type 2 diabetes mellitus with hyperglycemia (high blood sugar due to the body not properly using insulin), cognitive communication deficit (difficulty understanding or expressing thoughts), essential hypertension (chronic high blood pressure),…

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 one of five sampled residents (Resident 186) reviewed for unnecessary medications such as psychotropic (any drug that affects the mental function, behavior, and mood) medications had an end date (expiration date of the physician order) for the use of Ativan (help calm the nervous system) as needed (PRN). This failure had the potential for Resident 186 to become over-medicated, restrict mobility, and experience adverse side effects (unexpected or harmful consequences of medication) such as dizziness and sedation (decrease in awareness).Findings: During a review of Resident 186's admission Record, the admission Record indicated the facility originally admitted Resident 186 on 3/9/2026 and readmitted Resident 186 on 4/27/2026 with diagnoses that included epilepsy (a brain disorder that causes repeated, unprovoked seizures), aphasia (a disorder that makes it difficult to speak), type 2 Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), muscle weakness, dysphagia…

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

Based on interview and record review, the facility failed to provide a written notice of transfer or discharge to the Office of the State Long-Term Care Ombudsman (LTC Ombudsman-an independent, neutral official who investigates and resolves complaints) for one of 10 sampled residents (Resident 3) on 5/11/2026, when Resident 3 was transferred to hospital (GACH) on 5/11/2026. This deficient practice had the potential to prevent the LTC Ombudsman from being informed of Resident 3's facility-initiated transfer and from identifying, monitoring, or addressing potential resident rights concerns related to the transfer.Findings: During a review of Resident 3's admission record, the admission record indicated the facility originally admitted Resident 3 on 3/14/2026 and re-admitted the resident on 4/3/2026 with diagnoses including acute and chronic respiratory failure (condition in which your blood does not get enough oxygen or has too much carbon dioxide), and encephalopathy (a condition in which the functioning of the brain is affected by some agent or condition-such as viral infection 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 interview and record review the facility failed to ensure the Minimum Data Set (MDS, a resident assessment tool) for the use of tobacco was accurately completed for one of two sampled residents (Resident 57).This deficient practice had the potential for Resident 57 to receive inadequate and improper care at the facility.Findings: During a review of Resident 57's admission Record, the admission Record indicated the facility admitted the resident on 3/7/2025 with diagnoses that included spondylosis (age related wear and tear of the spinal disks in the neck), type 2 diabetes (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing), diverticulosis (the presence of small, bulging pouches in the lining of the large intestine), muscle weakness, and history of falling. During a review of Resident 57's Care Plan Report dated 9/9/2025, the Care Plan Report indicated the resident was a smoker. The Care Plan Report indicated Resident 57 was at risk for injury, non-compliance…

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 update and revise the End Stage Renal Disease (ESRD, irreversible kidney disease) and dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) care plan (a plan of care that summarizes a resident's health conditions, current treatments, and specific care and services facility staff (in general) need to provide a resident to promote healing and prevent a worsening of a condition) for one out of five sampled residents (Resident 14). By Failing to update Resident 14's care plan on 5/5/2026 when the resident's pick-up time for dialysis was changed. This failure had potential for Resident 14 to miss dialysis and receive care that was not in alignment with the resident's physician orders.Findings:During a review of Resident 14's admission Record, the admission Record indicated the facility admitted the resident on 5/20/2025 with diagnoses that included ESRD and dependence on renal (kidney) dialysis. During a review of Resident 14's Care Plan Report dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to follow professional standards of practice (the everyday rules and behaviors that keep patients safe and ensure high-quality healthcare) for medication administration (the process of giving medicine to a resident) by failing to ensure subcutaneous (fatty tissue under the skin) injection sites were rotated for two of two sampled residents (Resident 80 and Resident 186):Specifically, the facility failed to:1. Ensure two of two sampled residents (Resident 80 and Resident 186's) insulin (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication) injection sites were rotated (a method to ensure repeated injections are not administered in the same area).2. Ensure one of two sampled residents (Resident 186's) Enoxaparin (a prescription blood thinner) injections sites were rotated. This failure had the potential to cause skin breakdown, bruising, tissue damage, and/or ineffective medication…

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, interviews, and record reviews the facility failed to provide necessary services to maintain good oral care (oral hygiene, the practice of keeping the mouth, teeth, and gums clean and free of disease) for one of one sampled resident (Resident 83) who was dependent on staff for oral hygiene. This failure had potential to affect Resident 83's dignity (providing care that respects a resident's self-esteem, identity, and personal choices) and place the resident at risk for aspiration (accidentally breathing food, liquid, or saliva into the airway and lungs) and tooth decay (damage and destruction of teeth).Findings: During a review of Resident 83's admission Record, the admission Record indicated the facility admitted the resident on 7/25/2013 with diagnoses that included quadriplegia (paralysis from the neck down, including legs and arms, usually due to a spinal cord injury), hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body), hemiparesis (weakness or the inability to move on one side of the body), gastrostomy (a surgical opening…

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 care and services to prevent aspiration (when food, liquid, or stomach contents accidentally enter the airway or lungs instead of the stomach) for one of three sampled residents (Resident 17) investigated under the accidents care area by failing to: -Ensure to clarify the route of administration of two Boost (nutritional drinks and shakes designed to provide everyday nutritional support) supplement orders for Resident 17. -Ensure to implement a risk for aspiration care plan (a personalized roadmap that guides how facility staff will manage treatments, medication, therapy goals, and safety precautions for residents) for Resident 17. This failure had the potential to increase Resident 17's risk for aspiration.Findings: During a review of Resident 17's admission Record, the admission Record indicated the facility readmitted the Resident on 9/15/2025 with diagnoses that included larynx (commonly called the voice box, a hollow organ in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure to maintain gastrostomy tube (G-tube, is a tube inserted through the abdomen that delivers nutrition directly to the stomach) care for two of nine sampled residents (Resident 175 and Resident 186) reviewed for tube feeding by failing to: -Ensure the enteral feeding (a way of delivering liquid nutrition directly to your stomach or intestines) tubes for Resident 175 and Resident 186 were capped (covered) and not open to air as indicated by the facility's Policies and Procedures (P&Ps) titled, Infection and Prevention and Control, last reviewed 4/14/2026, and P&P titled Enteral Feeding - Safety Precautions, last reviewed 4/14/2026. This failure placed Resident 175 and Resident 186 at risk for infection.Cross reference F880 Findings:1.During a review of Resident 175's admission Record, the admission Record indicated the facility originally admitted Resident 175 on 5/23/2025 and readmitted Resident 175 on 1/16/2026 with diagnoses that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure one of 14 residents (Resident 80) sampled for respiratory care receive necessary respiratory care and services in accordance with professional standards of practice, by failing to ensure Resident 80's nasal cannula tubing (a device that gives you additional oxygen [an invisible, odorless, and tasteless gas that makes up about 21% of the air we breathe] through your nose) and oxygen humidifier (a water bottled attached to the oxygen machine that adds moisture to oxygen preventing your nose, throat and airways from drying out, cracking, or getting sore) were labeled and dated. This deficient practice had the potential for Resident 80 to experience an increased risk for respiratory infections (illnesses that affect the parts of your body involved in breathing, such as your nose, throat, and lungs).Findings: During a review of Resident 80's admission Record, the admission Record indicated the facility originally admitted Resident 80 on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to:Implement care plan for hemodialysis (HD, an invasive procedure to filter blood to remove waste and excess water through a machine, to replace kidney function), when a case manager (CM) 2 failed to schedule transportation at prescribed pick-up time for one of one resident (Resident 190).Ensure proper communication was implemented between the facility and hemodialysis center on one of one resident's (Resident 190) hemodialysis treatment and care.Ensure the transportation was not late during hemodialysis appointments for one of one resident (Resident 190).This deficient practices resulted in Resident 190's hemodialysis session shortened, and had a potential to cause fluid retention, shortness of breath, and altered laboratory test results.Findings:During a review of face sheet of Resident 190, dated 4/29/2026, the face sheet indicated the resident 190 was admitted to the facility on [DATE] with diagnoses of acute respiratory failure with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure safe medication administration and accurate accountability of all controlled medications (medications with a high potential for abuse) for three of five sampled residents (Resident 7, Resident 98, and Resident 151) by failing to: 1.Clarify the physician's order for Resident 7's gastrostomy tube (g-tube - a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems) administration of pantoprazole (a medication used to treat gastro-esophageal reflux disease (GERD - a condition where stomach acid flows back up into the esophagus and causes heartburn) granules (crumbs). 2. Ensure one of four inspected medication carts (Station 4 Medication Cart 1) maintained accurate documentation of Resident 98's hydrocodone-acetaminophen (a controlled medication [medications that the use and possession of are controlled by the federal government] in combination with…

