The Rehabilitation Center On Pico

Based on observation, interview, and record review, the facility failed to ensure Licensed Vocational Nurse 4 (LVN 4) verified medication dosage prior to medication administration for one of seven sampled residents (Resident 31). As a result, Resident 31 received vitamin C (ascorbic acid, a nutrient crucial for immune function and wound healing) at a dose much higher than the dose prescribed. Placing residents at risk for medication errors and negative adverse effects. Findings: During a review of Resident 31's medication orders, the medication orders indicated an active order dated 2/18/2026 at 2:40 PM for ascorbic acid (vitamin C) 250 mg by mouth one time a day. During a medication administration observation on 3/18/2026 at 9:31 AM, LVN 4 was observed preparing medications for Resident 31. LVN 4 prepared 9 medications and 1 of those 9 medications was a tablet of vitamin C 500 milligrams (mg, a unit to measure mass). During concurrent observation and interview on 3/18/2026 at 11:06 AM, LVN 4 was asked to show the vitamin C bottles in the medication cart. LVN 4 looked and stated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow infection control practices for one of five sampled residents (Resident 67) reviewed for infection control by failing to: -Ensure staff (in general) did not store the trash and soiled (dirty) linen carts inside shower room [ROOM NUMBER]. -Ensure staff (in general) cleaned shower room [ROOM NUMBER] after the Social Services Assistant (SSA) removed the trash and soiled linen carts before Certified Nursing Assistant 2 (CNA2) bathed Resident 67 on 3/17/2026 at 9:06 AM. This failure placed Resident 67 at risk of infection. Findings:During a review of Resident 1's admission Record, the admission Recorded indicated the facility admitted Resident 67 on 3/3/2009 and readmitted the resident on 6/23/2015 with diagnoses including right elbow contracture (a permanent tightening or shortening of muscles, tendons, skin, or tissues, usually replacing flexible tissue with inelastic, fiber-like tissue) and dysphagia (difficulty swallowing). During 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 develop a Comprehensive Care Plan (CP- a personalized document that outlines a resident's needs, goals, and the specific services required to achieve them, ensuring consistent and holistic care) for one of three sampled residents (Resident 1), to address Resident 1's Urinary Tract Infection (UTI- infection that happens when bacteria enter the urethra, and infect the urinary tract) after returning from the hospital to the facility.This failure placed Resident 1 at risk for recurrent hospitalizations, which the resident experienced six times from 11/2/2025 through 1/10/2026.During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was initially admitted to the facility on [DATE] with diagnosis metabolic encephalopathy (brain dysfunction caused by diseases or toxins in the body) and readmitted to the facility on [DATE] with diagnosis of UTI.During a review of Resident 1's Minimum Data Set (MDS- a resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of five sampled residents (Resident 2) had the call light within reach.This failure resulted in Resident 2's inability to call staff for assistance, since she was unable to reach the call light.During a review of Resident 2's admission Record, dated 7/3/25, indicated Resident 2 was admitted to the facility on [DATE], with a diagnoses including; hemiplegia (muscle weakness on one side of the body) and hemiparesis (paralysis on one side of the body) following cerebral infarction (CVA-stroke, loss of blood flow to a part of the brain) affecting the left dominant side, diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), hypertension (HTN-high blood pressure), and atrial fibrillation (Afib-irregular heart beat which affects the blood pumping mechanism of the heart). During a review of Resident 2's Minimum Data Set (MDS - a standardized assessment and care screening tool)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to ensure one of five sampled residents (Resident 1) was provided with the ordered oxygen therapy. This failure resulted in Resident 1 being left without ordered oxygen therapy after personal hygiene care by Certified Nursing Assistant (CNA) and experiencing a temporary desaturation (decrease in the oxygen level of the blood). During a review of Resident 1's admission Record, dated 7/3/25, indicated the resident was admitted to the facility on [DATE] with diagnoses including dementia (a progressive state of decline in mental abilities), fibromyalgia (a chronic disorder characterized by widespread musculoskeletal pain, fatigue, and sleep disturbances), HTN and muscle weakness. During a review of Resident 1's History & Physical, dated 12/20/24 indicated the resident does not have the capacity to understand and make decisions. During a review of Resident 1's MDS dated [DATE], indicated the resident had severely impaired cognition (the mental process of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure medical records were accurately documented and complete for one of three sampled residents (Resident 2). Resident 2 had a history of depression not a current diagnosis of depression, as indicated on Resident 2's face sheet. This deficient practice had the potential to cause errors in medical treatment, plan of care, and delivery of necessary care and services. Findings: A review of the face sheet indicated Resident 2 was admitted to the facility on [DATE] with diagnosis including dementia (a progressive state of decline in mental abilities) and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). During a review of the Psychiatrist Progress Note dated 8/23/2024, the Psychiatrist Progress Note indicated Resident 2 had a treatment plan that included no psychiatric medication at that time and was encouraged to participate in group activities. A review of the history and physical 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 revise (update) the care plan for 3 sampled residents (Resident 82, 84, and 1) by: -Failing to update the elopement (the act of leaving a facility unsupervised and without prior authorization) / wandering care plan quarterly (every 3 months) as per the facility's policy for Resident 82. -Failing to update the activities care plan quarterly to reflect Resident 84's activity preferences. -Failing to update and revise a Pressure Ulcer (damage to the layers of the skin caused by prolonged pressure on a part of the body) Care Plan to meet the individual needs for Resident 1 with a ischium (a bone in the pelvis that forms the lower and back part of the hip bone) pressure ulcer. This deficient practice had the potential to affect the provision of necessary care, treatment, and services for Resident's 82, 84, and 1. Findings: a. A review Resident 82's admission Record indicated the resident was admitted to the facility on [DATE] and readmitted on [DATE] with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure three of five sampled residents (Resident 66, 31 and Resident 10) received care and services in accordance with professional standards of practice. Resident 66 did not have the administration site rotated when receiving insulin (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication). Resident 31 and Resident 10 did not receive medications in a timely manner. These deficient practices caused an increased risk in the residents reaching their mental, physical and psychosocial needs. Findings: a. During a review of Resident 66's admission Record, the admission Record indicated the facility admitted the resident on 4/14/2023 with diagnoses including Type II diabetes (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing) and morbid obesity (a severe form of obesity characterized by an excessive amount of body fat that significantly impacts health and…

