University Park Healthcare Center

Based on observation, interview, and record review, the facility failed to: Store unopened insulin lispro (a medication used to control blood sugar) in the refrigerator per the manufacturer's requirements in one of two inspected medication carts (Medication Cart 2.)Store gabapentin solution (a medication used to treat pain) in the refrigerator per the manufacturer's requirements in one of two inspected medication carts (Medication Cart 1). The deficient practice of failing to store medications in the refrigerator according to the manufacturer's requirements, increased the risk that residents could have received medication that had become ineffective or toxic due to improper storage possibly leading to health complications resulting in hospitalization or death.Findings: During a concurrent observation and interview on 4/1/2026 at 11:01 AM of Medication Cart 2 with the Licensed Vocational Nurse (LVN 4), one unopened insulin lispro pen was found stored at room temperature without a labeled open date. The insulin lispro pen product labeling indicated unopened insulin lispro pens had to…

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

Based on observation and interview the facility failed to ensure one of one sampled resident (Resident 1) was made aware of pre-appointment instructions for a Computed Tomography (CT, an imaging procedure used to create detailed images of internal body structures) angiogram (a procedure that uses dye to visualize blood throw through arteries or veins) and cardiac echocardiogram (cardiac echo, an ultrasound test that creates images of the heart's structure) as scheduled on 3/30/2026 at 10 AM as per physician's orders dated 2/18/2026. As a result, Resident 1 could not have the CT angiogram done on 3/30/26, placing the resident at risk for a delay in care and treatment.Findings: During a review of Resident 1's admission Record, the admission Record indicated the facility re-admitted the resident on 11/12/2024 with diagnoses that included End Stage Renal Disease (ESRD, irreversible kidney failure), dependence on renal dialysis (process of removing waste products and excess fluid from the body), hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body),…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 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 for one of six sampled residents (Resident 68). This deficient practice had the potential to result in staff delay in meeting Resident 68'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 68.Findings: During a review of Resident 68's admission Record, the record indicated the facility originally admitted Resident 68 on 2/7/2025 and readmitted the resident on 3/13/2026, with diagnoses that included spondyloarthropathy (a chronic autoimmune disease that causes pain and stiffness of the joints) of the spine, dementia (a progressive state of decline in mental abilities) and major depression disorder (a mood disorder that…

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

Based on interview and record review, the facility failed to notify the resident's physician timely for one of three sampled residents (Resident 1). The facility failed to notify Resident 1's physician when Resident 1 had been refusing to take Depakote (medication used to treat including mental and mood conditions). This deficient practice had the potential for Resident 1's symptoms of paranoid schizophrenia (a mental illness that is characterized by disturbances in thought) manifested by delusions (having false or unrealistic beliefs) to worsen.During a review of the admission Record indicated the facility admitted Resident 1 on 11/7/24 with diagnoses including paranoid schizophrenia, psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality) and muscle weakness.During a review of the Physician Order dated 12/4/24 at 4:29 p.m., indicated physician's order to give Resident 1 Depakote tablet 125 milligrams (mg- metric unit of measurement, used for medication dosage and/or amount) delayed release by mouth for schizophrenia…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 Cross Reference F686Based on interview, and record review, the facility failed to ensure physician orders were implemented on 11/29/2025 and 12/1/2025 for five out of five sampled residents (Resident 1, Resident 2, Resident 3, Resident 4, and Resident 5), who required daily treatment for wound (a physical injury to the body, like a cut or tear in the skin) management to maintain the highest practicable physical well-being.This failure resulted in lack of daily wound treatment for:a. Resident 1's stoma (a surgically created opening in the body, usually on the abdomen, that connects an internal organ (like the bowel or urinary system) to the outside, allowing waste (urine or feces) to exit into a collection bag), left ischium (the curved bone forming the base of each half of the pelvis), perineal area (the diamond-shaped region of skin and muscle between the anus and the genitals, extending from the pubic bone to the tailbone), scrotum, and sacrococcyx (lower part of the spine and tail bone). b. Resident 2's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Cross Reference F684 Based on interview, and record review, the facility failed to ensure physician orders were implemented on 11/29/2025 and 12/1/2025 for five out of five sampled residents (Resident 1, Resident 2, Resident 3, and Resident 5), who required daily treatment for wound (a physical injury to the body, like a cut or tear in the skin) management to prevent the development of and or deterioration of pressure injuries (Pressure sore/ulcer-is localized damage to skin and underlying tissues from intense or prolonged pressure, often over bony areas like hips, heels, or tailbone, due to reduced blood flow, exacerbated by friction, shear, and moisture).This failure resulted in lack of daily wound treatment for:a. Resident 1's stoma (a surgically created opening in the body, usually on the abdomen, that connects an internal organ (like the bowel or urinary system) to the outside, allowing waste (urine or feces) to exit into a collection bag), left ischium (the curved bone forming the base of each half 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 interview and record review, the facility failed to ensure the discharge summary and plan policy was followed by failing to have the post-discharge plan filled out completely and signed for one of three sampled residents (Resident 1). This failure resulted in Resident 1's post-discharge plan not being completed or signed accordingly. During a review of Resident 1's admission Record, dated 11/20/25 indicated the resident was admitted to the facility on [DATE] with diagnoses including schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior) anxiety disorder (symptoms of intense anxiety or panic that are directly caused by a physical health problem) , anemia (a condition where the body does not have enough healthy red blood cells), peripheral venous insufficiency (occurs when the walls and/or valves in the veins are not working effectively, making it difficult for blood to return to the heart).During a review of Resident 1's History and Physical (H&P) dated 5/14/25 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 accurately assess for wandering behaviors for one of three sampled residents (Resident 1).This failure resulted in inaccurate Minimum Data Set (MDS- resident assessment tool) and had the potential to affect the residents care and services. During a review of Resident 1's admission Record, dated 11/20/25 indicated the resident was admitted to the facility on [DATE] with diagnoses including schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior) anxiety disorder (symptoms of intense anxiety or panic that are directly caused by a physical health problem) , anemia (a condition where the body does not have enough healthy red blood cells), peripheral venous insufficiency (occurs when the walls and/or valves in the veins are not working effectively, making it difficult for blood to return to the heart).During a review of Resident 1's History and Physical (H&P) dated 5/14/25 indicated the resident had capacity to understand and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to: 1. Supervise and monitor the whereabouts of one of three sampled residents (Resident 2). Resident 2 had a history of inappropriate sexual behaviors, pulling off his pants, self-pleasuring throughout the day, and rubbing his genitals (genitalia- refers to reproductive organs/private parts) in the presence of residents residing in the facility according to Resident 2's care plan (CP) on (Resident 2) has altered behavior manifested by (m/b) invading roommate's space and episode of sexual inappropriate behavior (rubbing his crotch). 2. Protect one of three sampled residents (Resident 1) from sexual abuse (non-consensual sexual contact of any type or sexual harassment) by Resident 2 (Resident 1's roommate). On 10/29/2025 at 8:33AM, a Certified Nursing Assistant (CNA-unknown) informed Social Service Assistant (SSA) that Resident 2 had inappropriately attempted to touched Resident 1's leg according to Resident 2's care plan (CP) on (Resident 2) has altered…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 within 2 hours an allegation of resident-to-resident sexual abuse (non-consensual sexual contact of any type or sexual harassment) to the California Department of Public Health (CDPH) for one of three sampled residents (Resident 2). On 10/29/2025 at approximately 7AM-8AM Resident 2 had one hand down his pants and touching himself and with his other hand was trying to touch Resident 1's leg. This failure resulted in a delayed onsite inspection by the CDPH and had the potential for Resident 1 to experience ongoing abuse from Resident 2. A review of Resident 1's admission Record, indicated, the facility admitted Resident 1on 6/13/2023 with diagnoses including metabolic encephalopathy (a brain dysfunction caused by a chemical imbalance in the body), unspecified dementia (a progressive state of decline in mental abilities), hemiplegia(total paralysis of the arm, leg, and trunk on the same side of the body)and hemiparesis ( partial weakness on one 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.