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

Based on observation, interview, and record review, the facility failed to ensure the facility's pharmacy and consultant pharmacist (a professional responsible for reviewing each resident's medication profile monthly to identify and report changes) addressed medication irregularities for one of five sampled residents (Resident 7) by failing to: -Ensure the medication administration instructions for Resident 7's pantoprazole (a medication used to treat gastro-esophageal reflux disease [GERD - a condition where stomach acid flows back up into the esophagus and causes heartburn]) granules (crumbs) via gastrostomy tube (g-tube - a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems) were appropriate in accordance with the manufacturer's specifications. -Ensure drug to drug interaction (occurs when two or more drugs react with each other, which may lead to unexpected side effects or alter the effectiveness of the medications) between Resident 7's pantoprazole granules and mycophenolate mofetil (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 one of five residents (Resident 2) sampled for unnecessary medications (a medication that may be doing more harm than good or isn't needed for the resident's current condition) was administered medication in accordance with physician orders and professional standards of practice. By failing to ensure:1. Resident 2 was not administered Hydrocodone-Acetaminophen (a controlled medication [medications that the use and possession of are controlled by the federal government] in combination with acetaminophen [APAP - a medication used to treat pain] used to treat severe pain) tablet 7.5-325 mg, give 2 tablets by mouth every 4 hours as needed for severe pain (7-10) NTE 3 g/day, hold if RR<12 and call MD, order date 2/21/2026, when the Resident's pain level was out of the ordered parameters (the specific, measurable guidelines, dosages, and conditions that dictate how, when, and why a medication is administered). This deficient practice placed Resident 2…

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 a medication error rate of less than 5% (percent) during medication pass for one of five sampled residents (Resident 7) by failing to: -Ensure Resident 7's pantoprazole (a medication used to treat gastro-esophageal reflux disease ([GERD] - a condition where stomach acid flows back up into the esophagus and causes heartburn) delayed-release granules were administered via gastrostomy tube ([g-tube] - a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems) safely and in accordance with manufacturer's specifications. -Ensure drug-drug interaction between Resident 7's pantoprazole granules and mycophenolate mofetil (a medication used to suppress immune response in transplant patients) suspension was clarified and reviewed with a physician before they were administered concurrently during medication pass. These failures failed to administer medications in accordance with manufacturer's specifications and professional…

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 residents (Resident 2) was free of a significant medication error (any preventable error in medication administration that can result in resident discomfort, jeopardizing health and safety, or requiring medical intervention). By failing to ensure: 1. Resident 2 was not administered Hydrocodone-Acetaminophen (a controlled medication [medications that the use and possession of are controlled by the federal government] in combination with acetaminophen [APAP - a medication used to treat pain] used to treat severe pain) tablet 7.5-325 mg, give 2 tablets by mouth every 4 hours as needed for severe pain (7-10) NTE 3 g/day, hold if RR<12 and call MD, order date 2/21/2026, when the Resident's pain level was out of the ordered parameters (the specific, measurable guidelines, dosages, and conditions that dictate how, when, and why a medication is administered). This deficient practice placed Resident 2 at risk for an overdose 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 ensure proper storage, labeling and disposal of medications in one of two inspected medication rooms (Station 3 Medication Room) and two of four inspected medication carts (Station 4 Medication Cart 1 and Controlled Care Unit Medication Cart Floor 2) as per manufacturer specifications and facility's policies and procedures (P&P) titled, Medication Storage in the Facility - Storage of Medications, dated 6/2016, Labeling of Biologicals and Storage of Biologicals, dated 1/2026 and Medication Destruction, dated 1/2026, by failing to: 1. Ensure Resident 1's lorazepam (a medication used to treat anxiety [feelings of worry and uneasiness) oral liquid was stored in a refrigerator at temperatures between 2-degree-Celsius [( C) is a unit of temperature] to 8 C or 36 Fahrenheit [( F) is a unit of temperature] to 46 F, as per manufacturer specifications, in Station 3 Medication Room Refrigerator. 2. Ensure Resident 119's discontinued ciprofloxacin (a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure the transportation was not late during hemodialysis appointments for one of one resident (Resident 190).This failure resulted in Resident 190's hemodialysis session shortened, and had a potential to cause fluid retention, shortness of breath, and altered laboratory test results.Findings:During a review of face sheet of Resident 190, dated 4/29/2026, the face sheet indicated the resident 190 was admitted to the facility on [DATE] with diagnoses of acute respiratory failure with hypoxia (sudden difficulty breathing and oxygen exchange due to damage in lungs), and end stage renal disease (irreversible loss kidney function), renal hemodialysis dependance (HD, a long term treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidneys have failed).During a review of Minimum Data Set (MDS, resident assessment tool) dated 5/5/2026, the MDS indicated the Resident 190's cognitive patterns were intact…