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

Based on observation, interview, and record review, the facility failed to ensure 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. Reach in refrigerator vents had dust buildup by the entrance door b. Reach in freezer B bottom shelves had dirt debris c. Reach in freezer shelves had dust buildup. d. Dry storage area shelves had dust buildup. e. Walk-in refrigerator vents had dust buildup. 2. Kitchen equipment and utensils were not maintained in its proper condition, smooth and easy to clean. a. Torn gasket in Freezer A. b. Two racks in the walk-in refrigerator had amber discoloration, rusted, cracked and chipped. c. Ten residents cracked trays. d. Scoop drawer was rusted. 3. Seven (7) dented cans were stored with non-dented cans. 4. Staff did not prevent cross-contamination (transfer of harmful bacteria from one place to another) during food preparation. a. Staff used the same whisk (a kitchen tool made of curve wire that is used to stir or beat such as eggs and cream) for puree…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 resident (Resident 12's) grievance (complaint) about missing items, which included a pair of shorts, a gown, and a brace for his left leg was documented and investigated. This failure led to the resident's grievance being dismissed and had the potential to lead to financial loss, and inability to safely ambulate without the leg brace. Findings: A review of Resident 12's admission record indicated the resident was admitted to the facility on [DATE] with diagnoses including severe obesity (accumulation of body fat that can negatively impact health), hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body), and gout (causes sudden pain and swelling in the joints). A review of Resident 12's Minimum Data Set (MDS - a resident assessment tool), dated 2/10/25, indicated the resident was alert and oriented with good recall. The MDS indicated Resident 12 had no inattention, disorganized thinking, or altered levels…

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

Based on interview and record review, the facility failed to develop an individualized person-centered care plan to meet the resident's needs for one of five sampled residents (Resident 66), as evidenced by failing to create a care plan with goals and interventions for Resident 66's refusal of insulin (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication). This deficient practice had the potential to lead to inadequate and the delay of care for Resident 66. Findings: During a review of Resident 66's admission Record, the admission Record indicated the facility admitted the resident on 4/14/2023 with diagnoses including Type II diabetes (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing) and morbid obesity (a severe form of obesity characterized by an excessive amount of body fat that significantly impacts health and well-being). A review of the Physician's Orders dated 1/23/2024, indicated the resident was to receive Lispro Insulin (a medication used to manage diabetes by lowering…