Based on interview and record review, the facility failed to ensure services provided to the resident meet professional standard of practice for one of three sampled residents (Resident 1).For Resident 1 the facility failed to ensure the certified nursing assistant (CNA 1) and CNA 1's friend did not ask for money from Resident 1.This deficient practice may potentially expose Resident 1 to financial abuse (willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting harm, pain or mental anguish). During a review of the admission Record indicated the facility admitted Resident 1 on 2/19/08 and re-admitted on 6/8 /23 with diagnoses including quadriplegia (paralysis from the neck down, including legs, and arms, usually due to a spinal cord injury), diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) and anemia (a condition where the body does not have enough healthy red blood cells).During a review of the Minimum Data Set (MDS, a resident assessment tool) dated 8/1/25 indicated Resident 1 was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide comfortable room temperature for one of four sampled residents (Resident 1). For Resident 1, the facility failed to ensure Resident 1's room had a room temperature between 71 degrees ( ) Fahrenheit (F, measurement of temperature) to 81 F. Resident 1's room had a room temperature of 84 F on 8/28/25.This deficient practice resulted in Resident 1 stating his room .gets hot and stated he felt uncomfortable. During a review of the admission Record indicated the facility admitted Resident 1 on 6/5/21 and re-admitted on [DATE] with diagnoses including end stage renal disease (kidneys [body organ that remove waste and balance body's fluids] no longer work to meet the body's needs) and depression. During a review of the Minimum Data Set (MDS, a resident assessment tool) dated 6/1/25 indicated Resident 1 was cognitively intact. Resident 1 needed moderate assistance (helper does less than the effort) with toileting hygiene, shower/bathe,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 two of 18 sampled residents (Resident 55 and 291) as evidenced by: -Failing to ensure the facility staff changed Resident 55's nasal cannula was changed weekly, the nasal cannula tubing was not on the floor and ensure the facility staff dated and changed Resident 55's oxygen humidifier (a medical device that adds moisture to oxygen to make it more comfortable to breathe) after 24 hours. -Failing to ensure Resident 291's nasal cannula tubing was changed weekly. These deficient practices had the potential for Resident 55 and 291 to experience complications associated with oxygen therapy, such as infection and respiratory distress. Findings: a. During a review of Resident 55's admission Record, the admission Record indicated the facility admitted the resident on 6/24/2024 with diagnoses that included chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty 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 interview and record review, the facility failed to ensure quetiapine (a medication used to treat mental illness) was used only for conditions or diagnoses as documented in the clinical record in one of five residents sampled for unnecessary medications (Resident 39.) The deficient practice of failing to ensure quetiapine was only used for conditions or diagnoses as documented in the clinical record increased the risk that Resident 39 could have experienced adverse effects related to his psychotropic (medications that affect brain activities associated with mental processes and behavior) medication therapy, such as drowsiness, dizziness, constipation, or increased risk of fall, possibly leading to impairment or decline in his mental or physical condition or functional or psychosocial status. Findings: A review of Resident 39's admission Record (a record containing diagnostic and demographic resident information), dated 2/12/25, 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 interview and record review, the facility failed to initiate the process for a resident representative timely for two of eight sampled residents (Resident 48 and Resident 19) when the facility identified the residents were not able to make medical decisions and did not start the application process for conservatorship until months later. This deficient practice had the potential for the residents to not have a responsible party to assist in making medical decisions based on the resident's best interests and wishes. Findings: a. A review of Resident 48's admission Record indicated Resident 48 was admitted to the facility on [DATE] with diagnoses including hemiplegia (weakness to one side of the body) and hemiparesis (inability to move one side of the body) following cerebral infarction (blockage of the flow of blood brain, causing or resulting in brain tissue death) affecting left non-dominant side and muscle weakness. A review of Resident 48's Minimum Data Set (MDS, resident assessment 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 seven sampled residents (Resident 62) participated in care plan (a plan of care that summarizes a resident's health conditions, specific care needs, and current treatments) meetings to discuss care and discharge goals. This deficient practice had the potential to violate Resident 62's right to be an active participant in their care. Findings: A review of the Resident 62's admission Record indicated the resident was admitted to the facility on [DATE] and readmitted to the facility on [DATE], with diagnoses that included anxiety, bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), schizophrenia (a mental illness that is characterized by disturbances in thought), and polyneuropathy (a condition where multiple peripheral nerves (nerves outside the brain and spinal cord) are damaged). A review of the 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.