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

Based on observation, interview, and record review the facility failed to ensure the call light (a device used by a resident to signal his or her need for assistance) was within reach for one of four sampled residents (Resident 85). This deficient practice had the potential to result in staff delay in meeting Resident 85's needs for activities of daily living (ADLS, activities a person performs daily such as bathing, dressing, and toileting), prolonged distress and increased risk of falls for Resident 85.Findings:During a review of Resident 85's admission Record, the admission Record indicated the facility admitted Resident 85 on 2/21/2025 with diagnoses that included essential primary hypertension (HTN-high blood pressure), history of falling, gastro-esophageal reflux disease (stomach acid is rising into the esophagus, the hollow, muscular tube that carries food and liquid from your throat to the stomach), difficulty walking, reduced mobility, muscle weakness, and dementia (a progressive state of decline in mental abilities). During a review of Resident 85's Care Plan Report,…

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 two of four sampled residents (Residents 1 and 2) received care in accordance with the professional standards of practice by failing to answer resident call system in a timely manner. This deficient practice resulted in Resident 1 and Resident 2 feeling neglected, anxious, and helpless. A review of Resident 1's admission record indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE] with a diagnosis including chronic respiratory failure (a condition lungs have long-term trouble getting enough oxygen into the blood stream causing difficulty breathing often caused by a disease or injury), unspecified abnormalities of gait and mobility (when the pattern in which you walk and move is not normal), generalized anxiety disorder (a person is often worried or anxious about many things and finds it hard to control).A review of Resident 2's admission record indicated Resident 2 was initially admitted to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure Licensed Vocational Nurse 1 (LVN1) and Certified Nursing Assistant 2 (CNA2) had the competencies necessary to care for two of four sampled residents (Resident 1 and Resident 4) by failing to: 1. Ensure LVN 1, a registry nurse (a staffing agency which provide nursing personnel per shift or temporarily), assigned to Resident 1 had a full skills checklist or performance evaluations in his employee file. 2. Ensure CNA 2, a regular staff member, assigned to Resident 4 had a full skills checklist. This failure had the potential for the employees to have a lack of understanding of their job description and duties and had the potential to neglect (Resident 1 and Resident 4). Findings: During a review of Resident 1's admission Record, the admission Record indicated the facility admitted the resident on 9/24/2019 with diagnoses that included Type 2 Diabetes ((DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), chronic…

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) received the necessary care and nursing services to prevent recurrent dislodgement of a nephrostomy tube (a tube that is placed directly into the kidney to drain urine from the kidney). This deficient practice resulted in Resident 1 ' s recurrent transfers to General Acute Care Hospital (GACH) on 1/9/2025, 3/23/2025, and 4/6/2025 due to a dislodged nephrostomy tube, requiring repeated invasive procedures (medical procedure where the body is entered or invaded through an incision, percutaneous [through the skin] puncture, or insertion of an instrument). Placing the resident at risk for sepsis (a life-threatening condition that arises when the body's response to an infection damages its own tissues and organs, potentially leading to organ failure and death) and death. Findings: A review of Resident 1 ' s admission record indicated the facility initially admitted the resident to the facility on 8/29/2018…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that two of nine sampled residents (Resident 64 and Resident 130) were free from physical restraints (any method or device, attached to or near a person's body, that restricts their freedom of movement or access to their body, and which cannot be easily removed) by failing to document the release of the hand mittens (soft, padded mittens used to prevent patients, especially those who are restless, confused, or have cognitive impairments, from pulling out essential lines or tubes), monitoring of skin breakdown (occurs when prolonged pressure on the skin damages the underlying tissues), and monitoring of impaired circulation (a condition where blood flow is reduced or blocked in certain areas of the body) every 2 hours. This deficient practice had the potential for Resident 64 and Resident 130 to develop skin breakdown and injury. Findings: a. During a review of Resident 64's admission Record, the admission Record indicated the…

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

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 for two of two sampled resident (Resident 119 and 122), by failing to: -Develop and implement a care plan for Resident 119's rectal tube (a long, thin tube inserted into the rectum [the lower part of the large intestine] to help with issues like relieving gas buildup or managing fecal incontinence, or for administering medications or fluids rectally). -Develop and implement care plans for Resident 122's edema (swelling caused by too much fluid trapped in the body's tissues) and pressure ulcer (damage to the layers of the skin caused by prolonged pressure on a part of the body; Stage 1: red, warm to touch, stays red when pushed down on, Stage 2: break in top layer of skin, stage 3 crater-like appearance damage to top layers and fat layers, Stage 4: damage to all layers of skin, including muscle, bone may be visible). These deficient practices had the potential to delay and affect the quality of care…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure three of 32 sampled residents received the care and services in accordance with professional standards of practice as evidenced by: -Failing to rotate the insulin administration sites for Resident 49 and Resident 121. -Failing to reassess Resident 127's high blood pressure. These deficient practices had the potential for Resident 49 and 121 to experience lipohypertrophy (a condition where lumps of fat and scar tissue form under the skin, often at insulin injection sites, due to repeated injections in the same area that can impair insulin absorption and lead to inconsistent blood sugar levels and difficulty managing diabetes) and lipodystrophy (a complete or partial loss or abnormal distribution of fat tissue); and for Resident 127 to experience uncontrolled high blood pressure. Findings: a. A review of Resident 49's admission Record dated 3/26/2025, indicated the resident was originally admitted to the facility on [DATE] 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 observations, interviews, and records review, the facility failed to ensure nurses would rotate insulin (synthetic hormone used to control blood sugar level) injection site as per orders, for two of 43 sampled residents (Residents 49, 86), -Failed to ensure there was no discrepancy between the inventory and accountability record of Resident 85's oxycodone (a potent opioid narcotic used to treat pain). -Failed to ensure the Cubex (a computer-controlled system that automates drug dispensing in a health facility) activity record matched the electronic medication administration record (eMAR) for Resident 89's Norco (a combination of hydrocodone and acetaminophen, a potent narcotic to treat pain) administration. These decent practices had the potentials for medication errors, adverse effects, and drug diversion. Findings: a. A review of Resident 49's admission record indicated the resident was admitted on [DATE] with diagnoses including, but not limited to, type 2 diabetes (a chronic condition that affects…

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 reviews, the facility failed to ensure there were specific behavior documentations and consolidated monthly data to track progress or decline (documentation needed to make data-driven treatment decisions and adjustments to interventions) for two of two sampled residents (Residents 7 and 92) who received antipsychotic drugs (a class of drugs used to treat psychotic disorders [mental health conditions characterized by a loss of touch with reality, leading to distorted perceptions, thoughts, and behaviors]). -Failed to place a 14-day limit (a measure to prevent over-prescribing and ensure appropriate use, requiring a physician's re-evaluation and documentation for continued use beyond the 14-days) on an as needed order for Ativan (Lorazepam - a medication used to treat anxiety) for one out of 32 sampled residents (Resident 5). These deficient practices had the potential of the residents receiving unnecessary psychotropic medications (a medication that affects the mind and brain,…