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

Based on observation, interview, and record review, the facility failed to provide necessary respiratory care services for one of 25 sampled residents (Resident 42), by failing to ensure Resident 42's oxygen nasal cannula tubing (a device that gives you additional oxygen through your nose) was not resting on the floor while Resident 42 was using the oxygen nasal cannula. This deficient practice had the potential for Resident 42 to experience respiratory infections (infections of parts of the body involved in breathing) associated with using an unsanitary (dirty, unhealthy, or unclean in a way that could endanger health) oxygen nasal cannula tubing. Findings: During a review of Resident 42's admission Record, the admission Record indicated the facility originally admitted Resident 42 on 1/18/2019 and last admitted the resident on 3/16/2024 with diagnoses that included chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), acute and chronic respiratory failure with hypoxia (your lungs suddenly [acute] or gradually [chronic] aren't able to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure pain management was provided for one of 25 sampled residents (Resident 5) that was consistent with professional standards of practice. Resident 5's pain was not reassessed to ensure pain medication was effective. This deficient practice resulted in Resident 5 experiencing uncontrolled pain. Findings: A review of Resident 5's admission record indicated the resident was admitted to the facility on [DATE] with the diagnoses including fibromyalgia (a chronic condition where someone experiences widespread pain and tenderness throughout their body), unspecified arthritis (a disease that causes damage, stillness, and pain in your joints), and migraine (intense throbbing head pain). A review of the Minimum Data Set (MDS - a resident assessment tool) dated 12/11/2024, indicated Resident 5 had the ability to make herself understood and had the ability to understand others. A review of the At Risk for Pain care plan related to Fibromyalgia…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 medication error rate was less than five percent (%). There were six medication errors out of 30 total opportunities which contributed to an overall medication error rate of 20 % for one of three sampled residents (Resident 50) observed during medication administration (MedPass). The facility failed to have a medication distribution system to ensure safe administration of medications and ensure Resident 50 was administered medication in accordance with the physician's orders and the facility's policy and procedures titled, Medication Administration - General Guidelines. The deficient practice of failing to administer medications in accordance with the physician's orders increased the risk that Resident 50 may experience adverse reactions, complications, that could lead to a decline in the residents' condition, harm, or hospitalization. Cross Reference with F760 Findings: During a review of Resident 50's admission Record…

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

Based on observation, interview and record review, the facility failed to ensure kitchen staff were routinely trained and evaluated for competency skills when staff were: -Unable to verbalize the cooling process of food. -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 failures 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 90 of 92 medically compromised residents who received food and ice from the kitchen. Findings: a. During an observation on 2/24/2025 at 9:33 a.m. in the walk-in refrigerator, observed cooked turkey sausage in a container with prepared date of 2/23/2025 and with the use by date of 2/26/2025. Observed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 prepare foods in a form designed to meet individual needs when puree yellow zucchini did not hold its shape on the plate and the puree Spanish rice had chunks of rice for residents on puree diet (foods that are smooth with pudding like consistency). These failures had the potential to result in difficulty in swallowing, chewing, decreased in food intake and nutrient intake to 9 of 92 residents on puree diet, resulting to unintended (not planned) weight loss and chocking (when food gets stuck in your airway, blocking the flow of air to your lungs). Findings: During a review of the facility's menu spreadsheet (a sheet containing the kind and amount of food each diet would receive) titled Winter Menus, dated 2/24/2025, the spreadsheet indicated residents on puree diet would include the following foods on the tray: Puree cilantro lime chicken number 6 scoop (2/3 cup [c] a household measurement) Gravy or sauce of choice 1 ounce (oz, a unit of measurement) Puree Spanish rice number 8 scoop (1/2 c) Puree zucchini…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 three of three dumpsters (large trash container designed to be emptied into a truck) were not completely closed or covered when not actively used. This failure had a potential to result to attracting birds, flies, insects, pest and possibly spread infection to 90 of 92 facility residents. Findings: During an observation on 2/25/2025 at 9:39 a.m. of the dumpster, two (2) of 3 dumpsters were overflowing with trash and not completely covered when not actively used. During an observation on 2/25/2025 at 2:08 p.m. of the dumpster, 3 of 3 dumpsters were overflowing with trash and not completely covered when not actively used. During an observation on 2/25/2025 at 2:23 p.m. of the dumpster, 3 of 3 dumpsters were overflowing with trash and not completely covered when not actively used. Observed the first dumpster had an uncovered gap in the middle, second dumpster was overflowing with trash and the third dumpster was not completely closed. During a concurrent observation and…