Based on observation, interview, and record review the facility failed to ensure the call light (an alerting device for nurses or other nursing personnel to assist a patient when in need) was within reach for one of 18 sampled Residents (Resident 51). This deficient practice had the potential to result in Resident 51 not having their needs met and not being able to alert and call facility staff for help during an emergency. Findings: During a review of Resident 51's admission Record, the admission Record indicated the facility re-admitted the resident on 8/24/2022 with diagnoses that included Human Immunodeficiency Virus (HIV, a virus that attacks cells that help the body fight infection), gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly into the stomach common for people with swallowing problems), epilepsy (a disorder in which nerve cell activity in the brain is disturbed causing seizures [episodes of abnormal brain activity that causes uncontrolled body movements]) blindness, dysphagia (difficulty swallowing), cerebral infarction…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 respect resident rights to self-determination and resident choice by failing to provide one of 18 residents (Resident 9) with his preference for a daily shave. This deficient practice had the potential to affect Resident 9's quality of life and psychosocial well-being (how good you feel about yourself mentally, emotionally, and in your relationships with others) Findings: A review of Resident 9's admission Record indicated the facility admitted Resident 9 on 6/6/2024 with diagnoses including seizures, chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), muscle weakness, bipolar disorder (a mental illness that causes extreme mood swings), anxiety, hereditary and idiopathic neuropathy (group of inherited disorders that affect the peripheral nervous system [a network of nerves that runs throughout the head, neck, and body]), exposure to war and other hostilities, abnormal posture (stiff body movements and chronic abnormal positions of the body), and history of traumatic 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to notify the resident's physician (MD 1) for one of eight sampled residents (Resident 48) for a change in condition (COC) for multiple continued refusals during Restorative Nursing Aide (RNA, nursing aide program that help residents to maintain their function and joint mobility) by failing to assess, address and report to MD 1 after Restorative Nursing Aide (RNA 3)'s reports of Resident 48's refusals to participate on the RNA Weekly Summary 11/8/24, 11/15/24, 11/22/24, 11/29/24 in accordance with the facility policy and procedure. These deficient practices resulted in the delay in assessment and prevented Resident 48 from receiving alternative interventions and services to improve ROM and prevent worsening left hand contractures (loss of motion of a joint). CROSS REFERENCE to F688 Findings: During a review of Resident 48's admission Record indicated Resident 48 was admitted to the facility on [DATE] with diagnoses including but not limited…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 for one of 18 sampled residents (Resident 60) to meet the resident's needs. The facility failed to develop a care plan for Resident 60's allegation of abuse on 2/10/2025. This deficient practice had the potential lead to the inadequate and delay of the delivery of care of Resident 60. Findings: During a review of Resident 60's admission Record, the record indicated the facility re-admitted the resident on 11/12/2024 with diagnoses that included end stage renal disease (loss of kidney function in which the kidneys no long work to meet the body's needs), dependence on renal dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed), hypertension (high blood pressure), hemiplegia (severe or complete loss of strength or paralysis on one side of the body), and hemiparesis (mild or partial weakness or loss of strength on one side of the body). During a review of Resident 60's Minimum Data Set (MDS, a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of 18 sampled residents (Resident 292) received the necessary care and services to prevent accidents and falls as evidenced by failing to accurately assess Resident 292 when completing fall risk assessments. This deficient practice had the potential to place Resident 292 at an increased risk for recurrent falls. Findings: During a review of Resident 292's admission Record, the record indicated the facility admitted the resident on 1/29/2025 with diagnoses that included hemiplegia (severe or complete loss of strength or paralysis on one side of the body) and hemiparesis (mild or partial weakness or loss of strength on one side of the body) following cerebral infarction (stroke, occurs when blood flow to the brain is interrupted, causing brain cells to die), lack of coordination, acute respiratory failure (a condition in which your blood doesn't have enough oxygen causing shortness of breath and difficulty breathing, often caused…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide the care and services necessary to prevent complications from colostomy (a surgical procedure that creates an opening in the abdomen that allows waste to pass out of the body) for one out of 18 sampled residents (Resident 4) by failing to: -Ensure orders were in place for colostomy care for Resident 4 was readmitted to the facility on [DATE] with a colostomy, there we no orders in place for colostomy care until 2/10/2025. -Ensure staff documented colostomy care given to Resident 4 in the resident's electronic health record (EHR). -Ensure staff dated Resident 4's colostomy bag with the date and time the bag was changed. This deficient practice had the potential for Resident 4 to not receive timely colostomy care and treatment resulting in infection, skin irritation, bleeding from the colostomy stoma (an opening on the abdomen connected to the digestive system [breaks down the food we eat into tiny parts to give us fuel and 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 perform weekly weights and provide a Magic Cup supplement (a frozen dessert that can be served as ice cream or pudding and is used to help residents gain or maintain weight, or to add calories and protein to meals) twice a day with meals for one of 18 sampled residents (Resident 61), who had a history of significant weight loss. This deficient practice had the potential for Resident 61 to experience additional weight loss. Findings: During a review of Resident 61's admission Record, the admission Record indicated the facility admitted the resident on 9/6/2024 with diagnoses that included schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), blindness to the left and right eye, glaucoma (an eye disease that occurs when fluid builds up in the eye, damaging the optic nerve), anemia (a condition where the body does not have enough healthy red blood cells) and psychosis (a severe…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 Restorative Nursing Assistant (a Certified Nursing Assistant who has completed an additional training program that allows them to work with a resident and provide skill practice in such activities as walking and mobility, dressing, and grooming, eating and swallowing, transferring, amputation care, and communication in order to improve and maintain function in physical abilities and activities and prevent further loss of those abilities) Certificate for one of two sampled Restorative Nursing Assistants (Restorative Nursing Assistant 1 [RNA 1]). This failure resulted in RNA 1 providing care to residents without proof RNA 1 had the education or skills to provide restorative nursing aid care placing residents at risk for injury or reducing in their functional abilities (a person's capacity to perform everyday tasks and activities). Findings: During concurrent interview and record review on 2/14/2025 at 7:59 AM with the Director of Staff Development (DSD), RNA 1's employee record was review. RNA 1's employee record…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that its medication error rate was less than five percent (%). Six medication errors out of 27 total opportunities contributed to an overall medication error rate of 22.22 % affecting three of four residents observed for medication administration (Residents 5, 34, and 191.) The medication errors noted were as follows: 1. Omitted or late administration of vitamin D (a vitamin supplement) to Resident 191 2. Omitted or late administration of artificial tears (a medication used to treat dry eyes) to Resident 34. 3. Attempted to administer crushed escitalopram (a medication used to treat mental illness) along with a mixture of crushed hydrochlorothiazide (a medication used to treat high blood pressure), losartan (a medication used to treat high blood pressure) and aspirin (a medication used to prevent blood clots.) 4. Attempted to administer crushed hydrochlorothiazide along with a mixture of crushed escitalopram, losartan, and aspirin.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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. Remove 36 doses of discontinued divalproex (a medication used to treat seizures) 125 milligrams (mg - a unit of measurement for mass) tablets one of two inspected medication carts (Medication Cart 2.) 2. Store dronabinol (a medication used to increase appetite) 10 mg capsules in the refrigerator per the manufacturer's requirements in one of two inspected medication carts (Medication Cart 1.) The deficient practices of failing to store medications per the manufacturers' requirements and remove discontinued medications from the medication cart increased the risk of residents experiencing adverse effects (dangerous, unwanted side effects of medication) due to improper storage of medication possibly leading to health complications resulting in hospitalization or death. Findings: During an observation on [DATE] at 8:06 AM with the Licensed Vocational Nurse (LVN 1), LVN 1 was observed preparing the following medications for Resident 191: 1.…