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 kitchen staff were regularly trained and evaluated for competency skills when staff were unable to demonstrate correct dishwashing procedures. -Unable to verbalize and demonstrate the correct process of checking quaternary ammonium compound (QUAT, a chemical that disinfect) sanitizer concentration testing for the red buckets and three compartment sink's (sink for dishwashing that have wash, rinse and sanitize compartments) use. These deficient practices had the potential to result in harmful bacterial growth and cross contamination (transfer of harmful bacteria from one place to another) that could lead to foodborne illness (a disease caused by consuming food or drinks that are contaminated by germs or chemicals) in 133 of 206 medically compromised residents who received food and ice from the kitchen. Findings: a.During an observation on 3/25/2025 at 8:59 AM, of the preparation sink, Dietary Aide 1 (DA 1) was observed rinsing the mixer in the preparation sink (sink designated for food preparation).…

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

Based on observation, interview, and record review, the facility failed to follow the menu and did not meet nutritional needs of 83 of 206 residents on regular texture diets (diet with no texture restriction) by serving four (4) ounces ([oz], a unit of measurement) instead of three (3) oz. of pork barbecue (BBQ). This deficient practice had the potential to result in excessive nutrients intake of protein, fat, and sodium causing ineffective therapeutic diet provisions, increase blood pressure, increase fat and cholesterol in the diet and unplanned weight gain. Findings: During a review of the facilities' daily spreadsheet (a list of food, amount of food that each diet would receive) titled Cycle 1 2025 Winter, dated 3/25/2025, the spreadsheet indicated residents on regular texture consistencies would include 3 oz of BBQ pork. During a concurrent observation and interview on 3/25/2025 at 11:55 a.m. of the BBQ pork portion size, [NAME] 1 weighed the BBQ portions using the facility scale and had the following portion sizes: 3.5 oz, 4 oz, 4 oz, 4 oz and 3.9 oz. [NAME] 1 stated the BBQ…

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 prepare food utilizing methods that conserved flavor and appearance when the pureed cabbage did not hold its shape on the plate. -The pork barbecue (BBQ) served for third and fourth station was dry, and the vegetables were olive green in color. This deficient practice placed 91 of 206 (including Resident 127 and 105) facility residents on regular consistency texture (texture with no restriction) and puree diets (food with soft pudding like consistency) at risk of unplanned weight loss, a consequence of poor food intake. Findings: a. During a review of the facilities' daily spreadsheet (a list of food, amount of food that each diet would receive) titled Cycle 1 2025 Winter, dated 3/25/2025, the spreadsheet indicated residents on regular texture consistencies would include - BBQ pork 3 ounces ([oz] a unit of measurement) - Baked beans ½ cup ([c] household measurement) - Creamy coleslaw ½ c - Biscuit 1 piece - Peach cobbler 1 square -…

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: 1. Kitchen equipment and kitchen areas were not cleaned and sanitized. a. [NAME] reach-in freezer gasket had dirt buildup and dried up ice cream spill on the bottom shelves. b. Reach-in freezer vents had dirt and dust buildup. c. Vegetable reach-in freezer had dirt and food particles on the bottom shelves. 2. Tuna salad was stored at 43.2 degrees Fahrenheit ([°F], a scale of temperature) and turkey slices were stored at at 48°F, instead of the required 41°F of less. 3. Two dented cans were stored with non-dented cans for the emergency supply canned goods. 4. Kitchen equipment and utensils were not maintained in proper condition, smooth and easy to clean. a. Fifty (50) of 50 resident's trays were cracked. b. [NAME] and green chopping boards had chips and scratches. 5. Improper washing of kitchen equipment and utensils a. Pans were stacked wet while air drying and was stored stacked wet. b. Staff rinse the kitchen…

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

Based on observation, interview, and record review, the facility failed to ensure residents food brought in from outside the facility were stored at safe temperature range of 41 degrees Fahrenheit (°F, a scale of temperature) and below. This deficient practice had the potential to result in harmful bacterial growth and cross contamination (transfer of harmful bacteria from one place to another) that could lead to foodborne illness (a disease caused by consuming food or drinks that are contaminated by germs or chemicals) in 133 of 206 medically compromised residents who store food in the resident's refrigerator. Findings: During a review of the facility's Policies and Procedures (P&P), titled, Refrigerator/Freezer Temperature Records, dated 11/20/2024, the P&P indicated The facility has procedures to ensure safe and sanitary storage, handling, and consumption of foods brought to residents by family and other visitors. Note: The facility strives to support each resident's right to safe food storage, handling, and preparation. To ensure safe food practices and the prevention 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.

Based on observation, interview, and record review, the facility failed to dispose garbage and refuse properly when two of four dumpsters (large trash container designed to be emptied into a truck) were not completely closed and covered when not in use, and the surrounding ground was not kept clear of spilled liquids, soiled gloves, and trash. This failure had a potential to result to attracting birds, flies, insects, pest and possibly spread infection to facility residents. Findings: During a concurrent observation of the facility dumpsters and interview on 3/26/2025 at 10:13 am, the Dietary Supervisor (DS) observed 2 of 4 black dumpsters overflowing with trash, not completely covered when not in use and the dumpster grounds had food spillage and other trash such as used gloves and soiled paper cups. The DS stated the dumpsters had to be completely covered because rodents could get into the trash. The DS stated the dumpsters were too close to the kitchen and it would be a potential hazard as birds and other animals could transfer bacteria to residents. The DS further stated there…

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 six sampled residents was free of significant medication error during medication administration (or med pass) observations (Resident 127). This failure had the potential of adverse effect, and/or worsening of resident's health condition. Findings: During an observation and a concurrent interview on 3/27/25 at 9:16 AM, the licensed vocational nurse (LVN 5) was outside Resident 127's room, about to prepare medications for administration. LVN 5 stated Resident 127's blood pressure was 194/86 (normal blood pressure ranges 120-129 / 80-84). LVN 5 proceeded to prepare 9 medications. One of 9 medications was furosemide (generic for Lasix, a diuretic used in the treatment of edema associated with congestive heart failure, and renal disease). LVN 5 stated Resident 127 would have dialysis in the afternoon, therefore LVN 5 held (not giving) the furosemide; then, LVN 5 proceeded to administer the rest of the 9 medications to Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure keys that provide access to medication (med) carts would not be left on top of an unattended med cart. This deficient practice had the potential of unsecure drug storage and unauthorized access. Findings: During an observation on 3/26/25 at 9:40 AM, the licensed vocational nurse (LVN 4) used one of the keys on a keychain to unlock the med cart in the Subacute unit (SAU, a nursing unit that provides a level of medical care that is less intensive than acute care but more specialized than typical skilled nursing care). Later, LVN 4 placed the keys on top of the med cart, pushed in a lock to lock the med cart, and headed inside the room to start med pass. At 9:41 AM, LVN 4 was at the bedside of Resident 124. The med cart was parked at the door of the resident's room, unattended. During an observation on 3/27/25 at 9:36 AM in SAU, there was a med cart unattended outside room [ROOM NUMBER]. There was a set of keys on top of the med cart.…