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

Based on interview and record review, the facility failed to ensure two of nine sampled facility employees (Licensed Vocational Nurse [LVN] 6 and Restorative Nurse Assistant [RNA] 1) were screened with documented evidence for PPD test (a purified protein derivative [PPD] skin test is a test that determines if you have tuberculosis [TB], a serious infection, usually of the lungs) and clearance as required by the facility's policy and procedure. This deficient practice had the potential to place residents, visitors, and facility staff to tuberculosis exposure by allowing staff to work without proof they were either negative for or did not have symptoms of tuberculosis infection. Findings: During a review of LVN 6's employee file, dated 1/12/2025, LVN 6's employee file indicated LVN 6 solely answered the facility's questionnaire for the Healthcare Worker Tuberculosis Symptom Screen. LVN 6's employee file indicated the PPD skin test documentation and chest x-ray documentation were both blank. The employee file did not indicate whether LVN 6 previously had tested positive for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide a functioning call light for one sampled resident (Resident 86). This deficient practice had the potential to result in a delay in meeting Resident 86's needs for hydration, toileting, and activities of daily living. Findings: A review of the admission Record for Resident 86 indicated the resident was admitted to the facility on [DATE], with diagnoses including Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), schizophrenia (a mental illness that is characterized by disturbances in thought), muscle weakness, and gait and mobility abnormalities (change in walking pattern). A review of the quarterly Minimum Data Set (MDS - a resident assessment tool) dated 1/22/2025, indicated Resident 86 had moderate cognitive impairment a decline in thinking and memory that makes it hard to complete complex tasks) and needed assistance for toilet use, personal…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to accurately assess for pressure ulcer/injury (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence) risk and pressure ulcer peri-wound (surrounding skin) for one of two sampled residents (Resident 1). This failure resulted in inaccurate identification and documentation of a pressure ulcer for Resident 1 and had the potential to adversely affect the treatment and interventions for the pressure ulcer. Cross-reference with F686 Findings: During a review of Resident 1's admission Record, dated 1/29/25, the admission record indicated, the resident was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), muscle weakness, adult failure to thrive (a decline caused by chronic diseases and functional impairments which can cause weight loss, decreased appetite, poor nutrition and inactivity),…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to 1. ensure one of two sampled residents (Resident 1), had measures in place to prevent pressure ulcer/injury (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence) from developing. 2. follow the care plan for pressure ulcer prevention interventions. This resulted in Resident 1 developing an area of non-blanchable redness (possible deep tissue injury, type of pressure ulcer where the injury develops from the bone out to the skin and shows up as a red/purple non-blanchable area [when the skin is pressed but the area pressed does not turn white blood pressed out indicating injury to the underlying tissues]) to their left lateral (away from the middle of the body) heel. Cross-reference with F641. Findings: 1. During a review of Resident 1's admission Record, dated 1/29/25, the admission record indicated, the resident was admitted to the facility on [DATE] with diagnoses including 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 follow its policy and procedures for Intravenous (IV, small tube inserted directly into vein) catheter care to change the IV site within the 72 to 96 hour window for one of four sampled residents (Resident 2). This failure had the potential to result in Resident 2 being exposed to IV site infection. Findings: A review of Resident 2's admission Record, dated 10/10/24, indicated the resident was admitted to the facility on [DATE] with diagnoses including urinary tract infection (UTI-an infection in the bladder/urinary tract), diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), quadriplegia (paralysis from the neck down, including legs and arms, usually due to a spinal cord injury), and muscle weakness. A review of Resident 2's Minimum Data Set (MDS, a federally mandated resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to ensure one of four sampled residents ' (Resident 1) was provided the appropriate oxygen therapy delivery device. On 10/4/24 at 3:45 am Resident 1 was desaturating (decease in blood oxygen levels), and had trouble breathing. This failure resulted in Resident 1 receiving oxygen via a simple mask (oxygen delivery via a mask placed over nose and mouth that can deliver 40 to 60% oxygen at six to 10 liters per minute (L/min) rather than a non-rebreather mask (oxygen delivery via a mask with a one-way valve and reservoir bag