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

Based on observation, interview and record review, the facility failed to ensure staff followed fortified diet (diet to increase caloric intake) guidelines during lunch preparation and tray line observation on 2/10/2025 (a system of food preparation, in which trays move along an assembly line) when: -Fortified diets were not prepared and were not served to residents who were on fortified diets. This deficient practice had the potential to result in meal dissatisfaction, decreased caloric intake and weight loss for seven residents who required a fortified diet. Findings: During the tray line observation on 2/10/2025 at 12:10 PM, Dietary Aide (DA1) did not communicate the fortified diet orders written on the meal tickets during tray line for lunch service. A review of resident's tray or meal tickets on the food carts indicated orders for fortified diets. DA1 did not read out loud the fortified diet and Cook1 who was serving the food did not add any additional food items per the fortified menu. During a concurrent observation and interview with Cook1 on 2/10/2025 at 12:40PM, Cook1…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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: -15 residents on pureed diet received the pureed corn salad in the correct texture (pureed texture is smooth and free of lumps, hold their shape, while not being too firm or sticky, and should not weep) when the dietary aide prepared and served thin and soupy corn salad instead of pureed corn salad that held its shape and had pudding like consistency. -Two residents on finely chopped diet (modified diet with food prepared approximately 1/8-1/4 inches) and three residents on ground meat diet (hamburger meat consistency) received meat texture in the form that met their needs when [NAME] 1 served flaked fish instead of finely chopped and ground fish per resident diet orders. This deficiency had the potential to result in decreased intake related to inconsistent and large size meats, meal dissatisfaction and increased choking and aspiration (inhalation of food or liquids into the lungs) food risk for residents on pureed diet. Findings: a. During an observation of the tray line service for lunch 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 ensure safe and sanitary food storage practices in the kitchen when: -Several food items located in the reach in refrigerator were not dated: four turkey and cheese sandwiches, one plate of salad with chopped ham. -One tuna salad sandwich and one turkey and cheese sandwich were stored in the reach in refrigerator with date of 2/7/25 exceeding storage periods for prepared sandwiches. -One bag of deli meat in a plastic bag stored in the reach in freezer with no label or date. Ice crystals were observed in the plastic bag with the deli meat. These deficient practices had the potential to result in harmful bacteria growth that could lead to food borne illness in 83 out of 84 residents and decreased quality of food stored in the freezer due to frost bite and no date. Findings: During an observation in the kitchen on 2/10/25 at 8:30 AM there were four turkey and cheese sandwiches and one plate of chopped lettuce with chopped ham stored in the reach in refrigerator with no date. During the same observation on 2/10/24…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 have a policy and procedure for their Bioethics Committee (a multidisciplinary group within a healthcare institution that is consulted when difficult medical decisions need to be made for patients who lack the capacity to make informed choices themselves). This deficient practice placed 13 residents (Residents 84, 48, 27, 25, 3, 20, 28, 41, 12, 11, 86, 19, and 2), who were represented by the facility's Bioethics committee, at risk for ineffective care, needs not being met, and a decline in health. Cross Reference F551 Findings: A review of the admission Record indicated Resident 19 was admitted to the facility on [DATE] with diagnoses including metabolic encephalopathy (a condition where the brain's function is impaired due to an underlying metabolic disturbance), schizophrenia (a mental illness that is characterized by disturbances in thought), dementia (a progressive state of decline in mental abilities), bipolar disorder (sometimes called…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 for seven sampled residents (Residents 77, 53, 341, 32, 62, 21, and 19) were accurately documented. These seven residents had the exact same vital signs documented by the same Licensed Vocational Nurse (LVN) 4 as the previous shift, on dates 2/8, 2/9, 2/10 and 2/11/2025. This deficient practice caused an increased risk for inadequate care of the residents. Cross Reference F684 Findings: A review of the admission Record indicated Resident 19 was admitted to the facility on [DATE] with diagnoses including metabolic encephalopathy (a condition where the brain's function is impaired due to an underlying metabolic disturbance), schizophrenia (a mental illness that is characterized by disturbances in thought), dementia (a progressive state of decline in mental abilities), bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to protect the resident's right to be free from abuse (deliberate, aggressive, or violent behavior with the intention to cause harm) for one of three sampled residents (Resident 1), who had a diagnosis of Schizophrenia (a mental illness that is characterized by disturbances in thought) and mood disorder (a mental health condition that affects a person's emotional state, causing long periods of sadness, depression, mania, or elation). Resident 1 approached and physically became aggressive to Resident 2, while Resident 2 rested in bed and was awaken to see Resident 1 standing over him. As a result, on 11/9/2024, Resident 2 sustained a skin tear on the left ear. Findings: A review of Resident 1's admission Record indicated the resident was originally admitted to the facility on [DATE] with diagnoses including anxiety (feeling of fear, dread and uneasiness that can be a normal reaction to stress) and depressive episodes (a period of time when someone…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to notify the resident ' s representative when resident was moved from one room to another for one of two sampled residents (Resident 1). For Resident 1 who was moved from Room A to Room B on 10/11/24, the facility failed to inform Resident 1 ' s responsible party (RP) and the reason for the change of rooms before moving Resident 1 on 10/11/24. This deficient practice resulted in Resident 1 and Resident 1 ' s RP not given their right to know and the reason for the move before moving Resident 1 from Room A to Room B. Findings: During a review of the admission Record indicated Resident 1 was admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses including cerebral infarction (when the blood supply to the part of the brain is blocked or reduced) affecting the right side and developmental disorder of speech and language. During a review of the Minimum Data Set (MDS, federally mandated resident assessment tool) dated 8/1/24 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 residents that had a fall were assessed by the physical therapist (PT, health professionals that evaluate and take measures to enhance a person ' s physical function for two of two sampled residents (Resident 1 and Resident 2). The facility failed to ensure a PT evaluation was done for Resident 1 after Resident 1 had an unwitnessed fall on 8/12/24. The facility also failed to perform a PT evaluation for Resident 2 when Resident 2 had an unwitnessed fall on 8/14/24. These deficient practices had the potential for the facility not to identify the causative factors of the fall and ensure Resident 1 and Resident 2 were provided with safety awareness and interventions to prevent further falls. Findings: 1.During a review of the admission Record indicated the facility admitted Resident 1 on 9/2/22 with diagnoses including hemiplegia (one sided muscle paralysis or weakness) and hemiparesis (one sided muscle weakness) following cerebral infarction (loss…