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 allow one sampled resident (Resident 1) to return to the facility following a hospitalization on 11/16/2024, 11/24/2024, and 2/3/2025. Resident 1 was transferred to general acute the acute care hospital (GACH) on 8/24/2024. This deficient practice had the potential to result in psychosocial harm for Resident 1, had caused emotional distress and confusion for Resident 1's decision maker family member (FM). Findings: During a review of Resident 1's admission Records, dated 1/31/2025, the admission record indicated, Resident 1 was initially admitted to the facility on 8/302024 and readmitted on [DATE] with a diagnosis including chronic respiratory failure a condition in which your blood doesn't have enough oxygen causing shortness of breath and difficulty breathing, often caused by a disease or injury) dysphagia (difficulty swallowing) generalized muscle weakness (weakening, shrinking, and loss of muscle), type 2 diabetes (DM-a disorder characterized by…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to implement its ' policy and procedures (P&P) titled Fall Management Program, for one of three sampled residents (Resident 1), who was identified as fall risk and was dependent on staff for orientation and ambulation. This deficient practice resulted in Resident 1 ' s having recurrent unwitnessed falls within 30 days (on 12/17/24; 1/2/2025; and 1/21/2025) in the facility and had the potential for a serious injury or harm to Resident 1. Findings: Resident 1 had three unwitnessed falls on 12/17/2024, 1/2/2025, and 1/21/2025. Resident 1 was transferred to acute general care hospital (GACH) for computed tomography (CT scan- a medical diagnostic imaging procedure to produce images of the inside of the body) to rule out a head injury status post fall. On 1/2/2025 Resident 1 had a fall while trying to get out of bed unassisted to go to bathroom, Resident 1 was sent out to GACH for CT scan. On 1/21/2025 Resident 1 was found sitting on the floor mat…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 4's), assigned staff (certified nurse assistant and licensed vocational nurse) had a background check and license information in their employee file. This deficient practice caused an increased risk in abuse to Resident 4. Findings: A review of Residents 4's admission record indicated the resident was admitted to the facility on [DATE], with diagnoses including traumatic subdural hemorrhage (collection of blood between the brain and skull), persistent vegetative state (disorder of consciousness that occurs when someone has severe brain damage and is in a state of partial arousal), tracheostomy (a procedure to create an opening in the neck for airway to the lungs), and chronic respiratory failure (serious condition that makes it difficult to breathe on your own). A review of Resident 4's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated [DATE], indicated the resident had severely…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop and implement a comprehensive care plan that meet the care/services based on the resident ' s individual assessed needs for one of three sampled residents (Resident 1) by failing to develop a care plan for the antibiotic vancomycin (a strong antibiotic used to treat an infection of the intestines caused by Clostridium difficile, which can cause watery or bloody diarrhea, this medicine may cause some serious side effects, including damage to your hearing and kidneys. These side effects may be more likely to occur in elderly patients). This deficient practice had the potential to result in serious skin reactions, hearing loss, and kidney disfunction. Findings: A review of Resident 1's admission Record indicated Resident 1 was initially admitted on [DATE] and was readmitted on [DATE] with diagnosis that included diabetes mellitus 2 (a condition that happens because of a problem in the way the body regulates and uses sugar as a fuel), anoxic brain…

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 administer medication as per physician ' s order for one of two sampled residents (Resident 1). By failing to: 1. Follow physician order to administer Filgrastim (medication that helps the body make more neutrophils [blood cells that helps the body fight infections] 300 micrograms/0.5 milliliter (mcg. /ml., unit of measurement) to Resident 1. The Filgrastim 300 mcg. /0.5 ml was not given to Resident 1 on 6/22/24 at 9 a.m. or on 7/11/24 at 9 a.m. 2. Ensure there was an adequate supply of the Filgrastim 300 mcg. /0.5 ml. readily available for Resident 1. 3. Notify Resident 1 ' s primary physician or oncologist (a doctor who had special training in diagnosing and treating cancer) when the Filgrastim 300 mcg. /0.5 ml. was not available, and Resident 1 missed the doses of Filgrastim on 6/22/24 at 9 a.m. and 7/11/24 at 9 a.m. These deficient practices had the potential for Resident 1 to have increased risk of contracting infection. Findings: A review of Resident 1 ' s admission Record indicated the facility admitted Resident 1 on…

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

Based on observation, interview, and record review the facility failed to follow their policy and procedure titled Resident Isolation- Categories of Transmission Based Precautions with a review date of 2/21/24 for one of two sampled residents (Resident 1) who was on contact isolation (prevent transmission of infectious agent which are spread by direct or indirect contact with the resident and the resident ' s environment). On 7/16/24 at 9 a.m., certified nursing assistant 1 (CNA 1) did not use a protective gown while taking Resident 1 ' s vital signs (measure the basic function of the body that included temperature and blood pressure). This deficient practice had the potential to spread infection to staff and residents. Findings: A review of Resident 1 ' s admission Record indicated the facility admitted Resident 1 on 3/22/24 with diagnoses including diffuse large B-cell lymphoma (cancer of the cells that are part of the body ' s immune system [body system that protects that helps the body fight infections and other diseases] and muscle weakness. A review of Resident 1 ' s Minimum…

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 one sampled resident (Resident 2) psychotherpeutic medication (a drug that changes brain function and results in alterations in perception, mood, consciousness, or behavior) consent forms were signed by physician prior to administration to the resident. This deficient practice violated the resident's right to make an informed decision regarding the use of psychoactive medications. Findings: A review of Resident 2's admission Record indicated the facility admitted the resident on 5/9/2024 with diagnoses including malignant neoplasm of the colon (cancer develops from polyps in the colon's inner lining), diabetes Type II (a long-term medical condition in which the body does not use insulin [a hormone that lowers the level of sugar in the blood] properly), and schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves). A review of the History and Physical, dated 5/10/2024, indicated Resident 2 had the capacity to understand and make decisions. A review of Resident 2's Minimum Data Set…

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 residents are given their right to privacy for one of two sampled residents (Resident 1). Resident 1 who had an indwelling catheter (a hollow tube left implanted in the bladder [organ that stores urine] to promote urine drainage), the facility failed to provide a privacy cover for the indwelling catheter drainage bag. This deficient practice resulted in failing to provide Resident 1 the right for personal privacy and dignity. During a review of the admission Record indicated the facility admitted Resident 1 on 8/29/18 and readmitted on [DATE] with diagnoses including chronic respiratory failure (not enough oxygen passes in the breathing organs to the blood), obstructive and reflux uropathy (hindrance of normal urine flow) and retention of urine (inability to empty all the urine from the bladder. During a review of the Minimum Data Set (MDS, standardized care and health screening tool) dated 6/16/24 indicated Resident 1 had severely…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure the care plan was implemented and the effectiveness of the interventions were reviewed for one of two sampled residents (Resident 1). For Resident 1, the facility failed to: 1. Review the effectiveness of the care plan interventions and revise the care plan each time Resident 1's nephrostomy tube (thin plastic tube that is passed from the back through the skin into the kidney [pair of organs that take away waste matter from the blood] to help drain the urine) was dislodged. 2. Ensure the nephrostomy tube was anchored and secured to prevent from pulling or being dislodged. 3. Ensure nephrostomy drainage bag was kept below Resident 1's bladder. These deficient practices resulted in Resident 1's nephrostomy tube being dislodged on 1/31/24, 2/22/24, 5/7/24, 6/16/24 and 7/3/24. Resident 1 had to be sent to the general acute hospital (GACH) each time to have the nephrostomy tube re-inserted. Findings: During a review of the admission…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to protect the skin of residents from prolonged pressure caused by medical device for one of two sampled residents (Resident 1). For Resident 1, the facility failed to ensure the nephrostomy (thin plastic tube that is passed from the back through the skin into the kidney [pair of organs that take away waste matter from the blood] to help drain the urine) regulator did not cause prolonged pressure to Resident 1's abdomen. On 7/1/24 at 9:16 a.m., Resident 1 was observed with a mark caused by the nephrostomy regulator on right side of her abdomen. This deficient practice had the potential for Resident 1 to develop pressure ulcer related to the medical device. Findings: During a review of the admission Record indicated the facility admitted Resident 1 on 8/29/2018 and readmitted on [DATE] with diagnoses including chronic respiratory failure (not enough oxygen passes in the breathing organs to the blood), obstructive and reflux uropathy (hindrance…