that delivers 100% oxygen during an emergency situation). Findings: During a review of Resident 1 ' s admission Record, dated 10/10/24, indicated the resident was admitted to the facility on [DATE] with diagnoses including hemiplegia (muscle weakness on one side of the body) and hemiparesis (muscle paralysis on one side of the body) following cerebral infarction (blockage of blood flow in the brain) of the left non- dominate side,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop a comprehensive person-centered care planning for a medical diagnosis psychosis (a mental disorder condition characterized by a disconnection from reality, seeing and hearing things that other people cannot, and believing things that are not true) for one of four sampled residents (Resident 2). This deficient practice had the potential to negatively affect the delivery of provision of care necessary during events of psychotic episodes for Resident 2. Findings: A review of Resident 2's admission record indicated the resident was admitted to the facility on [DATE] with diagnoses including generalized muscle weakness, unspecified depression (a disease that causes low mood or loss of interest in activities, disrupts sleep patterns, and irritability), mood affective disorder (a condition that affects a person's emotions), and unspecified psychosis (a mental disorder condition characterized by a disconnection from reality, seeing and hearing things…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to protect the resident ' s right to be free from physical abuse (deliberately aggressive or violent behavior with the intention to cause harm) for one of five sampled residents (Resident 5 ) when on 4/16/2024 Resident 4 slapped Resident 5 with an open hand. This deficient practice caused Resident 5 pain and redness to the cheek. Findings: A review of Resident 5 ' s admission Record indicated the facility admitted Resident 5 on 3/6/2024 with diagnoses including cerebral infarction (a condition that occurs when something blocks blood supply to part of the brain), Down syndrome (a condition in which a person has an extra copy of chromosome 21), and Alzheimer ' s Disease (a brain disorders the slowly destroys memory and thinking skills and eventually, the ability to carry out the simplest tasks). A review of Resident 5's Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated 3/12/2024, indicated the resident ' s cognitive skills…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 policy and procedures for proper food handling practices was followed by failing to keep a log for the temperatures of the snack cart beverages. This deficient practice had the potential to result in compromised food quality or harmful bacteria growth that could lead to foodborne illness. Findings: During an observation with concurrent interview on 4/15/24 at 10:23 am with Dietary Director (DD), in front of the kitchen door, the snack cart two thermoses of hot drinks to be served during snack time in the activities room was observed. The DD stated he checks the temperature for the liquids before they are sent out to the activities room and states the temperature should be above 140 degrees Fahrenheit for food safety and states he temperature was checked right before sending them out and the temperatures were 142 degrees Fahrenheit, the DD further stated he does not have a log for the snack cart thermoses. A review of the facility's policy and procedures titled Food Temperatures, with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to ensure one of four sampled residents (Resident 1), had a consult for wound care specialist ordered. This deficeint practice resulted in a delay in the wound care specialist evaluating Resident 1's wounds, placing Resident 1 at risk for worsening wounds. Findings: A review of Resident 1's admission Record dated 4/4/24, indicated Resident 1 was admitted to the facility on [DATE], with diagnoses including, acute respiratory failure (a condition where your blood does not have enough oxygen), hypertension (high blood pressure), heart failure (a condition where the hear does not pump as well as it should), cardiomegaly (enlarged heart), and muscle weakness. A review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 1/2/24 indicated Resident 1 had severe impaired cognition (ability to think, understand and make daily decisions) and required set up assistance (helper sets up . resident completes activity, helper…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 comprehensive, person centered care plan for one sampled resident (Resident 1). Resident 1 did not have a resident specific care plan for Fall Risk and the care plan was not revised or updated timely. This deficient practice caused an increased risk in falls for Resident 1, who fell on 3/24/2024 with injury. Findings: A review of Resident 1's admission Record indicated the facility originally admitted the resident on 10/10/2023, and was readmitted on [DATE], with diagnoses including generalized anxiety disorder (produces fear, worry, and a constant feeling of being overwhelmed), major depressive disorder (a mental health condition that causes a persistently low or depressed mood and a loss of interest in activities that once brought joy), and muscle