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

Based on interview, and record review, the facility failed to develop a baseline care plan for one of two sampled residents (Resident 1) within 48 hours of resident's admission. Resident 1 did not have a baseline care plan within 48 hours of admission to the facility. This deficient practice had the potential for delayed administration of necessary care and services. Findings: A review of Resident 1 ' s admission Record (Face Sheet) indicated the facility admitted the resident on 5/22/2024, with diagnoses including anxiety disorder (a condition with excessive worry and fear that interferes with daily activities), and schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves). A review of Resident 1 ' s Minimum Data Set (MDS - a standardized assessment and screening tool) dated 5/25/2024, indicated the resident's cognitive skills (ability to think, learn, remember, and make decisions) for daily decision making was moderately impaired (decisions poor, cues/supervision required). The MDS indicated Resident 1 required partial/moderate assistance for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to implement the care plan for one of three sampled residents (Resident 1). For Resident 1, who had altered skin integrity in the right antecubital space (part of the arm in front of the elbow) and the bilateral inner thigh, the facility failed to: 1. Assess Resident 1 ' s right antecubital space and bilateral inner thigh every shift as indicated in the comprehensive care plan. 2. Assess Resident 1 ' s skin condition when Resident 1 was re-admitted to the facility on [DATE]. These deficient practices had the potential for the Resident 1 to have infection on the antecubital space, the inner thigh, and the skin graft site. Findings: During a review of the admission Record indicated the facility admitted Resident 1 on 12/27/23 and readmitted Resident 1 on 4/19/24 with diagnoses including schizophrenia (serious mental illness that affects how a person thinks, feels, and behaves) and anxiety disorder. During a review of the Minimum Data Set (MDS, 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 protect the resident ' s right to be free from physical abuse (intentional bodily injury) for one sampled resident (Resident 1). Resident 1 and Resident 2 were not supervised while in the facility's smoking patio. As a result, on 4/21/2024 Resident 2 picked up a sign and hit Resident 1 in the head with the sign, resulting in Resident 1 having a small abrasion (superficial rub or wearing off the skin, usually caused by a scrape) to the right side of his head. Findings: A review of Resident 1 ' s admission Record indicated the facility admitted the resident on 1/9/2024, with diagnoses including metabolic encephalopathy (problem in the brain caused by a chemical imbalance in the blood), diabetes mellitus (a disease in which the body does not control the amount of glucose, which is a type of sugar in the blood and the kidneys make a large amount of urine), and neuropathy (nerve problem that causes pain, numbness, tingling, swelling, or muscle weakness 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 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 two sampled residents (Resident 1). Resident 2 picked up a folding chair and hit Resident 1 in the head with a chair. This deficient practice resulted in Resident 1 being subjected to physical abuse while under the care of the facility and resulted in Resident 1 having a small laceration (a skin wound) to the left forehead. Findings: A review of Resident 1's admission Record indicated the facility admitted the resident on 11/29/2023, with diagnoses including dementia (loss of cognitive functioning - thinking, remembering, and reasoning - to such an extent that it interferes with a person's daily life and activities), unspecified psychosis (a collection of symptoms that affect the mind, where there has been some loss of contact with reality), and anxiety (feelings of fear, dread, and uneasiness that may…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop an individualized (resident-specific) care plan for one sampled resident (Resident 2) regarding Resident 2's negative behavior. This failure resulted in Resident 2 having an altercation with another resident in the facility after interventions were not in place when Resident 2 had altercations with staff members. Findings: A review of Resident 2's admission Record indicated the facility initially admitted the resident on 11/27/2023 and was readmitted on [DATE], with diagnoses including schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves), 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 unspecified psychosis (a collection of symptoms that affect the mind, where there has been some loss of contact with reality). A review of Resident 2's Minimum Data Set (MDS - a standardized 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 interview and record review the facility failed to notify the medical doctor (MD) during a change of condition in blood sugar level (BSL, measurement of glucose [sugar] in the blood using a glucometer) for one of three sampled residents (Resident 1). This deficient practice had potential for the resident not receiving needed treatment for elevated blood sugar, placing the resident at risk for confusion and soma. Findings: A review of Resident 1's admission Record indicated the facility admitted the resident on 6/8/23 with diagnoses including diabetes mellitus (disease that occurs when blood glucose is too high), and cerebral infarction (when the blood supply to the part of the brain is blocked or reduced). A review of Resident 1's minimum data set (MDS, standardized care and health screening tool) dated 1/17/24 indicated Resident 1 was cognitively impaired (condition in which people have more memory or thinking problems than other people their age). Resident 1 required supervision with eating, oral hygiene, toileting, shower, upper and lower body dressing, and 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 interview and record review, the facility failed to ensure the Facility Verification of Informed Consent (a principle in medical ethics, medical law, and media studies, that a patient must have sufficient information and understanding before making decisions about their medical care) forms were fully completed for six different psychotropic (medications that affect the mind, emotions, and behavior) medications for two of three sampled residents (Resident 69 and 240). This deficient practice had the potential for the residents to not be fully informed of the risk and benefits of the psychotropic medication they were receiving. Cross Reference F842 Findings: A review of Resident 69's admission Record indicated the facility admitted the resident on 6/13/2023 with diagnoses including paranoid schizophrenia (a severe, lifelong brain disorder that causes people to interpret reality abnormally), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest that can…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide appropriate treatments and services to minimize decline in joint range of motion (ROM, full movement potential of a joint) for four of seven sampled residents (Residents 37, 43, 54, and 45) who had limited ROM or were assessed at risk for decline in joint ROM, as indicated in the resident's care plans. The facility failed to: -Ensure Resident 37 received quarterly rehabilitation joint mobility screens to monitor changes in joint range of motion; -Ensure Resident 37 received Restorative Nursing Aide program (RNA, nursing aide program that help residents to maintain their function and joint mobility) treatments for ROM as ordered five (5) times a week during September 2023, October 2023, and November 2023 and ensure Resident 37 received RNA treatments for feeding six (6) times a week as ordered during September 2023 and October 2023. -Ensure Resident 43 received RNA treatments for ROM as ordered five times a week during January…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 Director of Nursing (DON) did not act as the Registered Nurse (RN) Supervisor simultaneously (at the same time) for two weeks in December 2023 with a resident cencus above 60 and two weeks in January 2024 with a resident census of 82. This deficient practice caused a decrease the quality of care the residents received. Cross Reference F880 and F689 Findings: A review of the facility's Staff Sign-in and Assignment sheets for 12/2023 indicated the DON acted as RN Supervisor for the 7 AM - 3 PM shift on 12/1/2023, 12/4 - 12/8/2023, 12/13 - 12/14/2023, 12/19 - 12/22/2023, and 12/26 - 12/28/2023. The Staff Sign-in and Assignment sheets did not indicate there was a RN Supervisor for the 3 PM - 11 PM or 11 PM - 7 AM shifts on those dates with a resident cencus above 60. Based on interview and record review, the facility failed to ensure one of five sampled residents (Resident 66), who had diagnosis of schizophrenia (a serious mental disorder in which people interpret reality abnormally) and had a history…