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 their policy regarding reporting of an injury of unknown source in accordance with state or federal law for one of one sampled resident (Resident 1). This resulted in a delay of an onsite inspection by the Department of Public Health to ensure the residents' injury and accidents were investigated and had potential for an ongoing unknown injury. Findings: A review of Resident 1's admission Record indicated the resident was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including metabolic encephalopathy (a chemical imbalance in the blood affecting the brain), dysphagia (difficulty swallowing food or liquid) following unspecified cerebrovascular disease (a group of conditions that affect blood flow and the blood vessels in the brain), and unspecified dementia (loss of cognitive functioning-thinking, remembering, and reasoning). A review of Resident 1's History and Physical (H&P) dated 5/13/2024 indicated,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure two of 12 sampled residents (Resident 90 and 96) had the Advance Directives (written statement of a person's wishes regarding medical treatment made to ensure those wishes are carried out should the person be unable to communicate them to a doctor) or Advanced Directives Acknowledgement forms (a signed acknowledgment indicating the resident and/or resident representative were provided with information regarding creating an Advanced Directive) documented in the residents' active medical record. This deficient practice had the potential for Residents 90 and 96 to be denied the right to request or refuse medical care and treatment. Findings: a. A review of Resident 90's admission record indicated the facility admitted Resident 90 on 12/22/2023 with diagnoses that included end stage renal disease (ESRD - a condition in which the kidneys are no longer able to function at a level for day-to-day life), type 2 diabetes mellitus (a chronic condition that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to develop and/or implement resident specific care plans for three of four sampled residents (Resident 9, Resident 31, and Resident 70) by failing to: -Develop and implement a care plan to monitor and provide interventions for Resident 9's weight loss. -Develop and implement a care plan to monitor and provide interventions for Resident 31's urinary tract infection (UTI - an illness in any part of the urinary tract, the system of organs that makes urine). -Implement and administer oxygen therapy (a treatment that provides you with supplemental, or extra, oxygen) as indicated in the care plan for Resident 70. These failures had the potential for Resident 9 to have continued weight loss, Resident 31 to not be provided personalized treatment for UTI, and unnecessary respiratory distress (difficulty breathing) for Resident 70. Findings: a. A review of Resident 9's admission Record indicated the facility admitted the resident on 10/8/2023, with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide skin and pressure ulcer (injuries to the skin and underlying tissue, primarily caused by prolonged pressure on the skin) care consistent with professional standards of practice and per physician's orders for three of five sampled residents (Resident 259, 54 and 137) on Low Air Loss Mattresses (LALM - a pressure-relieving mattress used to prevent and treat pressure injuries), by failing to ensure the LALM's were set at the appropriate level. This deficient practice had the potential to delay healing, placed Resident 259, 54 and 137 at risk for developing new pressure injuries, worsening of existing ones, and complications resulting from untreated or improperly treated pressure injuries which could result in systemic infections that could lead to death. Findings: a. A review of Resident 259's admission record indicated the facility admitted Resident 259 on 3/8/2024 with diagnoses including Type II diabetes mellitus (a chronic…

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) received the appropriate treatment and services outlined in the resident's care plan needed to maintain adequate hydration and nutrition for two of two sampled residents (Residents 109 and 130) receiving enteral nutrition (A form of nutrition that is delivered directly into the digestive system as a liquid) by failing to: -Ensure Resident 109 had an irrigation syringe (a syringe use to flush water into the tubing of a feeding tube [medical device used to provide nutrients and water to the stomach] to prevent clogs) at his bedside. -Ensure Resident 130's water was labeled with the time it was hung as per facility policy and procedures (P&P) titled Enteral Feeding - Safety Precautions last revised on 3/2023. These deficient practices had the potential to result in malnutrition (lack of proper nutrition), dehydration (lack of sufficient water in the body), infection, organ failure, 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 ensure two of two sampled residents (Resident 2 and Resident 6) receiving Heparin (anticoagulant: a medication that slows the formation of blood clots) were free from unnecessary medications when the facility failed to ensure Resident 2 and Resident 6's Medical Doctor (MD) ordered prothrombin time (PT- measures the time it takes for the liquid portion of your blood to clot) and international normalized ratio (INR- tells you how long it takes for your blood to clot) monitoring as indicated in the facility's policy and procedures (P&P) titled, Anticoagulant Therapy, dated 3/1/2020. This deficient practice placed Resident 2 and Resident 6 at risk of adverse effects (undesired harmful effects) such as uncontrollable bleeding, organ failure, and death. Findings: a. A review of Resident 2's admission Record indicated the facility admitted the resident on 3/4/2023 with diagnoses that included quadriplegia (inability to move, feel, or control the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility staff failed to ensure three of 17 sampled residents (Resident 135, Resident 1, and Resident 75), were free from significant medication errors by the administration of medications that may have been stored in unstable refrigerator temperatures in the Subacute refrigerator on Nursing Station 2 between 3/11/2024 to 3/13/2024. -For Resident 135, was documented to have been administered 11 doses of Vancomycin (an antibiotic to treat infection) Oral (by mouth) Solution and two doses of Epogen (also known as Retacrit and Procrit, a glycoprotein [proteins with a sugar attached] that stimulates red blood cell production) between 3/11/2024 to 3/13/2024 -For Resident 1, was documented to have been administered eight doses of Gabapentin (a medication that can be used for neuropathy [a condition where there is damage to the nerves] or seizures [sudden, uncontrolled burst of electrical activity in the brain]) Oral Solution and two doses of Epogen between…

