Vernon Healthcare Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure Certified Nursing Assistant (CNA) 1 was within three to five feet ([ft.] - unit of length) for one sample resident (Resident 2) who was placed on one-to-one (1:1, close supervision) monitoring.This deficient practice of CNA 2 not standing three to five feet of Resident 2 had the potential for the resident to have another altercation.Findings:During a review of Resident 2's admission Record (front page of the chart that contains a summary of basic information about the resident), the admission Record indicated Resident 2 was admitted to the facility on [DATE] and readmitted [DATE]. Resident 2 diagnoses included schizophrenia (a mental illness that is characterized by disturbances in thought), anxiety (a mental health condition characterized by excessive, persistent, and uncontrollable worry that interferes with daily functioning), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to: 1.Ensure a Change of condition ([COC] -a significant deviation from a patient baseline condition that requires immediate assessment and intervention to prevent further decline) form was initiated for Resident 3 with a skin rash (an area of irritation, inflamed, or damaged skin). 2. Provide treatment for Resident 3's skin rash. 3. Give a complete assessment report to General Acute Care Hospital ([GACH] -a hospital 24-hour medical services) regarding Resident 3's skin rash prior to admission. This deficient practice of not reporting, treating, or monitoring Resident 3's skin rash resulted in a diagnosis with scabies (highly contagious skin infestation).During a review of Resident 3's admission Record ([Face Sheet] front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated Resident 3 was initially admitted to the facility on [DATE] and was readmitted on [DATE]. Resident 3's diagnoses…