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

Based on observation, interview and record review, the facility failed to ensure the standardized recipes for the lunch menu were followed on 1/22/2024 when: -Dietary Aide (DA) 3 failed to follow food production recipe for the puree diet dessert (food that is blended to a pudding consistency, no chewing required). Seven residents on regular puree diet received pureed peaches for dessert instead of puree peach upside down cake, per the menu. -Cook 1 served steamed green beans instead of 'Lyonnaise green beans' per the recipe, served turkey breast instead of 'Herb rubbed turkey breast' and added sweet Asian flavor seasoning to the gravy when the recipe did not indicate to add. 46 residents on regular texture diet, 26 residents on mechanical soft texture diet (food texture modified for residents who have chewing or swallowing difficulties) and 8 residents on puree diet did not receive food that was on the menu. This deficient practice had the potential to result in meal dissatisfaction, decreased nutritional intake and weight loss. Findings: According to the facility lunch menu 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.

Based on observation, interview, and record review the facility failed to prepare food by methods that conserved flavor, texture, and appearance for 80 out of 82 residents who received food from the kitchen. The texture of the pureed yams was sticky and gummy with glossy and shinny appearance. The color of the pureed yams was light orange, lighter than the yams on regular diet. The pureed green beans were salty and tasted like the chicken base flavor. The pureed turkey was diluted and bland covered with sweet gravy. This deficient practice had the potential to result in meal dissatisfaction, decreased food intake and placed residents at risk for unplanned weight loss. Findings: During initial facility tour on 1/22/2024 at 8 AM, complaints about the flavor and texture of food were identified. During an observation and interview with [NAME] 1 in the kitchen on 1/22/2024 at 10:30 AM, [NAME] 1 was preparing the lunch menu. [NAME] 1 stated the lunch included oven baked chicken, green beans, and yams. [NAME] 1 stated the turkey was cooking on the stove top, the green beans were steaming…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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: -Personal water bottle and food was stored in the facility two door refrigerator. -One scoop stored inside bulk flour container and the handle in contact with the food. -Floor and shelving in the dry food storage area were dirty. There were food debris on the floors and under the shelves in the dry storage area. There was food debris and crumbs inside storage bins with packets of yellow cake mix. -Used and dirty kitchen wash/wiping cloths were hand washed in the manual dishwashing sink and air dried on the edges of the sink. The sink was used for washing dirty pots and pans, the sink and edges of the sink was not sanitized prior to hanging the towels. These deficient practices had the potential to result in harmful bacteria growth and cross contamination (transfer of harmful bacteria from one place to another) that could lead to foodborne illness in 80 out 82 residents who received food from the facility. Findings: 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 licensed staff did not falsify the six Facility Verification of Informed Consent (a principle in medical ethics, medical law and media studies, that a patient must have sufficient information and understanding before making decisions about their medical care) forms for psychotropic medications (medications that affect the mind, emotions, and behavior) for two of three sampled residents (Resident 69 and 240). This deficient practice had a potential for the residents to receive psychotropic medication without being fully informed of the risk and benefits leading to a decline in the residents' health and a diminished quality of life. Cross Reference F552 Findings: a. A review of Resident 69's admission Record indicated the facility admitted the resident on 6/13/2023 with diagnoses including paranoid schizophrenia (a severe, lifelong brain disorder that causes people to interpret reality abnormally), major depressive disorder (a mood disorder that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure one of three sampled residents (Resident 30) did not keep medication at their bedside without a physician's order and without being assessed to determine if the resident was capable of self-administering medications. These deficient practices had the potential to result in unsafe medication administration or omission. Findings: A review of Resident 30's admission record indicated Resident 30 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included sequelae of cerebral infarction (occurs when something blocks blood supply to part of the brain), hypertension (a condition in which blood pressure is higher than normal), and paranoid schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves). A review of Resident 30's Minimum Data Set (MDS - a comprehensive assessment and care screening tool) dated 1/4/2024, indicated Resident 30 was cognitively intact (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 two of 18 sampled residents (Resident 30 and 39) had a working call light (an alerting device for nurses or other nursing personnel to assist a patient when in need) within reach. This deficient practice had the potential to result in residents not being able to summon a health care worker for help as needed. Findings: a. A review of Resident 30's admission record indicated Resident 30 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included sequelae of cerebral infarction (occurs when something blocks blood supply to part of the brain), hypertension (a condition in which blood pressure is higher than normal), and paranoid schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves). A review of Resident 30's Minimum Data Set (MDS - an assessment and care screening tool), dated 1/4/2024, indicated Resident 30 was cognitively intact (able to understand and make…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 report an injury of unknown cause to the state survey agency (SSA) within 24 hours for one of four sampled residents (Resident 85). This deficient resulted in a delay of an onsite inspection by the Department of Public Health and had potential for an ongoing unknown injuries and resident-to-resident altercation. Findings: A review of Resident 85's admission record indicated the facility originally admitted Resident 85 on 12/15/2023 and readmitted her on 1/17/2024 with diagnosis including schizoaffective disorder bipolar type (condition in which one experience psychotic symptoms, such as hallucinations or delusions), major depressive disorder (characterized by a persistent feeling of sadness or a lack of interest in outside stimuli) and anxiety (a mental health condition with feeling of worry, anxiety, or fear interfering with one`s daily activities). A review of Resident 85's Office Visit Note for admission to