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 store, discard, and/or label medications in accordance with the facility's policy and procedure. The following were observed during inspection of one of five medication carts (MedCart 1) on Nursing Station 3 and one of two medication storage rooms (Subacute Medroom) on Nursing Station 2: 1. One Insulin Glargine Injectable Pen (a long-acting insulin, a hormone that lowers the level of glucose, a type of sugar in the blood) used to treat diabetes (a group of disease that result in too much sugar in the blood) for Resident 117 stored in the MedCart 1 not labeled with an opened date or date when first stored at room temperature. 2. One Humulin N KwikPen (an intermediate-acting insulin used to treat diabetes) for Resident 111 was stored in the MedCart 1 not labeled with an opened date or date when first stored at room temperature. 3. One vial of Humulin N Insulin labeled for Resident 123, which had a sticker attached for a different 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 provide reasonable accommodations to meet resident needs for one of one sampled resident (Resident 64) by failing to ensure the resident's call light (a device with a button or touch pad a resident uses to set off an alarm that flashes/rings to alert the facility staff the resident needs assistance) was within reach of the resident. This deficient practice had the potential to prevent Resident 1 from using the call light to alert staff for assistance, leading to a delay in care and services. Findings: A review of Resident 64's admission Record indicated the facility admitted the resident on 1/25/2024 with diagnoses that included Type II diabetes mellitus (a chronic condition that affects the way the body processes blood sugar [glucose]), muscle weakness (lack of physical or muscle strength and the feeling that extra effort is required to move your arms, legs, or other muscles), and hypertension (HTN - elevated blood pressure). A review of Resident 64's Minimum Data Set (MDS- a standardized assessment and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to notify the physician of a change of condition (COC) for one sampled resident (Resident 128) on 2/29/2024 when the resident was found to have a skin tear to the right elbow. This deficient practice placed Resident 128 at risk for a delay in healing, treatment and medical care needed to prevent pain and infection. Findings: A review of Resident 128's admission Record indicated the facility admitted the resident on 4/6/2023 with diagnoses that included hemiplegia (symptom that involves one-sided paralysis) and hemiparesis (partial paralysis on one side of the body), reduced mobility, and muscle weakness (decrease in muscle strength). A review of Resident 128's History and Physical (H&P) signed and dated 8/9/2023, indicated Resident 128 had the capacity to understand and make decisions. A review of Resident 128's Minimum Data Set (MDS - a standardized resident assessment and care screening tool) dated 12/1/2023, indicated the resident's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a resident's written notice of emergency transfer was provided to the state long-term care Ombudsman (representative appointed by the government who assists residents in long-term care facilities with issues related to day-to-day care, health, safety, and personal preferences) as soon as practicable for one of the six sampled residents (Resident 107), per facility policy and procedures titled Notice of Transfer Discharge dated 3/2023. This deficient practice had the potential to result in the State Long Term Care Ombudsman not being unaware of the resident's status and whereabouts. Findings: A review of Resident 107's admission Record indicated the resident was originally admitted to the facility on [DATE] and was readmitted on [DATE], with diagnoses that included Type II diabetes mellitus (an impairment in the way the body regulates and uses glucose [sugar] as a fuel) with hyperglycemia (abnormally high level of sugar in the blood), dysphagia…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, facility failed to provide one sampled Spanish speaking resident (Resident 126) Spanish translation needed to ensure the resident understood and was able to communicate health care needs, concerns, and plan of care. This deficient practice denied Resident 126 the right to participate in medical decisions, decisions regarding actives of daily living (ADL's: activities related to personal care. They include bathing or showering, dressing, getting in and out of bed or a chair, walking, using the toilet, and eating) and actively participate in plan of care. Findings: A review of Resident 126's admission Record indicated the facility admitted Resident 126 on 2/23/2023 with diagnoses that included acute respiratory failure (condition in which not enough oxygen passes from the lungs into the blood) with hypoxia (low levels of oxygen in your body), tracheostomy (a procedure to help air and oxygen reach the lungs by creating an opening into the trachea (windpipe) from outside 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, interviews, and record reviews, the facility failed to provide necessary services to maintain good health status for one of five sampled residents (Resident 81) dependent on staff for activities of daily living (ADL's: activities related to personal care, bathing or showering, dressing, getting in and out of bed or a chair, walking, using the toilet, and eating) by failing to provide one to one (1:1) feeding assistance as per physician's order to Resident 81 during breakfast on 3/12/2024. This failure has the potential for the resident at the facility to experience poor oral intake and be at risk for weight loss and aspiration. Findings: A review of Resident 81's admission record indicated the facility admitted Resident 81 on 2/13/2024 with diagnoses including unspecified fall, generalized muscle weakness (lack of physical or muscle strength and the feeling that extra effort is required to move your arms, legs, or other muscles), and unspecified fracture (broken bone) of upper end of left humerus (upper arm). A review of the Minimum Data Set (MDS- a…

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

Based on observation, interview, and record review, the facility failed to ensure one of five sampled residents (Resident 155) identified as at risk for falls was free from accidents by failing to ensure a physician's ordered floor mat (padded mats placed on the floor on either side of the bed to cushion a fall) was placed next to bed for Resident 155. This deficient practice placed Resident 155 at increased risk for falls and complications related to fall injuries such as fractures, cuts, and internal bleeding. Findings: A review of Resident 155's admission Record indicated the facility admitted the resident on 2/27/2024 with diagnoses including muscle weakness (lack of physical or muscle strength and the feeling that extra effort is required to move your arms, legs, or other muscles), unspecified fall, and difficulty in walking, A review of Resident 155's Minimum Data Set (MDS- a standardized assessment and screening tool) dated 3/4/2024, indicated the resident was cognitively (the skills your brain uses to think, read, learn, remember, reason, and express thoughts) intact. The…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide necessary respiratory care services for one sampled resident (Resident 70) by failing to administer two liters of continuous (without interruption) oxygen therapy (administration of oxygen at concentrations greater than that in the air with the intent of treating or preventing the symptoms of low oxygen) as per physician's order. This deficient practice placed Resident 70 at risk for hypoxia (insufficient amount of oxygen reaching the body's tissues) and respiratory distress (difficulty breathing). Findings: A review of Resident 70's admission Record indicated Resident 70 was admitted to the facility on [DATE] with diagnoses that included dysphagia (difficulty swallowing), hemiplegia (paralysis of one side of the body) affecting right dominant side, aphasia (an impairment of language affecting the ability to express or understand speech) and seizures (sudden, uncontrolled body movements and changes in behavior that occur because…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to keep accurate records for one sampled resident (Resident 209's) pain medication, Percocet (a combination medication used to help relieve moderate to severe pain which contains an opioid pain reliever [oxycodone] and a non-opioid pain reliever [acetaminophen]), by failing to ensure the Controlled Medication (a drug or substance that is controlled by the government because it may be abused or cause addiction) form matched the information on the medication administration record (MAR, a written record of all medications given to a resident). This deficient practice increased the risk of medications may not be administered as prescribed to Resident 209, increasing the risk for medication errors, uncontrolled pain, which could negatively affect the Resident 209's health and well-being. Findings: A review of Resident 209's admission Record (a document containing medical and demographic information) indicated the resident was initially admitted to 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 maintain a medication error rate of less than 5 % (percent) during medication pass for one of three sampled residents (Residents 53) observed during medication administration by failing to: -Ensure Resident 53 was administered the entire dose of each medication as ordered and per facility policy and procedures (P&P) titled, Medication Administration-General Guidelines, updated 11/2021. -Ensure facility staff administered medications within 60 minutes of the scheduled time as per facility P&P titled, Medication Administration-General Guidelines, updated 11/2021. These deficient practices resulted in five medication errors out of 25 opportunities resulting in a medication error rate of 20 percent (%), placing Resident 53 at risk for decreasing therapeutic effects, worsening in medical conditions, hospitalization and/or death. Findings: A review of Resident 53's admission Record indicated the facility initially admitted Resident 53 on 7/20/2021 and readmitted the resident on 11/21/2023. Resident 53's diagnoses…