weakness (decrease in muscle strength). A review of Resident 1's Fall Risk Evaluation dated 10/10/2023, indicated the resident had a history of one to two falls within the past three months, had 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 to store food in a sanitary manner to prevent the growth of microorganisms that could cause food borne illness (food poisoning, any illness resulting from the food spoilage of contaminated food, pathogenic bacteria, viruses, or parasites that contaminate food) as evidenced by: -Failing to dispose of food items past the use by date. -Failing to ensure to store food with a label, open date, and use by date. These deficient practices had the potential to lead to food borne illness for all residents who received food from the kitchen. Findings: During a concurrent observation and interview on 2/20/2024 at 8:05 AM, an initial kitchen tour was conducted with [NAME] 1. There was a container of food coloring with a use by date of 10/23/2023 in the dry storage area of the kitchen. During observation, four bags of refried beans, four bags of frozen plantains, and two bags of frozen Italian mixed vegetables, all without a label or indication of a received or use by date. Upon further observation, a bag of opened…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 care in a manner that maintained or enhanced resident's dignity and respect for one of four sampled residents (Resident 11), by standing over the resident while assisting her during a meal. This deficient practice had the potential to affect Resident 11's sense of self-worth, self-esteem, and psychosocial wellbeing. Findings: A review of Resident 11's admission Record (Face Sheet) indicated the facility readmitted the resident on 6/25/2016, with diagnoses including hemiplegia (weakness of one side of the body), hemiparesis (one-sided muscle weakness), and need for assistance with personal care. A review of Resident 11's Minimum Data Set (MDS - a standardized assessment and care screening tool) dated 1/26/2024, indicated the resident had severely impaired cognition (never/rarely made decisions), was dependent for eating, oral and toileting hygiene, showering / bathing, dressing, and personal hygiene. A review of Resident 11's Dietary Profile dated 2/8/2024, indicated the resident was required total…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 current copy of the resident's Advance Directive (AD, a written instruction, recognized under State law, relating to the provision of health care when the individual is unable to make decisions for themselves) was in the resident's medical chart for one of four sampled residents (Resident 80). This deficient practice had the potential for the facility to not honor the resident's medical decisions regarding end-of-life treatment. Findings: A review of Resident 80's admission Record indicated the facility originally admitted the resident on 7/28/2023, and readmitted on [DATE], with diagnoses including anxiety disorder (a mental health disorder that produces fear, worry, and a constant feeling of being overwhelmed), history of falling, and dementia (a group of symptoms affecting memory, thinking and social abilities). A review of Resident 80's Minimum Data Set (MDS, a standardized assessment and care screening tool) dated 2/7/2024, 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 report a fall with injury to the State Survey Agency (SSA) in a timely manner for one of six sampled residents (Resident 3). This deficient practice resulted in a delay of an onsite inspection by the Department of Public Health and had potential for ongoing injuries to Resident 3. Findings: A review of the Resident 3's admission Record indicated the facility re-admitted the resident on 6/23/2015 with diagnoses including hemiplegia (paralysis of one side of the body), contracture (a fixed tightening of muscle, tendons, ligaments, or skin. It causes a deformity and prevents normal movement of the associated body part.) of muscle of the right hand, contracture of the right elbow, difficulty in walking, cognitive (ability to think, understand, and reason) impairment, and glaucoma (a chronic, progressive eye disease caused by damage to the optic nerve, which leads to visual field loss). A review of Resident 3's History and Physical dated 4/26/2022,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 a care plan for two of six sampled residents (Resident 5 and Resident 30) to address the resident's medical, physical, and psychosocial needs. Resident 5 did not have a communication board which could affect his care., and there was no care plan developed for Resident 30's oral status including missing teeth and chewing deficit. These failures had the potential for Residents 5 and Resident 30 to receive care that was not personalized to meet the specific needs identified above, which could result in decreased quality of care and quality of life. Findings: a. A review of Resident 5's admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses including dysphagia (difficulty swallowing), hemiplegia (paralysis of one side of the body) and hemiparesis (inability to move one side of the body) affecting right dominant side, cerebrovascular accident (CVA - stroke; damage to the brain from…