the facility, dated 12/16/2023, indicated the resident was alert but not oriented, and lacked decision making…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 person-centered care plan was developed for two of 18 sampled residents (Resident 14 and Resident 39), as evidenced by: -Failing to ensure a care plan was in place for the non-compliance (failing or refusing to comply with a regulation) for Resident 14. -Failing to develop a care plan for dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities) for Resident 39. This deficient practice had the potential to result in a failure to deliver necessary care and result in the decline of Resident 14's and Resident 39's health. Findings: a. A review of Resident 14's admission Record indicated the facility re-admitted the resident on 12/12/2023 with diagnoses that included chronic obstructive pulmonary disease (COPD, a disease that causes airflow blockage and breathing-related problems), acute respiratory failure (occurs when the lungs cannot release enough oxygen into your blood), and dependence on supplemental oxygen (a treatment that provides you with extra oxygen 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 one of six sampled staff (Licensed Vocational Nurse [LVN] 6) had a Cardiopulmonary Resuscitation (CPR, an emergency lifesaving procedure performed when the heart stops beating) certificate that was up to date. This deficient practice had the potential for facility residents to receive emergency care that was not up to date leading to resident harm and/or death. Findings: A review of LVN 6's employee file indicated LVN 6 had a CPR certificate that expired on 12/2023. During a concurrent interview and record review, on [DATE] at 1 PM, LVN 6's employee file was reviewed with LVN 6. LVN 6 verified her CPR certificate expired on 12/2023. LVN 6 stated she was not aware that her CPR certificate had expired and indicated she had not yet renewed or obtained a new CPR certificate. During a concurrent interview and record review, on [DATE] at 3:10 PM, LVN 6's employee file was reviewed with the Director of Nursing (DON). The DON verified that LVN 6's CPR…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 obtain ensure the resdient's the low air loss mattress setting was correct for one of two sampled residents (Resident 70). This deficient practice had the potential to result in the failure of the delivery of necessary care to maintain the skin integrity (the health of skin) of Resident 70. Findings: A review of Resident 70's admission Record indicated the facility admitted Resident 70 on 11/11/2023 and readmitted him on 12/19/2023 with diagnoses including gastrostomy (surgically made opening into stomach from the abdominal wall for the introduction of food), Type II diabetes (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 epilepsy (a brain disorder that causes recurring seizures). A review of Resident 70's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 11/17/2023, indicated Resident 70 had severely impaired cognition (mental action or process of acquiring knowledge and understanding)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 oxygen tubing, oxygen mask (device used to deliver supplemental oxygen or increased airflow to a patient or person in need of respiratory help), and nebulizer (a small machine that turns liquid medicine into a mist that can be easily inhaled) were stored according to infection control practices for one of three sampled residents (Resident 14). This deficient practice had the potential to result in infection control issues and the decline in health for Resident 14. Findings: A review of Resident 14's admission Record indicated the facility initially admitted the resident on 5/1/2023 and re-admitted the resident on 12/12/2023 with diagnoses that included chronic obstructive pulmonary disease (COPD, a disease that causes airflow blockage and breathing-related problems), acute respiratory failure (occurs when the lungs can't release enough oxygen into your blood), and dependence on supplemental oxygen (a treatment that provides you with extra oxygen to breathe in). A review of Resident 14's Minimum Data…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 medications that require refrigeration were stored in the refrigerator according to the manufacturers requirements for two sampled residents (Resident 39 and Resident 17). This deficient practice caused an increased risk in ineffective medications due to improper storage or labeling possibly leading to health complications resulting in hospitalization or death. Findings: During an observation on 1/25/2024 at 7:48 AM, of Medication Cart 1, with the Director of Staff Development (DSD), the following medications were found stored in a manner contrary to their respective manufactures requirements: - One insulin Novolog (a medication used to control blood sugar) flexpen for Resident 39 and one for Resident 17 were found unopened and stored in the medication cart. According to the manufacturers product labeling unopened pens of Novolg should be stored in the refrigerator. - One unopened insulin glargine pen for Resident 39 was found stored at room temperature inside the medication cart. According 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to notify a physician(s) that three of three sampled residents (Residents 2, 4 and 5) wanted to leave the facility to leave the facility against medical advice. As a result: 1. Resident 2 whose diagnoses included schizophrenia (a serious mental illness that affects how a person thinks, feels, behaves). Resident 2 had moderate cognitive impairment (when a person has trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life), left AMA on 12/29/2023 at 12:30 A.M. 2. Resident 4 whose diagnoses included suicidal ideation (thinking about or planning suicide), left AMA on 7/26/2023 at 9:50 A.M. 3. 3. Resident 5 diagnoses included schizoaffective disorder (a serious mental illness that affects how a person thinks, feels, and/or behaves), left AMA on 7/31/2023 at 11:30 P.M. Residents 2, 4, and 5 were placed at risk of being homeless, interrupted medication therapy, lack of post discharge and follow-up care, decline…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to implement its policy and procedures on abuse (willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain, or mental anguish) for two of two sampled residents (Resident 1 and Resident 2). On 12/1/23, Resident 1 and Resident 2 had a verbal altercation. The facility failed to: 1. Provide nursing interventions immediately to Resident 1 and Resident 2 after the altercation on 12/1/23, that would include assessment and monitoring of their psychosocial well-being. 2. Notify immediately the director of nursing (DON) about the altercation between Resident 1 and Resident 2 right after the incident on 12/1/23. These deficient practices had the potential for Resident 1 and Resident 2 to suffer from physical and psychosocial (mental, emotional, social, and spiritual aspects of a person ' s life) harm. Findings: 1. During a review of Resident 1 ' s admission Record indicated the facility admitted Resident 1…