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 one of six sampled residents (Resident 23's) preferred meal choices were implemented as requested by Resident 23. This failure resulted in a violation of Resident 23's right to have preferred meal choices, with the potential for decreased food intake and inadequate nutrition. Findings: A review of Resident 23's admission Record indicated the facility admitted Resident 5 on 6/15/2023 with diagnoses including major depressive order (MDD - a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), hemiplegia (the total loss of ability to move one side of the body) and hemiparesis (one-sided muscle weakness), Type II diabetes (DM2 - condition that results in too much sugar circulating in the blood), myalgia (muscle aches and pain) of the head and neck, dysphagia (difficulty swallowing), and gastroesophageal reflux disease (GERD- occurs when stomach acid repeatedly flows back into the tube connecting your mouth and stomach. 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: -Store food in accordance with professional standards of practice for food service safety by not labeling 3 boxes of juice with the open date (date indicating packaging opened; used to determine amount of time food can be safely consumed). -Ensure kitchen staff did not use expired quaternary test strips (test strips dipped in sanitizing solution used to detect if the chemical sanitizing solution is the required concentration to meet local health regulations) to check that the quaternary sanitizing solution (ammonium solution used for sanitizing surfaces) was effective. These deficient practices had the potential to cause food-borne illnesses. Findings: During a concurrent observation and interview on 3/11/2024, at 11:30 AM, the Dietary Supervisor 1 (DS 1) observed 3 boxes of juice base, connected to a juice dispenser, without an open date. DS 1 stated that each of the 3 boxes of juice base should have been labeled with their respective open date. DS 1 stated that the staff should be placing the received date,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide consistent and preferred activities of choice for one of three sampled residents (Resident 5). This failure resulted in Resident 5 feeling angry and had the potential to decrease Resident ' s 5 ' s psychosocial (physical, emotional and/or mental) well-being. Findings: A review of Resident 5's admission record indicated the resident was admitted to the facility on [DATE] with diagnoses including major depressive order, hemiplegia (the total loss of ability to move one side of the body) and hemiparesis (one-sided muscle weakness), Type II diabetes, myalgia (muscle aches and pain) of the head and neck, and difficulty walking. A review of the Minimum Data Set (MDS – a standardized resident assessment care screening tool) dated 11/28/2023 indicated Resident 5's cognitive status (ability to think, remember and reason) was intact. The MDS dated [DATE] indicated Resident 5's preferences for activities and care were listening to music and keeping up…

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 1) ' s clinical record was updated per facility ' s policy and procedure by failing to: 1. Ensure Resident 1 ' s clinical records were updated regarding Physician Orders for Life-Sustaining Treatment (POLST - is a form designed to improve patient care by creating a portable medical order form that records patients' treatment wishes so that emergency personnel know what treatments the patient wants in the event of a medical emergency). 2.Ensure Resident 1 ' s medical records were updated to show documentation that advance directives (written statement of a person's wishes regarding medical treatment made to ensure those wishes are carried out should the person be unable to communicate them to a doctor) were discussed and written information were provided to the residents and/or responsible parties. This deficient practice violated resident ' s and/or representatives ' right to be fully informed of the option…

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 sufficiently prepare one of one sampled resident (Resident 1) for a safe and orderly discharge from the facility. This deficient practice resulted in Resident 1 ' s requiring transfer to a general acute care hospital (GACH) one hour after discharge from the facility on 1/29/24. Findings: A review of Resident 1 ' s Record of admission indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including sepsis (a life-threatening condition that arises when the body ' s response to infection causes injury to its own tissues and organs), pneumonia (lung infection that inflames air sacs with fluid or pus), muscle weakness, difficulty in walking, and history of falling. A review of the Minimum Data Set (MDS - a comprehensive assessment and care screening tool), dated 1/10/2024, indicated Resident 1 ' s cognitive (mental action or process of acquiring knowledge and understanding) skills for daily…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility staff failed to ensure one of one sampled residents (Resident 2) received appropriate treatment and services to prevent urinary tract infections (UTI-an infection in any part of your urinary system your kidneys, ureters, bladder and urethra) by failing to ensure Resident 2 ' s indwelling urinary (foley) catheter (a flexible plastic tube inserted into the bladder that remains there to provide continuous urinary drainage) was placed below the level of the bladder at all times. This deficient practice had the potential to lead to urine backflowing up into Resident 2 ' s bladder resulting in a UTI, systemin infection, organ failure, and death. Findings: A review of Resident 2 ' s admission Record indicated resident was admitted to the facility on [DATE] with diagnoses including pleural effusion (an abnormal collection of fluid between the thin layers of tissue [pleura] lining the lung and the wall of the chest cavity), hypothyroidism (or underactive…

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 necessary respiratory care services for one out of one sampled resident (Resident 2) by failing to ensure Resident 2 ' s nasal cannula (NC -a connector attached to oxygen) tubing and humidifier (a device used to make supplemental oxygen moist) were changed weekly as per facility ' s policy and procedure title Oxygen Therapy with a revision date of March 2023. This deficient practice had the potential for the residents to develop respiratory infection. Findings: A review of Resident 2 ' s admission Record indicated resident was admitted to the facility on [DATE] with diagnoses including pleural effusion (an abnormal collection of fluid between the thin layers of tissue [pleura] lining the lung and the wall of the chest cavity), hypothyroidism (or underactive thyroid, happens when your thyroid gland doesn't make enough thyroid hormones to meet your body's needs), and retention of urine (when the bladder doesn't empty completely 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 ensure two of four sampled residents (Resident 1, Resident 2) were provided care and services for toenail care to maintain good grooming and personal hygiene. This deficient practice had the potential to result in a negative impact on Resident 1 ' s and Resident 2 ' s quality of life and self-esteem. Findings: A review of Resident ' 1s admission Record (Face Sheet) indicated Resident 1 was originally admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included hemiplegia and hemiparesis following a cerebrovascular disease affecting his right dominant side (paralysis or weakness of one side of the body following a stroke) and muscle weakness. A review of Resident 1 ' s Minimum Data Set (MDS – a comprehensive screening tool), dated 7/26/2023, indicated Resident 1 needed extensive assistance from staff (resident involved in activity but staff provide weight-bearing support) in personal hygiene. 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.