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

Based on interview and record review, the facility failed to revise the care plan for antidepressant medication (used to treat depression, a mood disorder that causes a persistent feeling of sadness and loss of interest that can interfere with daily living) when the medication dosage was increased for one of six sampled residents (Resident 69). This deficient practice had the potential to result in Resident 69 receiving inadequate care and services at the facility. Findings: A review of Resident 69's admission Record indicated the facility admitted the resident on 4/14/2023 with diagnoses including major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest that can interfere with daily living), psychosis (a collection of symptoms that affect the mind, where there has been some loss of contact with reality), and dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities). A review of Resident 69's Minimum Data Set (MDS, a standardized assessment and care screening tool) dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of six sampled residents (Resident 59) received quality of care according to the standards of practice and facility policy, from 10/23/2023 through 11/29/2023 and 12/6/2023 through 2/17/2024, while receiving the medication Sprycel (generic name of Dasatinib, a kinase inhibitors that works by blocking the action of an abnormal protein that signals cancer cells to multiply) for the treatment of leukemia (cancer of the body's blood-forming tissues). This deficient practice resulted in: -Unsafe self-administration of Sprycel by Resident 59 without a Physician's Order and the Interdisciplinary Teams (IDT) approval. -No monitoring of Resident 59's Sprycel treatment for adverse reactions and/or side effects. -The lack of collaboration from the IDT in the treatment of Resident 59's leukemia. Cross Reference: F711 Findings: A review of Resident 59's admission Record indicated the resident was readmitted to the facility on [DATE] with 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to administer two liters of continuous oxygen therapy (administration of oxygen at concentrations greater than that in ambient air) as ordered for one sampled resident (Resident 69). This deficient practice resulted in compromised respiratory care for Resident 69 with a potential for preventable hypoxia (decreased amount of oxygen reaching the body's tissues) with respiratory distress (difficulty breathing). Findings: A review of Resident 69's admission Record indicated the resident was readmitted to the facility on [DATE] with diagnoses including chronic respiratory failure (a long-term condition that occurs when the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body) with hypoxia, immunodeficiency (failure of the immune system to protect the body adequately from infection), muscle weakness, dementia (a gradual decline in mental ability), morbid obesity (a severe and dangerous level of being…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 six sampled residents (Resident 59's) total program of care was reviewed, including medications. Resident 59 was taking a luekemia (cancer in the blood) medication for over three months with the Medical Director's knowledge, but without a physician's order or facility staff knowledge. This deficient practice indicated the facility Medical Director and the facility staff did not have an active role in the care of Resident 59. Cross Reference F684 Findings: A review of Resident 59's admission Record indicated the resident was readmitted to the facility on [DATE] with diagnoses including leukemia, hypertension (high blood pressure), gastro esophageal reflux disease (GERD - chronic digestive disease where the contents of the stomach refluxes and irritates the esophagus) and Type II Diabetes (condition that results in too much sugar circulating in the blood). The record also indicated Resident 59's attending physician was the facility's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to administer blood pressure (BP) medications safely and as ordered for one of four residents (Resident 41) by not checking the heart rate (HR) as indicated prior to administration. This deficient practice had the potential of preventable complications such as bradycardia (a slow heart rate), dizziness, shortness of breath, fatigue or chest pain for Resident 41, negatively impacting Resident 41's health and well-being. Findings: A review of Resident 41's admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses including essential hypertension (abnormally high blood pressure without a known cause), hyperlipidemia (high levels of fat particles in the blood), quadriplegia (paralysis from the neck down, affecting all four limbs), spinal stenosis (the narrowing of one or more spaces within the spine), and dysphagia (difficulty swallowing). A review of Resident 41's Minimum Data Set (MDS - a standardized…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that one of three sampled resident (Resident 1) had a right to retain personal possessions by ensuring that all belongings were accounted for in Resident 1 ' s medical record. This