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

Based on interview and record review the facility failed to respect residents rights for one of six sampled residents (Resident 4). On 10/12/2023, Resident 4 was watching television (TV) and Resident 4's roommate complained that the TV volume was too loud. The licensed vocational nurse (LVN 1) went inside Resident 4's room and turned off the TV without asking for Resident 4's permission. This deficient practice resulted in Resident 4 stating that he felt angry, upset, and stated LVN 1 was unprofessional and disrespectful for turning off the TV without asking for his permission. Findings: During a review of the admission Record indicated the facility admitted Resident 4 on 9/15/2020 with diagnoses including absence of right and left leg below the knee and abnormal posture. During a review of the Minimum Data Set (MDS, standardized care and health screening tool) dated 9/30/2023 indicated Resident 4 was cognitively intact (ability to think and make decisions). Resident 4 needed one-person physical assistance with bed mobility, transfer, eating, toilet use, personal hygiene, 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 provide documented evidence that an allegation of abuse (willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish) was thoroughly investigated for one of six sampled residents (Resident 3). On 10/29/2023, Resident 3 alleged that licensed vocational nurse (LVN 1) told Resident 3 that I will tase you . The facility failed to: 1. Include in the facility initial report dated 10/30/2023, the name of the alleged abuser, the potential witnesses and what steps were taken immediately to prevent the alleged abuser from having in contact with Resident 3. 2. Provide evidence that the allegation of abuse was thoroughly investigated that would include statements of the witnesses, the reasons why Resident 3 made the allegations and whether the facility substantiated or unsubstantiated Resident 3's allegation. These deficient practices had the potential for the facility to fail to protect Resident 3 from further abuse. Findings: During a review 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 interview and record review the facility failed to meet the requirements for the facility-initiated discharge for two of six sampled residents (Resident 1 and Resident 2). The facility issued an Eviction Notice to Resident 1 and Resident 2 on 10/18/23 indicating that Resident 1 and Resident 2 had to vacate the facility and remove all their personal belongings on the 30thday from the date of when the eviction notice was issued. The facility failed to ensure: 1. To implement their Policy and Procedure for Transfer and Discharge. 2. Resident 1 and Resident 2 have a place to go to once discharged from the facility. 3. The location where Resident 1 and Resident 2 will be discharged will be based on Resident 1 and Resident 2's choices and best interest. These deficient practices resulted in Resident 1 stated feeling sad, unable to sleep, tearful and worried for her and her husband (Resident 2). Findings: 1.During a review of the admission Record indicated the facility admitted Resident 1 on 11/19/2022 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 interviews and record review, for two of three residents (Residents 2 and 6 [Resident 1 ' s roommates]), the facility failed to protect the residents ' right to be free from physical abuse by Resident 1 in accordance with the facility ' s policy and procedures titled Abuse Prevention Program revised 12/2016. These deficient practices had the potential for isolation (detach/remove self from others) for Resident 2 and resulted in: 1. Resident 1 pushing Resident 6 and Resident 1 taking Resident 6 ' s eye glasses on 8/9/2023. 2. Resident 1 striking Resident 2 in the face on 8/20/2023. 3. Residents 2 and 6 were scared to be in the room with Resident 1. Findings: 1. A review of Resident 1 ' s admission record (facesheet) dated 7/27/2023, indicated the facility admitted Resident 1 on 7/27/2023 from a general acute care hospital (GACH), with diagnoses that included major depressive disorder (persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), type 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to implement its abuse prevention policy and procedures by failing to report to the State Agency (SA) the unusual occurrence of a resident to resident altercation (negative and aggressive physical, sexual, or verbal interactions between long-term care residents) to for two of four residents (Residents 1 and 6). This deficient practice placed Residents 1 and 6 at risk for further resident to resident altercations and resulted in altercation between Residents 1 and 2 having an altercation on 8/20/2023. Findings: A review of Resident 1 ' s admission record (facesheet) dated 7/27/2023, indicated Resident 1 the facility admitted on [DATE] from a General Acute Care Hospital (GACH), with diagnoses that included major depressive disorder (persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), type 2 diabetes (a condition that happens because of a problem in the way the body regulates and uses sugar as a fuel),…

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