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

Based on observation, interview, and record review the facility failed to ensure:1. One expired large can of cherry fruit filling, in the dry storage room was disposed. 2. Four cereal bowls on the shelf in dry storage were not dated.3. The refrigerator (reach in) had containers of applesauce, juice, and jelly without use by date (the last day a manufacturer recommends consuming a product for peak quality and safety).4. The Dietary Aide (DA) 1 had touched the cleaned dishes after touching dirty dishes without removing gloves and washing her hands.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 food borne illness in 87 out of 93 residents who received food from the kitchen.During a concurrent observation and interview on 1/6/2026 at 8:40 a.m., with Dietary Services Supervisor (DSS), in the dry storage room, there was one large can of expired cherry fruit filling and four bowls of dry cereal without a used by date was reviewed. The DSS stated that the 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 ensure one of six sampled residents (Resident 82) Certified Nursing Assistant (CNA) 1 was seated while feeding Resident 82. This deficient practice of CNA 1 not seated while feeding Resident 82 had the potential to cause him to feel uncomfortable.During a review of Resident 82's admission Record ([Face Sheet] front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated Resident 4 was initially admitted to the facility on [DATE] and was readmitted on [DATE]. Resident 82's diagnoses dysphagia (difficulty swallowing), hemiplegia (paralysis of the arm, leg, and trunk on the same side of the body), and aphasia (a disorder that makes it difficult to speak).During a review of Resident 82's Minimum Data Set ([MDS] a resident assessment tool), dated 10/24/2025, the MDS indicated Resident 82's cognition (ability to learn, reason, remember, understand, and make decisions) was severely impaired.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to: 1.Ensure beneficiary notices were accurately completed for two of two sampled residents (Resident 21 and Resident 109). This deficient practice had the potential to result in residents and/or their responsible parties not being notified of their payment options (Option 1-Resident will pay but can appeal insurance, Option 2- Resident will pay and cannot appeal insurance, Option 3- Resident no longer wants care or services provided) after Medicare Part A benefits expired. Findings:a. During a review of Resident 21's face sheet (front page of the chart that contains a summary of basic information about the resident), the face sheet indicated Resident 21 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), type 2 diabetes (a disorder characterized by…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to:1.Ensure a Complete Blood Count (CBC- a routine blood test that measures and evaluates your red blood cells, white blood cells, and platelets) and Comprehensive Metabolic Panel (CMP- a blood test checking organ function and chemical balance) labs were obtained for one of six sampled residents (Resident 4).This deficient practice had the potential to result in fluid and electrolyte imbalances.Findings:During a review of Resident 4's face sheet (front page of the chart that contains a summary of basic information about the resident), the face sheet indicated Resident 4 was originally admitted to the facility on [DATE] and readmitted to the facility on [DATE]. Resident 4's diagnoses included a encephalopathy (a disease in which the functioning of the brain is affected by an infection or toxins in the blood), dysphagia (difficulty swallowing), chronic kidney disease (a disease characterized by progressive damage and loss of function in the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of six sampled residents (Resident 2) Activities of Daily Living ([ADL] -routine task/activities such as bathing, dressing and toileting a person performs daily to care for themselves) was provided personal hygiene (the ability to maintain personal hygiene, including combing hair, shaving).This deficient practice of not maintaining standards of practice had the potential to compromise Resident 2's personal hygiene. During a review of Resident 2's admission Record ([Face Sheet] front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated Resident 2 was initially admitted to the facility on [DATE] and was readmitted on [DATE]. Resident 2's diagnoses dementia (a progressive state of decline in mental abilities), muscle weakness (a reduced ability to generate force in muscles, impacting strength function, and movement), and chronic obstructive pulmonary disease ([COPD] - 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: 1.Ensure a low air loss mattress (a mattress designed to prevent and treat pressure wounds) setting was correct for one of six sampled residents (Resident 3). This deficient practice had the potential to result in further skin breakdown.Findings:During a review of Resident 3's face sheet (front page of the chart that contains a summary of basic information about the resident), the face sheet indicated Resident 3 was originally admitted to the facility on [DATE] and readmitted to the facility on [DATE]. Resident 3's diagnoses included a stage 4 pressure ulcer (full thickness tissue loss with exposed bone, tendon, or muscle), dysphagia (difficulty swallowing), type 2 diabetes (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) and urinary tract infection (UTI- an infection in the bladder/urinary tract).During a review of Resident 3's history and physical (H&P) form, dated 10/1/2025, the H&P indicated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to properly remove expired items and failed to organize stored items in the medication storage room.This failure had the potential to result in staff using expired items for specimen collection and a delay of care for residents while searching for necessary care items.During an observation on [DATE] at 12:33 p.m., in the medication storage room, the following was observed:One open bottle of baby oil in the far-right upper cabinet,Two containers of air freshener, a used face mask, one BD Safety Glide 1mL syringe, and multiple specimen bags were in drawer 1, labeled elastic bandage rollsTwo expired Aptima urine specimen collection kits dated [DATE], (6) 4 mL expired vacutainers, and (1) expired HOLOGIC Aptima 2cc urine specimen container dated [DATE], in the second drawer 2 to the left.During an interview on [DATE] at 12:50 p.m., with LVN2, in the medication storage room, LVN2 stated that baby oil is not medication and should not be in the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure one of six sampled residents (Resident 2) recommendations for laboratory services were not completed. This deficient practice of not following up with the Medication Regimen Review ([MRR] - a medication list that is reviewed to ensure safety and effectiveness, eliminate unnecessary drugs) recommendations had the potential to cause a delay in emergency medical care and treatment.During a review of Resident 2's admission Record ([Face Sheet] front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated Resident 2 was initially admitted to the facility on [DATE] and was readmitted on [DATE]. Resident 2's diagnoses dementia (a progressive state of decline in mental abilities), muscle weakness (a reduced ability to generate force in muscles, impacting strength function, and movement), and chronic obstructive pulmonary disease ([COPD] - a chronic lung disease causing difficulty in breathing). During…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 Licensed Nurse 1(LVN1) failed to perform hand hygiene (cleansing hands with soap or an alcohol-based rub), at the door of room [ROOM NUMBER], prior to touching medication cups during preparation for medication administration.This failure had the potential for cross contamination (process by which bacteria or other microorganisms are unintentionally transferred from one object or person to another, with harmful effect) and risk to exposure of residents to infectious organisms (germs).During an observation on 1/8/2026 at 7:47 a.m., at medication cart #1, LVN1 failed to perform hand hygiene before preparing medication cups for medication administration (the action of dispensing, giving, or applying something) .During an interview on 1/8/2026 at 7:50 a.m. with LVN1, LVN1 stated cross contamination (the process by which bacteria or other germs are transferred from one substance or object to another) could occur, or a serious illness could be spread 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 document a change of condition (COC) assessment for one of six sampled Residents (Resident 6) when Resident 6 refused psychotropic medications. This deficient practice had the potential to result in Resident 6 not receiving proper monitoring and treatment for behavior changes and placed Resident 6 at risk for hospitalization. Findings:During a review of Resident 6's admission Record, the admission Record indicated Resident 6 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 6's diagnoses included schizoaffective disorder, bipolar disorder, epilepsy (a chronic neurological condition marked by recurrent, unprovoked seizures, which are sudden bursts of abnormal electrical activity in the brain).During a review of Resident 6's History and Physical (H&P) dated 12/4/2025, the H&P indicated Resident 6 had the capacity to make needs known but could not make medical decisions.During a review of Residents 6's Minimum Data Set…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to ensure a person-centered care plan was developed for one of six residents (Resident 6) who had been refusing to take medications. This failure had the potential for poor communication and result in the resident not receiving the necessary care and services to maintain its highest practicable physical, mental and psychosocial well-being. Findings:During a concurrent observation and interview on 12/9/2025 at 9:41 a.m., with Resident 6, Resident 6 was observed laying on bed covered with blankets. Resident 6 stated, I do not take medications but the nurses want me to take it. Resident 6 stated, I am okay, I do not need medication.During a review of Resident 6's admission Record, the admission Record indicated Resident 6 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 6's diagnoses included schizoaffective disorder (mental illness that is characterized by disturbances in thought), bipolar disorder (mood swings 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 interview, and record review, the facility failed to: 1). Ensure three (3) of six (6) sampled residents' (Residents 1, 4, and 6) medications were administered timely. This failure resulted in delayed interventions and had the potential to exacerbate (worsen) the residents' conditionand can cause resident transfer to the general acute care hospital. 2). Ensure the Controlled Drugs-Count Record (Narcotic [medications that are regulated by law due to their potential for misuse or harm] count sheet), for two (2) of 3 medication carts at the facility, were completely filled-up. This deficient practice had the potential for loss of accountability, drug diversion, or theft.Findings:a). During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 1's diagnoses included schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior) major depressive disorder (a mood…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 1. Ensure one of three sampled residents (Resident 1) who was transferred to a General Acute Care Hospital (GACH) on 8/15/2025 due to altered mental status ([AMS] - a significant change in a person's awareness, consciousness, and cognitive function, such as confusion, disorientation, drowsiness, or unresponsiveness) was readmitted to the facility when the GACH cleared him to return to the facility on 8/29/2025. This deficient practice resulted in Resident 1 remaining in the hospital for 14 days beyond the initial date of discharge. Findings:During a review of Resident 1's admission Record, the admission Record indicated, Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 1's diagnoses included liver cirrhosis (a chronic liver disease characterized by the formation of scar tissue in the liver), chronic obstructive pulmonary disease ([COPD] - a chronic lung disease causing difficulty in breathing), and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to obtain and document informed consent for the use of psychotropic medications (drugs that affect mental processes and behaviors) for one of two sampled residents (Resident 1).This deficient practice placed Resident 1 at risk for sustaining adverse effects from the medications and removed Resident 1's right to refuse psychotropic medications at a dose or route (e.g. by mouth, by injection, etc.) he did not want.Findings:During a review of Resident 1's admission Record, dated 7/31/2025, the admission Record indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including cognitive communication deficit (difficulties in communication), anxiety (intense, excessive, and persistent worry and fear about everyday situations), and dementia (a progressive state of decline in mental abilities). During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 4/28/2025,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure an as needed (PRN) psychoactive medication (drugs that affect brain chemistry and alter a person's mental state, mood, or behavior) order for one of two sampled residents (Resident 1) did not exceed 14 days. This deficient practice placed Resident 1 at risk of sustaining adverse effects related to the prolonged use of psychoactive medication without documented indication.Findings:During a review of Resident 1's admission Record, dated 7/31/2025, the admission Record indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including cognitive communication deficit (difficulties in communication), anxiety (intense, excessive, and persistent worry and fear about everyday situations), and dementia (a progressive state of decline in mental abilities). During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 4/28/2025, the MDS indicated Resident 1 had severely…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure an Interdisciplinary Team (IDT, a group of healthcare professionals from various disciplines who collaborate to provide comprehensive care) meeting, a fall risk evaluation, and a post-fall evaluation were conducted for one of two sampled residents (Resident 1) following a fall. This deficient practice placed Resident 1 at risk for sustaining repeat falls and potential injuries.Findings:During a review of Resident 1's admission Record, dated 7/31/2025, the admission Record indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including cognitive communication deficit (difficulties in communication), anxiety (intense, excessive, and persistent worry and fear about everyday situations), and dementia (a progressive state of decline in mental abilities). During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 4/28/2025, the MDS indicated Resident 1 had severely…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of two sampled residents (Resident 1), who had a diagnosis of schizophrenia (a serious mental disorder in which people interpret reality abnormally, may result in delusions and behavior that impairs daily functioning, may have grandiose delusions [strong beliefs of things that are untrue]), and history of aggressive behavior, was provided with the necessary behavioral health care in accordance with the comprehensive assessment and care plan. The facility failed to: 1. Ensure an accurate Minimum Data Set (MDS, a comprehensive quarterly resident assessment) to include Resident 1's history of aggressive physical and verbal behavior. 2. Develop effective and individualized care plan interventions for Resident 1's behaviors including supervision, frequency and re-evaluation. As a result, on 5/27/2025, Resident 1 entered Resident 2's room and was told to leave the room. Resident 1 and Resident 2 began a physical altercation and per the facility's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement their policy and procedure titled Fall management Program to conduct and initiate an Interdisciplinary Team (a group of professionals from various disciplines who collaborate to address a patient's needs) meeting post fall for one of four sampled residents (Resident 1) after sustaining three falls. These failures resulted in Resident 1 continuing to fall and had the potential to cause life threatening injuries. Findings: During a review of Resident 1's admission record dated 4/09/2025, the admissions record indicated Resident 1 was admitted to the facility on [DATE], with diagnosis of muscle weakness, other abnormalities of gait and mobility, and alcoholic cirrhosis of theliver without ascites (a stage of alcohol-related liver disease characterized by scarring and damage to the liver, but without the presence of fluid accumulation in the abdomen). During a review of Resident 1's Minimum Data Set (MDS -a federally mandated resident assessment…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to implement treatment orders for skin lesions for one of six sampled residents (Resident 3) by failing to: 1. Ensure physician orders were transcribed (putting data into written or printed form) into Resident 3 ' treatment administration record. 2. Ensure skin treatments were documented when it was performed for Resident 3. These deficient practices had the potential to place Resident 3 at risk of not receiving appropriate skin treatment and a delay in communication between licensed staff due to incomplete medical records. Findings: During a review of Resident 3 ' s Face Sheet (front page of the chart that contains a summary of basic information about the resident), the face sheet indicated Resident 3 was admitted to the facility on [DATE] with diagnoses that included Parkinson ' s Disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), paranoid schizophrenia (a mental illness that is…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to: 1. Implement its policy and procedure (P&P) titled, Abuse-Prevention, Screening, and Training Program, dated 7/2018, which indicated facility did not condone any form of resident abuse or neglect for one of four sampled residents (Resident 1). 2. Ensure staff followed Resident 2 ' s Care Plan titled, Resident has behavioral problem pacing (the act of walking back and forth) in hallway with increased agitation with intervention a sitter (staff who observes constantly and redirect patient from engaging in a harmful act) and to intervene as necessary to protect the rights and safety of others. This deficient practice resulted in Resident 2 hitting Resident 1 in the face. Findings: During a review of Resident 1 ' s admission Record (front page of the chart that contains a summary of basic information about the resident), the admission Record indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to: 1. Monitor one of five sampled residents (Resident 2) behaviors while prescribed psychotropic medications (medications that can alter brain chemistry, impact body functions, and modify a person thoughts, moods, feelings, awareness, and perceptions). These failure had the potential to result in inconsistent behavior monitoring and placed Resident 2 at risk for not receiving the necessary interventions for increased psychiatric behaviors. Findings: During a review of Resident 2 ' s admission Record (front page of the chart that contains a summary of basic information about the resident), the admission Record indicated Resident 2 was initially to the facility on 8/19/2024 and readmitted on [DATE] with diagnoses including schizophrenia (a mental illness that is characterized by disturbances in thought), and major depressive disorder ([MDD] – a mood disorder that causes a persistent feeling of sadness and loss of interest). During a review of Resident 2 '…