deficient practice had the potential to be misplace or lost in the facility. Findings: A review of Resident 1 ' s admission Record indicated Resident 1 was admitted to the facility on [DATE], with diagnoses including Parkinson ' s Disease (a disorder in the brain that affects movement, often including tremors), dysphagia (difficulty swallowing food or liquid) and protein calorie malnutrition (lack of sufficient nutrients in the body). A review of Resident 1's Minimum Data Set (MDS - a comprehensive standardized assessment and care-screening tool), dated 12/20/2023, indicated Resident 1 has moderately impaired cognition (mental action or process of acquiring knowledge and understanding) for daily decision-making. During a concurrent interview and record review with 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 interview and record review, the facility failed to provide a safe, and functional environment for residents, and staff by failing to ensure maintenance request log was updated as needed per facility policy. This deficient practice had the potential to miss any needed maintenance or delay provision of services to the residents. Findings: During a concurrent interview and record review with the Maintenance Director (MND) on 12/20/2023 at 10:56 a.m., facility ' s maintenance request log was reviewed. Log indicated last request was dated on 10/10/2023. MND stated that he (MND) had stopped updating the maintenance request log and was being made aware for any needed maintenance via paging or verbally reporting to him. During a concurrent interview and record review with the Director of Nursing (DON), on 12/20/2023 at 2:45 p.m., facility ' s policy and procedure (P&P), titled, Maintenance-Work Orders, revised on 11/15/2023 was reviewed. The P&P indicated that the Director of Maintenance will maintain completed work orders in a binder in the Director of Maintenance ' s office. The…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of the three sampled residents (Resident 1) was free from abuse. CNA student (CS 1) and CS 2 witnessed Certified Nurse Assistant (CNA 1) roughly handling and verbablly demaning towards Resident 1 when providing incontinent (having no or insufficient voluntary control over urination) care. This deficient practice resulted in Resident 1 crying and feeling upset. Findings: During an observation on 9/11/2023 at 12:53 pm, Resident 1 was observed sitting on a wheelchair using both feet to move around the hallway. Resident 1 touched the wall, handrail, own clothing, and wheelchair ' s arm rest repeatedly. Resident 1 was seen mumbling (talking) to self at times. Resident 1 looked around the surroundings several times but did not recognize the staff and residents nearby. During an interview on 9/11/2023 at 1:00 pm with Resident 2, the resident stated Resident 1 was combative during care, but would stop being combative when the staff left the 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 the interview and record review, the facility failed to ensure one of three samples residents (Resident 1) ' s care plans were followed when Certified Nurse Assistant (CNA 1) roughly handled the resident during incontinent care (having no or insufficient voluntary control over urination). This deficient practice resulted in Resident 1 refusing care, crying and being upset. Findings: During an observation on 9/11/2023 at 12:53 pm, Resident 1 was observed sitting on a wheelchair using both feet to move around the hallway. Resident 1 touched the wall, handrail, own clothing, and wheelchair ' s arm rest repeatedly. Resident 1 was seen mumbling (talking) to self at times. Resident 1 looked around the surroundings several times but did not recognize the staff and residents nearby. During an interview on 9/11/2023 at 1:00 pm with Resident 2, the resident stated Resident 1 was combative during care, but would stop being combative when the staff left the resident alone. During an interview on 9/11/2023 at 2:48…

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

Based on interview and record review the facility failed to ensure a safe discharge plan for one of three sampled residents (Resident 1) in accordance with the facility ' s policy and procedures titled Transfer and Discharge, dated 10/24/2022, evidenced by not conducting an interdisciplinary (IDT- a group of professional and direct care staff that have primary responsibility for the development of a plan for the care and treatment of a patient)team meeting prior to discharge. As a result, Resident 1 was discharged to a lower level of care facility (a facility that provides less services than a skilled nursing facility) who was not able to care for Resident 1 and was admitted to the General Acute Care Hospital (GACH) on the same day. Findings: A review of Resident 1 ' s admission Record (Face Sheet) dated 7/19/2021, indicated the facility admitted Resident 1 initially on 11/25/2011 and with the most recent readmission to the facility on 7/19/2021 with diagnoses that included amputation (the loss or removal of a body part such as a finger, toe, hand, foot, arm or leg) of the left arm…

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