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

Based on observation, interview, and record review, the facility failed to: 1. Ensure three tomatoes in the walk-in refrigerator did not contain rotten spots 2. Ensure two pitchers of lemonade and powdered lemonade mix was not stored on the sink at the sanitizer/detergent mixing area. 3. Ensure the sight glass tube (transparent area that allows you to check the level of a liquid) on the coffee machine did not contain build up. These deficient practices had the potential to result in food borne illness (sickness from eating food with harmful bacteria) for any resident consuming the tomatoes, residents getting sick from the coffee machine buildup, and illness related to a possible mix up of chemicals with the lemonade. Findings: a. During a concurrent observation and interview on 1/7/2025 at 8:37 a.m. with the Dietary Supervisor (DSS), in the walk-in refrigerator, three tomatoes were noted with rotten spots. The DSS stated you have to throw them out because it has mold. Residents can get sick. b. During a concurrent observation and interview on 1/7/2025 at 8:40 a.m. with the DSS, at…

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

Based on observation, interview, and record review, the facility failed to ensure one of 20 sampled residents (Resident 298) was free from significant medication errors by failing to administer medications as ordered from 12/1/2024 to 1/9/2025. 1. Two (2) doses of fluvoxamine maleate (used to treat obsessive-compulsive disorder [bothersome thoughts that will not go away and need to perform certain actions over and over] and social anxiety disorder [extreme fear of interacting with others or performing in front of others that interferes with normal life]) 2. Two (2) doses of pantoprazole sodium (treats conditions that cause too much stomach acid) 3. 10 doses of demeclocycline HCL (used to treat infections caused by bacteria) 4. 14 doses of risperidone (used to treat certain mental disorders) 5. Three (3) doses of Vascepa (used to lower high levels of fats in adults). 6. Five (5) doses of lactulose (used to treat constipation as well as reduce blood ammonia levels) This deficient practice of failing to administer medications in accordance with the physician order, increases the risk…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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: 1. Ensure the bottom of the drawer on medication cart #3 and a bottle of Pro-Stat liquid (a ready-to-drink concentrated liquid protein medical food) was free from sticky residue. This deficient practice had the potential for dust and other particles to adhere to the sticky residue. Findings: During an observation on 1/8/2025 at 2:13 p.m. with Licensed Vocational Nurse (LVN) 1, medication cart #3 was inspected. The bottom drawer on medication cart #3 had sticky residue on the bottom of the drawer. There were some boxes placed on top of the sticky residue which caused the boxes to adhere to the residue. There was also a bottle of Pro-Stat liquid with sticky residue around the cap at the top of the bottle. During an interview on 1/8/2025 at 2:21 p.m. with LVN 1, LVN 1 stated the bottom of the drawer is sticky and it should not be. LVN 1 also stated the bottle of Pro-Stat liquid is sticky around the cap and it is difficult to keep it clean. LVN 1 further stated that the medication cart should be kept clean and…

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

Based on observation, interview, and record review, the facility failed: 1. To post the recent survey results by California Department of Public Health ([CDPH] - state licensing and certification agency) in the areas of the facility that are prominent and accessible to the residents, resident representative, family members, and visitors. This deficient practice placed the residents, resident representative, family members, and visitors at risk of not knowing the status of the facility non-compliance outcome results and past performance history. Findings: During a concurrent observation and interview on 1/7/2025 at 9:42 a.m., with the Administrator (ADM) at station 1 hallway, the ADM stated the survey binder posted on the wall did not include the recent survey results conducted by CDPH on 12/2023. The ADM stated the survey results placed on the binder was 5/24/2021. The ADM stated the results of the last survey conducted by CDPH was kept at her office. The ADM stated she had no excuse by not posting the recent survey results. The ADM stated it was important to post the survey result…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to: 1. Ensure one out of eight sampled residents (Resident 20) had the trash emptied timely to prevent gnat production. This deficient practice resulted in an unsanitary environment for Resident 20. Findings: During a review of Resident 20's admission Record, the admission Record indicated Resident 20 was admitted to the facility on [DATE] with diagnoses including hypertension (HTN-high blood pressure), schizophrenia (a mental illness that is characterized by disturbances in thought), and depression. During a review of Resident 20's History and Physical (H&P), dated 4/1/2024, the H&P indicated Resident 20 can make needs known, but cannot make medical decisions. During a review of Resident 20's Minimum Data Set ([MDS] a resident assessment tool) dated 10/5/2024, the MDS indicated Resident 20 had moderate cognitive impairment. Resident 20 was independent with dressing, bathing, and eating. During a concurrent observation and interview on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to: 1. Transmit the discharge Minimum Data Set ([MDS] - a resident assessment tool) within 14 days after completion to Center of Medicare and Medicaid Services (CMS) for one of 22 sampled residents (Resident 81). This deficient practice had the potential to result in billing error and inaccurate data on resident care needs. Findings: During a review of Resident 81's admission Record (front page of the chart that contains a summary of basic information about the resident), the admission Record indicated, Resident 81 was initially admitted to the facility on [DATE] and readmitted on [DATE]. The admission Record indicated Resident 81's diagnoses included schizophrenia (a mental illness that is characterized by disturbances in thought), chronic obstructive pulmonary disease ([COPD] - a chronic lung disease causing difficulty in breathing), and encephalopathy (a group of conditions that cause brain dysfunction). During a review of Resident 81's History 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. Ensure one out of eight sampled residents (Resident 40 and Resident 49) received a Preadmission Screening and Resident Review ([PASARR] - a federal assessment requirement to help ensure that individuals who have a mental disorder or intellectual disabilities are placed in facilities that can provide the appropriate care) Level II evaluation. This deficient practice had the potential to result in Resident 40 not receiving the required mental health care and services. Findings: During a review of Resident 40's admission Record, the admission Record indicated Resident 40 was admitted to the facility on [DATE] with diagnoses including ([DM]-a disorder characterized by difficulty in blood sugar control and poor wound healing), schizophrenia (a mental illness that is characterized by disturbances in thought), and End Stage Renal Disease ([ESRD]-irreversible kidney failure). During a review of Resident 40's History and Physical (H&P), dated 6/13/2024, the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to: 1. Develop an individualized person-centered plan of care with measurable objective, timeframe, and interventions for resident with significant weight loss (5 percent ([%] - unit of measurement) in 1 month for one of three sampled residents (Resident 87). This deficient practice had the potential to place Resident 87 at risk for further weight loss related to not having nutritional interventions. Findings: During a review of Resident 87's admission Record (front page of the chart that contains a summary of basic information about the resident), the admission Record indicated, Resident 87 was initially admitted to the facility on [DATE] and readmitted on [DATE]. The admission Record indicated, Resident 87's diagnoses included dementia (a progressive state of decline in mental abilities), dysphagia (difficulty of swallowing), and unspecified severe protein-calorie malnutrition (a nutritional status in which reduced availability of nutrients leads 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: 1. Ensure one out of three sampled residents (Resident 56) had their weight taken consistently to monitor for weight changes. This deficient practice had the potential for Resident 56 to experience weight gain and weight loss without knowledge of the facility staff and can cause a delay in interventions. Findings: During a review of Resident 56's Weight Summary, it indicated Resident 56's weight was 180 pounds (lbs) on 6/14/2024, 171 lbs on 7/15/2024, and 171 lbs on 7/22/2024. During a review of Resident 56's admission Record (Face Sheet), the admission Record indicated Resident 56 was originally admitted on [DATE] and readmitted on [DATE] with diagnoses that included Type 2 Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), unspecified protein-calorie malnutrition (an imbalance of nutrient requirement and intake), pressure ulcer of sacral region (localized damage to the skin and/or underlying…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide vision care services to one of one sampled resident (Resident 37) by failing to: 1. Arrange for optometry (the profession of examining the eyesight and prescribing corrective lenses to improve vision and of diagnosing and sometimes treating diseases of the eye) consult after Resident 37 reported his missing prescription eyeglasses. This deficient practice had the potential to result in Resident 37's worsening of eye vision that would negatively affect his quality of life and would put him at risk for fall. Findings: During a review of Resident 37's admission Record (front page of the chart that contains a summary of basic information about the resident), the admission Record indicated, Resident 37 was initially admitted to the facility on [DATE] and readmitted on [DATE]. The admission Record indicated, Resident 37's diagnoses included parkinsonism (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to: 1. Ensure one out of eight sampled residents (Resident 52) had a low bed and bilateral floor mats for safety per physician's order. This deficient practice put Resident 52 at risk for injury if she had a fall. Findings: During a review of Resident 52's admission Record, the admission Record indicated Resident 52 was admitted to the facility on [DATE] with diagnoses including hypertension (HTN-high blood pressure), dementia (a progressive state of decline in mental abilities), and cardiomegaly (enlargement of the heart). During a review of Resident 52's History and Physical (H&P), dated 12/4/2024, the H&P indicated Resident 52 can make needs known, but cannot make medical decisions. During a review of Resident 52's Minimum Data Set ([MDS] a resident assessment tool) dated 12/17/2024, the MDS indicated Resident 52 was dependent on staff for toileting, showering, and dressing the lower body. During an observation on 1/8/2025 at 12:45 p.m.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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. Measure the arm circumference and external catheter (a long, thin, flexible tube inserted in the vein to deliver medicine) length for one out of two residents (Resident 56) who had a midline catheter (a thin, soft tube that is placed into a vein, usually in the upper arm). This deficient practice had the potential for staff to miss any complications associated with a midline for Resident 56. Findings: During a review of Resident 56's admission Record (Face Sheet), the admission Record indicated Resident 56 was originally admitted on [DATE] and readmitted on [DATE] with diagnoses that included Type 2 Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), pressure ulcer of sacral region (localized damage to the skin and/or underlying tissue), and urinary tract infection (UTI- an infection in the bladder/urinary tract). During a review of Resident 56's Minimum Data Set ([MDS]- a resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to: 1. Ensure one of eight sampled residents (Resident 41) received monitoring for his oxygen saturation (level of oxygen in the blood) to maintain it greater than 92% per physician order. This deficient practice had the potential to result in Resident 41 needing oxygen and not receiving it due to a lack of monitoring. Findings: During a review of Resident 41's admission Record, the admission Record indicated Resident 41 was admitted to the facility on [DATE] with diagnoses including emphysema ( a lung disease that causes shortness of breath), schizophrenia (a mental illness that is characterized by disturbances in thought), and hypertensive heart disease without heart failure (a group of conditions that occur when high blood pressure is left untreated and damages the heart. During a review of Resident 41's History and Physical (H&P), dated 3/2/2024, the H&P indicated Resident 41 had the capacity for medical decision making. During a review of Resident…

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

Based on observation, interview, and record review, the facility failed to: 1. Post the updated daily nurse staffing information that included facility name, the current date, the total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift: Registered Nurses (RN's), Licensed Vocational Nurses (LVN's), and Certified Nurse Aides (CNA's), along with resident census at the beginning of each day. This deficient practice had the potential of not having the information available to the residents and public in a timely manner. Findings: During a concurrent observation and interview on 1/7/2025 at 9:55 a.m., with the Director of Staff Development, the DSD stated the last nurse staffing information posted on the bulletin board by station 1 hallway was 12/18/2024. The DSD stated the nurse staffing information that was posted on the bulletin board was not up to date and current. The DSD stated she was new on her position and still taking time to learn something and getting it right. The DSD stated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to: 1. Ensure one out of eight sampled residents (Resident 40) had a Medication Regimen Review ([MRR]- a review of medications to identify problems/errors) completed for the month of November 2024. This deficient practice put Resident 40 at risk of having a drug interaction. Findings: During a review of Resident 40's admission Record, the admission Record indicated Resident 40 was admitted to the facility on [DATE] with diagnoses including ([DM]-a disorder characterized by difficulty in blood sugar control and poor wound healing), schizophrenia (a mental illness that is characterized by disturbances in thought), and End Stage Renal Disease ([ESRD]-irreversible kidney failure). During a review of Resident 40's History and Physical (H&P), dated 6/13/2024, the H&P indicated Resident 40 did not have capacity for medical decision making. During a review of Resident 40's Minimum Data Set ([MDS] a resident assessment tool) dated 11/20/2024, the MDS 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: 1. Ensure one of eight sampled residents (Resident 6) had monthly Complete Blood Count ([CBC]- a blood test that measures the number and type of cells in your blood) and Complete Metabolic Panel ([CMP]- a routine blood test that measures 14 substances in your blood to provide information about your metabolism, fluid and electrolyte balance, and how well your liver and kidneys are working) lab work drawn as ordered. 2. Ensure one out of eight sampled residents (Resident 40) had a CBC, and Basic Metabolic Panel ([BMP]- a blood test that measures eight different substances in the blood) completed per physician's orders. This deficient practice had the potential for Resident 6 and 40 to experience a delay in treatment. Findings: a. During a review of Resident 6's admission Record (Face Sheet), the admission Record indicated Resident 6 was originally admitted on [DATE] and readmitted on [DATE] with diagnoses that included hyperlipidemia (high…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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: 1. Three out of four dumpsters had the lid closed. This deficient practice had the potential to attract rodents to the trash area. Findings: During a concurrent observation and interview on 1/7/2025 at 8:20 a.m. with the Dietary Services Supervisor (DSS), three out of four dumpsters were observed with the lid off. The DSS stated the dumpsters should be closed so you don't attract animals. During a review of the 2022 U.S. Food and Drug Administration Food Code, code number 5-501.116 Cleaning Receptacles indicated, Outside receptacles must be constructed with tight-fitting lids or covers to prevent the scattering of the garbage or refuse by birds, the breeding of flies, or the entry of rodents.

Based on interview and record review, the facility failed to: 1. Provide the average daily census in the Facility's Assessment (a process for evaluating a facility's resident population and identifying the resources needed to provide care and services). This deficient practice had the potential to place residents at risk for delay of care and treatment services due to inability of the facility to plan for staffing needs of the resident and to allocate resources. Findings: During a concurrent interview and record review on 1/8/2025 at 8:51 a.m., with the Administrator (ADM), the Facility's Assessment was reviewed. The ADM stated the Facility's Assessment was updated on 7/22/2024 and revised on 11/15/2024. The ADM stated the Facility Assessment was incomplete and did not reflect the average daily census of the residents living in the facility. The ADM stated she was responsible for updating the Facility Assessment. The ADM stated the Facility Assessment should be revised as needed if there was a change in the resident population and operation of the facility. The ADM stated it was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to: 1. Ensure the pain management consult report for one of three sampled residents (Resident 56) was accessible and filed in their medical records. This failure had the potential to place Resident 56 at risk of not receiving appropriate care and delay in communication among staff due to incomplete medical records. 2. Indicate the correct discharge disposition for one of two sampled residents (Resident 97). This failure had the potential to lead to inadequate support services and safety concerns for the resident after discharge. Findings: a. During a review of Resident 56's admission Record (Face Sheet), the admission Record indicated Resident 56 was originally admitted on [DATE] and readmitted on [DATE] with diagnoses that included Type 2 Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), pressure ulcer of sacral region (localized damage to the skin and/or underlying tissue), and urinary tract…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to: 1. Ensure a resident who had a diagnosis of Alzheimer's Disease (a disease characterized by a progressive decline in mental abilities) understand the legal documents (documents affecting the legal rights of any person) including binding arbitration agreement (a binding agreement by the parties to submit to arbitration all or certain disputes which have arisen or may arise between them in respect of a defined legal relationship, whether contractual or not and the decision is final, can be enforced by a court, and can only be appealed on very narrow grounds) she signed during admission to the facility for one of four sampled residents (Resident 32). This deficient practice resulted for Resident 32 signing a facility contractual agreement without her full understanding. Findings: During a review of Resident 32's admission Record (front page of the chart that contains a summary of basic information about the resident), the admission Record indicated,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the facility's abuse prevention policy and procedure (P&P) was implemented for one of four sampled residents (Resident 9) when Certified Nursing Assistant (CNA) 1 failed to immediately report a verbal resident-to-resident altercation on 12/8/2024, between Resident 9 and Resident 10, to the supervising licensed nurse. This deficient practice resulted in Resident 9 being left in Room A with Resident 10, where Resident 10 then repeatedly struck Resident 9 in the face, and Resident 9 sustained pain to her head and face, and verbalized fear of further abuse. Findings: During a review of Resident 9's admission Record, the admission record indicated Resident 9 was admitted to the facility on [DATE]. Resident 9's admitting diagnoses included hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (one-sided muscle weakness), generalized muscle weakness, and polyosteoarthritis (a progressive…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 Certified Nursing Assistant (CNA) 1 had the appropriate compentencies and skills required when reporting resident abuse immediately after witnessing a resident-to-resident altercation between two of four sampled residents (Resident 9 and Resident 10). This failure placed Resident 9 at risk for continued abuse by Resident 10, and any resulting physical and/or psychosocial harm. Findings: During a review of Resident 9's admission Record, the admission record indicated Resident 9 was admitted to the facility on [DATE]. Resident 9's admitting diagnoses included hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (one-sided muscle weakness), generalized muscle weakness, and polyosteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage). During a review of Resident 9's Minimum Data Set (MDS, a resident assessment tool), dated 11/12/2024, the MDS indicated Resident 9 had…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 out of three sample residents (Resident 1) was free from physical abuse when Resident 2 punched Resident 1 in the face. This deficient practice of not monitoring Resident 1 ' s whereabouts resulted in Resident 1 being punched in the face by Resident 2. Findings: a. During a concurrent observation on 11/18/2024 at 10:20 a.m. with Director of Nursing, in the DON office Resident 1 came to the DON office and the DON pointed out a scratch under her right eye after being hit by Resident 2. During a review of Resident 1 ' s Skin Check, dated 11/18/2024, The Skin Check indicated nose discoloration. During a review of Resident 1 ' s admission Record (Face Sheet), the Face Sheet indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE]. Resident 1 ' s diagnoses included schizophrenia s (a chronic mental disorder that affects a person ' s ability to think, perceive, and interact with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to: 1. Ensure one of three sampled residents (Resident 1) had a care plan (the process of identifying a patient ' s needs and how they can be supported) for food brought in from the outside of the facility being left at the bedside. This failure placed Resident 13 at risk of not having his care needs met. Findings: During an observation on 11/15/2024 at 1:30 p.m. in Resident 1 ' s room, there were 2 bags of opened chips and a loaf of bread with an expiration date of 11/13/2024. During a review of Resident 1 ' s admission Record (Face Sheet), the Face Sheet indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE]. Resident 1 ' s diagnoses included major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing), and schizophrenia (a mental…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to: 1. Ensure one of three sampled residents (Resident 1) food items were labeled and dated at Resident 1 bedside. This deficient practice of not keeping track of Resident 1 ' s food items at the bedside had the potential to cause a foodborne illness. Findings: During a concurrent observation and interview, on 11/15/2024 at 1:30 p.m., 2 bags of opened potatoe chips and a loaf of bread was sitting on Resident 1's overhead table. Resident 1 stated she does not know how long she had the items. During a review of Resident 1 ' s admission Record (Face Sheet), the Face Sheet indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE]. Resident 1 ' s diagnoses included major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing), and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure an accurate Minimum Data Set ([MDS] – a federally mandated resident assessment tool) was completed accurately for one of five sampled residents (Resident 1) by failing to: 1. Ensure Resident 1 ' s Depakote (is an anticonvulsant and mood stabilizer medication) medication was coded as anticonvulsant and reflected in the MDS assessment under Section N (N0415-High-Risk Drug Classes) Medications. This deficient practice resulted in incorrect data transmitted to Center for Medicare and Medicaid Services (CMS) related to inappropriate MDS care screening and assessment tool practices. Findings: During a review of Resident 1 ' s admission Record (front page of the chart that contains a summary of basic information about the resident), the admission Record indicated, Resident 1 was initially admitted to the facility on [DATE] and was readmitted on [DATE]. The admission Record indicated Resident 1 ' s diagnoses included schizoaffective disorder (a mental…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 three of seven sampled residents (Residents 1, 2, and 6) were free from physical abuse when the following occurred: 1. Resident 7 punched Resident 2 in the face after Resident 2 entered Resident 7 ' s room and stole a jar of instant coffee without permission on 10/10/24. 2. Resident 2 threw a cup of coffee and kicked Resident 1 on 10/11/2024. 3. Resident 2 kicked Resident 6 in the left leg after Resident 6 confronted Resident 2 for attempting to steal a jar of Resident 6 ' s coffee. These deficient practices resulted in Resident 2 being punched in the face, Resident 1 suffering a left thumb wound, and Resident 6 being kicked causing severe left leg pain. Findings: During a review of Resident 2 ' s admission Record, the admission record indicated Resident 2 was admitted to the facility on [DATE]. Resident 2 ' s admitting diagnoses included a cognitive (ability to think and reason) communication deficit and schizophrenia (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 implement and revise the care plan interventions, initiated on 8/27/24, for one of eight sampled residents (Resident 2) to address his continued behavior of stealing residents food (Resident 1, Resident 6, and Resident 7). This deficient practice resulted in Resident 2 ' s continued thefts causing psychosocial distress for Resident 1, Resident 6, and Resident 7, and three resident-to-resident altercations that occurred on 10/10/24, 10/11/24, and 10/26/24. Findings: a. During a review of Resident 2 ' s admission Record, the record indicated Resident 2 was admitted to the facility on [DATE]. Resident 2 ' s admitting diagnoses included a cognitive (ability to think and reason) communication deficit and schizophrenia (a mental illness that is characterized by disturbances in thought). During a review of Resident 2 ' s History and Physical (H&P), dated 8/20/24, the H&P indicated Resident 2 could make his needs known, but could not make medical decisions.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 landing mats (cushions placed on the ground to minimize injury from a fall) were placed to both sides of the bed for one of six sampled residents (Resident 4). This deficient practice increased the potential for avoidable physical harm to Resident 4 related to possible injury sustained from a repeat fall. Findings: During a review of Resident 4 ' s admission Record, the record indicated Resident 4 was admitted on [DATE]. Resident 4 ' s admitting diagnoses included: schizophrenia (a mental illness that is characterized by disturbances in thought) and anxiety disorder (intense, excessive, and persistent worry and fear about everyday situations). During a review of Resident 4 ' s Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 9/14/2024, the MDS indicated Resident 4 had impaired cognition (when a person has trouble remembering, learning new things, concentrating, or making decisions that affect their…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow its policy and procedure (P&P) when it did not involve the Interdisciplinary Team (IDT) in discharge planning for two of three (Resident 1 and Resident 2) residents. This failure had the potential to result in resident goals, needs, and preferences to be unmet after discharge. a) During a review of Resident 1 ' s admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including cerebral infarction (illness affecting blood flow to the brain), psychoactive substance (substance that affects how the brain thinks) abuse-induced psychotic disorder (overuse resulting in mental illness), and insomnia (disorder that affects sleep). During a review of Resident 1 ' s History and Physical (H&P) dated 11/21/2023, the H&P indicated Resident 1 had a history of strokes (disrupted blood flow to the brain) and schizophrenia (mental disorder affecting thought and behavior). The H&P indicated Resident 1 did…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a written notice of discharge and the right to appeal, was provided to one of 3 residents ' (Resident 2) representative, prior to the resident ' s discharge to an assisted living facility (housing that provides nursing care, meals, and laundry services) on 10/2/2024. This failure resulted in Resident 2 ' s representative not knowing about Resident 2 ' s discharge. Findings: During a review of Resident 2 ' s admission Record dated 10/7/2024, the admission Record indicated Resident 2 was admitted to the facility on [DATE] with diagnoses including schizoaffective disorder (mental illness that affects a resident ' s thoughts, mood, and behavior), autistic disorder (a disorder that affects a resident ' s ability to communicate and interact), and anxiety disorder (a condition that causes strong feelings of fear and worry). The admission Record indicated Resident 2 had a designated responsible party (person to make medical decisions for the resident).…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, for one of three sampled residents (Resident 1), the facility staff failed to: 1. Report immediately (right away) to the Administrator (Admin) or designated representative, the allegation of abuse, mistreatment on 5/28/2024, night shift (11p.m. to 7 am.), as indicated in the facility ' s Operational Manual- Abuse & Neglect, titled Abuse-Reporting and Investigations. 2. Report to the California Department of Public Health (CDPH) District Office (DO), allegation of abuse, within two (2) hours, as indicated in the All Facilities Letter ([AFL] a letter from the Center for Health Care Quality (CHCQ), Licensing and Certification (L&C) Program to health facilities that are licensed or certified by L&C with information that include changes in requirements in healthcare, enforcement, new technologies, scope of practice, or general information that affects the health facility) 21-26, which indicated facilities must file a written or electronic report, incidents that involved abuse or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the allegation of abuse on 5/28/2024, night shift (11p.m. to 7 a.m.), for one of three sampled residents (Resident 1), was investigated. This deficient practice placed Resident 1 at risk for further abuse. Findings: During a review of Resident 1 ' s admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE]. Resident 1 ' s diagnoses included Stage 4 pressure ulcer (full thickness skin loss with extensive destruction; tissue necrosis; or damage to muscle, bones) on the sacral (tail bone) region and urinary tract infection ([UTI] an infection in any part of the urinary system). During a review of Resident 1 ' s Minimum Data Set ([MDS] a federally mandated resident assessment tool) dated 6/6/2024, the MDS indicated Resident 1 could understand and be understood by others. The MDS indicated Resident 1 was dependent and required a two or more person ' s assist with activities of daily living (ADLs) such as…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure 1 of three sampled residents (Resident 1), indwelling catheter (tube that drain urine from the bladder to a drain bag), was secured with anchoring device (a device to keep catheter tubing in place to prevent pulling, dislodgement). This failure had the potential for the catheter to get accidentally pulled out, causing pain, injury, and possible ([UTI] an infection in any part of the urinary system). Findings: During a review of Resident 1 ' s admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE]. Resident 1 ' s diagnoses included pressure ulcer (tissue loss with visible bone, tendon, or muscle) Stage four (4) on the sacral (tail bone) region and UTI . During a review of Resident 1 ' s Minimum Data Set ([MDS], a standardized assessment and care screening tool) dated 6/6/2024, the MDS indicated Resident 1 could understand and be understood by others. The MDS 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 ensure one of three sampled residents (Resident 1), was turned, and repositioned every two hours. This failure placed Resident 1 at risk for delay in wound healing, worsening of wound condition and risk for further skin breakdown. Findings: During a review of Resident 1 ' s admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE]. Resident 1 ' s diagnoses included Stage 4 pressure ulcer (full thickness skin loss with extensive destruction; tissue necrosis; or damage to muscle, bones) on the sacral (tail bone) region and urinary tract infection ([UTI] an infection in any part of the urinary system). During a review of Resident 1 ' s Minimum Data Set ([MDS] a federally mandated resident assessment tool) dated 6/6/2024, the MDS indicated Resident could understand and be understood by others. The MDS indicated Resident 1 was dependent and required a two or more person ' s assist with activities of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure the indwelling foley catheter (catheter tube draining urine from bladder into a bag outside the body) bag for one of 3 sampled residents (Resident 1) was not on the floor. This failure placed Resident 1 at risk for cross contamination and urinary tract infection (UTI- urine infection). Findings: During a review of Resident 1 ' s admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE]. Resident 1 ' s diagnoses included Stage 4 pressure ulcer (full thickness skin loss with extensive destruction; tissue necrosis; or damage to muscle, bones) on the sacral (tail bone) region and UTI. During a review of Resident 1 ' s Minimum Data Set ([MDS] a federally mandated resident assessment tool) dated 6/6/2024, the MDS indicated Resident 1 could understand and be understood by others. The MDS indicated Resident 1 was dependent and required a two or more person ' s assist with activities of daily living…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 administer 2 of 5 sampled resident ' s (Residents 2 and 3) medications timely as ordered by the physician. This deficient practice placed Residents 2 and 3 at risk for subtherapeutic drug levels (level too low to produce intended medical effect) and worsening of medical conditions or symptoms. Findings: During a review of Resident 2 admission Record, the admission Record indicated Resident 2 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including hypertension (high blood pressure), myocardial infarction (heart attack), atrial fibrillation ([Afib] irregular rapid heart rate that commonly causes poor blood flow) and congestive heart failure ([CHF] a condition where the heart cannot pump enough blood to meet the body ' s need). During a review of Resident ' s 2 Minimum Data Set ([MDS] a comprehensive resident assessment and care-screening tool) dated 6/14/2024. The MDS indicated Resident 2 had the ability to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the physician was notified regarding one of three residents ' (Resident 1) refusal to take medications. This failure placed Resident 1 at risk for medical complications that would lead to hospitalization and/or death. Findings: During a review of Resident 1 ' s admission Record, the admission Record indicated, Resident 1 was originallyadmitted to the facility on [DATE] and readmitted on [DATE]. Resident 1 ' s diagnoses included displaced (removed) comminuted (fragments) fracture (broken bone) of shaft of left femur (thigh) subsequent encounter for closed fracture (dislocation/sprain) with routine healing and Type 2 diabetes mellitus ([DM2] a long-term condition in which the body has trouble controlling blood sugar) with diabetic polyneuropathy (a complication of diabetes that affects the peripheral [away from center] nervous system, causing nerve loss). During a review of Resident 1 ' s Order Summary report dated 8/22/2024, the Order Summary…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 reassess a resident ' s pain level after administration of pain medication for one of three sampled residents (Resident 1). This failure resulted in Resident 1 ' s unresolved pain and had the potential to affect Resident 1 ' s highest practicable physical, mental, and psychosocial wellbeing. Findings: During a review of Resident 1 ' s admission Record, the admission Record indicated, Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 1 ' s diagnoses included displaced (removed) comminuted (fragments) fracture (broken bone) of shaft of left femur (thigh) subsequent encounter for closed fracture (dislocation/sprain) with routine healing and Type 2 diabetes mellitus ([DM] a long-term condition in which the body has trouble controlling blood sugar) with diabetic polyneuropathy (a complication of diabetes that affects the peripheral [away from center] nervous system, causing nerve loss). During a review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to check resident's blood sugar ([BS] main sugar found in the blood) levels and failed to administer medications as ordered by the physician for 1 of 4 sampled residents (Resident 1). These failures placed the resident at risk for diabetic reactions and potential life-threatening medical complications requiring hospitalization. Findings: During a concurrent interview and record review on 8/16/2024 at 11:40 a.m. with the Director of Nursing (DON), Resident 1 ' s July and August 2024 Medication Administration Records (MAR) were reviewed. Resident 1 ' s July 2024 MAR indicated the following: -No BS level on 7/5/2024, at 6:30 a.m. -No BS levels on 7/16/2024, at 4:30 p.m., and 9 p.m., -No BS levels on 7/30/2024, at 4:30 p.m. and 9 p.m. -No nurse ' s signature to indicate if Cilostazol tablet (medicine for leg pain) 100 milligrams ([mg] a unit of measurement) was administered to Resident 1 on 7/16/2024 and 7/30/2024 at 9 p.m. -No nurse ' s signature to indicate…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow professional standards of practice for two of three sampled residents (Resident 1 and Resident 5) by failing to: 1. Call the physician when Resident 1 requested for Trazadone (sleeping medication) to assist Resident 1 to sleep on 7/29/2024. 2. Assess and report to the physician to obtain treatment orders when Resident 5 was observed with small scratch and light skin discoloration on the left upper arm on 7/30/2024. This deficient practice had the potential to cause Resident 1 inability to sleep at night, affecting Resident 1 ' s quality of life. The deficient practice had the potential to result in Resident 5 ' s left arm skin issues to become worst and infected when interventions were not provided timely. Findings: a). During a review of Resident 1 ' s admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE]. Resident 1 ' s diagnoses included Stage 4 pressure ulcer (Full thickness skin…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 residents' (Resident 4) feet were offloaded (off pressure) to prevent pressure injuries (damage to the skin and underlying soft tissue caused by prolonged or severe pressure). This deficient practice of not offloading (minimizing or removing weight placed on the foot to help prevent and heal ulcers) the feet had the potential of causing pressure injuries to the heels of the feet. Findings: During a review of Resident 4 ' s admission Record, the admission Record indicated Resident 4 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 4 ' s diagnoses included encephalopathy (a group of conditions that cause brain dysfunction), cognitive communication deficit (a condition that makes it difficult to communicate), and contractures (a condition of shortening and hardening of muscles, tendons, or other tissue leading to deformity and rigidity of joints). During a review of Resident 4 ' s…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to serve food according to the facility's menu for two of three sampled residents, (Resident 1 and Resident 6). This resulted in residents not eating food according to the physician's order and had the potential for the residents' nutritional needs not met. Findings: a). During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE]. Resident 1's diagnoses included Stage 4 pressure ulcer (Full thickness skin loss with extensive destruction; tissue necrosis; or damage to muscle, bones) on the sacral region and polyneuropathy (weakness and a pins-and-needles sensation, burning pain or loss of sensation to extremities.) During a review of Resident 1's Minimum Data Set ([MDS] a standardize care screening and assessment tool) dated 6/20/2024, the MDS indicated Resident could understand and be understood by others. The MDS indicated Resident 1 required moderate assistance with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to serve food palatable (appetizing) for two of three sampled residents (Resident 1 and Resident 6). This deficient practice had the potential for residents' poor meal intake and weight loss. Findings: a). During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE]. Resident 1's diagnoses included Stage 4 pressure ulcer (Full thickness skin loss with extensive destruction; tissue necrosis; or damage to muscle, bones) on the sacral region and polyneuropathy (weakness and a pins-and-needles sensation, burning pain or loss of sensation to extremities.) During a review of Resident 1's Minimum Data Set ([MDS] a standardize care screening and assessment tool) dated 6/20/2024, the MDS indicated Resident could understand and be understood by others. The MDS indicated Resident 1 required moderate assistance with eating. The MDS indicated Resident 1was dependent and required a two…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 out of three Residents (Resident 5) had a revised care plan for pressure ulcers. The deficient practice had the potential for repeat occurrences Findings: During a review of Resident 5's admission Record (Face Sheet), the Face Sheet indicated Resident 5 was admitted to the facility on [DATE]. Resident 5's diagnoses included type 2 diabetes mellitus (a disorder that affects the blood sugar and is too high), end stage renal disease (the kidneys can no longer filter waste, excess fluids, and electrolytes from the blood), and chronic obstructive pulmonary disease (lung disease that causes breathing problems and restricted airflow). During a review of Resident 5's History and Physical (H&P), dated 7/3/2024, the H&P indicated Resident 5 has the fluctuating capacity to make decisions. During a review of Resident 5's Minimum Data Set ([MDS] a comprehensive assessment and care-screening tool), dated 7/10/2024, the MDS indicated, Resident 5 activities…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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. Receive the necessary treatment and services related to pressure ulcers for two of three sampled residents (Resident 5 and 6) that were complete and accurately documented by nursing. This deficient practice had the potential for Resident 5 and 6 to acquire new pressure ulcers and/or worsen current pressure ulcers. Findings: a. During a review of Resident 5's admission Record (Face Sheet), the Face Sheet indicated Resident 5 was admitted to the facility on [DATE]. Resident 5 ' s diagnoses included type 2 diabetes mellitus (a disorder that affects the blood sugar and is too high), end stage renal disease (the kidneys can no longer filter waste, excess fluids, and electrolytes from the blood), and chronic obstructive pulmonary disease (lung disease that causes breathing problems and restricted airflow). During a review of Resident 5's History and Physical (H&P), dated 7/3/2024, the H&P indicated Resident 5 has the fluctuating capacity to 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of five sampled residents ' (Resident 1) care plan on elopement (when a resident who is cognitively, physically, mentally, emotionally, and/or chemically impaired leaves a care-giving facility or environment unsupervised, unnoticed, and/or prior to their scheduled discharge) was updated after Resident 1 attempted to elope on 2/24/2024, while out on pass (OOP), with Family Member 1 (FM1). This failure resulted in Resident 1 eloping with FM2 on 7/20/2024 while OOP, exposing Resident 1 to alcohol exposure and placing Resident 1 at risk to alcohol intoxication, accidents, and injuries, leading to hospitalization. Findings: During a review of Resident 1 ' s admission Record, the admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including schizophrenia (a disorder that affects a person ' s ability to think, feel, and behave clearly), anxiety disorder (a disorder…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one out of five sampled residents (Resident 1), who was at risk for elopement (when a resident who is cognitively, physically, mentally, emotionally, and/or chemically impaired leaves a care-giving facility or environment unsupervised, unnoticed, and/or prior to their scheduled discharge) and had history of eloping on 2/24/2024, had a physician ' s order to go out on pass ([OOP] request by a resident to leave the hospital for a period of time and returns to continue their treatment that is ordered by physician) on 7/20/2024. This failure resulted in Resident 1 ' s admission to a general acute care hospital (GACH) on 7/21/2024 for evaluation/treatment/drug toxicology screening. This failure had the potential to cause accidents and severe medical complications and possible death. Findings: During a review of Resident 1 ' s admission Record, dated 7/24/2024, the admission Record indicated Resident 1 was originally admitted to the facility on [DATE]…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to provide wound care treatment ordered for three out of five sampled residents (Resident 2, 3, and 4). This failure had the potential to delay wound healing and cause wound infections. Findings: a). During a review of Resident 2 ' s admission Record, dated 7/24/2024, the admission Record indicated Resident 2 was admitted to the facility on [DATE] with diagnoses including quadriplegia (weakness or paralysis of all four limbs), chronic pain syndrome (persistent pain that lasts weeks to years), and cognitive communication deficit (difficulty reasoning and making decisions while communicating). During a review of Resident 2 ' s History and Physical (H&P), dated 6/19/2024, the H&P indicated Resident 2 was able to make needs known with clear speech. During a review of Resident 2 ' s Minimum Data Set ([MDS], a standardized assessment and care screening tool), dated 6/30/2024, the MDS indicated Resident 2 required partial assistance from staff for activities of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to: 1. Provide care in a manner that maintained or enhanced resident's dignity and respect in full recognition of his individuality for one of six sampled residents (Resident 2) when Business Office Staff (BOS) yelled at Resident 2. This deficient practice had the potential to negatively affect the psychosocial well-being of Resident 2. Findings: A review of Resident 2's admission Record, indicated Resident 2 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 2 ' s diagnoses included schizoaffective disorder (a mental illness that can affect your thoughts, mood, and behavior) and generalized anxiety disorder (a condition in which a person has excessive worry and feelings of fear, dread, and uneasiness). A review of Resident 2's History and Physical (H&P), dated 12/30/2023, indicated Resident 2 had the fluctuating capacity to understand and make decision. A review of Resident 2's Minimum Data Set ([MDS] a standardized…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to: 1. Ensure the physician was notified for one of six sampled residents (Resident 1) who had the behavior of refusing medications and activities of daily living ([ADL] daily self-care activities) care. This deficient practice had the potential to result in delayed necessary care and medical intervention. Findings: A review of Resident 1 ' s admission Record, indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 1's diagnoses included left femur fracture (a break in the thighbone), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves). A review of Resident 1's History and Physical (H&P), dated 5/28/2024, indicated Resident 1 can make needs known but cannot make medical decision. A review of Resident 1's Minimum Data Set ([MDS] a standardized assessment…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to: 1. Develop a comprehensive and resident-centered care plan (the process of identifying a patient ' s needs and facilitating holistic care and ensures collaboration among nurses, patients, and other healthcare providers) for one of six sampled residents (Resident 1) who had the behavior of refusing medications and activities of daily living ([ADL] daily self-care activities) care. This deficient practice had the potential to negatively affect the delivery of necessary care and services to Resident 1. Findings: A review of Resident 1 ' s admission Record, indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 1 ' s diagnoses included left femur fracture (a break in the thighbone), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves). A review of…

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

Based on interview and record review, the facility failed to: 1. Ensure facility staff had mandatory abuse training upon orientation for one of one randomly selected staff. This deficient practice had the potential for the facility staff not knowing on how to prevent abuse and the knowledge to minimize the risk of abuse. Findings: During a concurrent interview and record review on 7/8/2024 at 2:50 p.m., with the Director of Staff Development (DSD), employee file of the Business Office Staff (BOS) was reviewed. The DSD stated the BOS was hired on 7/18/2022. The DSD stated the BOS had no abuse training on file upon orientation. The DSD stated it was a facility requirement as well as state and federal that all facility staff should undergo abuse training upon employment. The DSD stated it was important for facility staff to be trained on abuse so they would know what constitutes abuse and the process of abuse reporting. The DSD stated it was his responsibility to provide abuse training to all facility staff. During an interview on 7/8/2024 at 3:50 p.m., with the Administrator (ADM),…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a physician order was implemented timely, for 1 of three residents, Resident 2. This failure resulted in the delay in obtaining results and the potential to delay medical care necessary to plan the care for the affected resident. Findings: A review of Resident 2's admission Record dated 6/4/24, indicated Resident 2 was originally admitted to the facility on [DATE] and re-admitted on [DATE] with diagnosis of acute and chronic respiratory failure (caused by conditions or injuries that affect breathing), chronic atrial fibrillation (a type of heart arrhythmia that causes the top chambers of your heart, the atria, to quiver and beat irregularly), and morbid obesity (overweight). A review of Resident 2's Minimum Data Set (MDS-an assessment and care planning tool) dated 4/13/24, indicated Resident 2 had clear speech, had the ability to express ideas and wants, and understands. The MDS indicated Resident 2 required assistance from staff with set up…

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

Based on observation, interview and record review, the facility failed to observe safe and sanitary food preparation practices in the kitchen by failing to ensure: 1. Dietary Aid (DA 1 and DA 2) properly wore hair restraints (hairnet or caps used to prevent hair from contacting food) while in the kitchen. 2. DA 2 donned (put on) gloves prior to handling food. 3. DA 3 did not store personal bottled water in the resident freezer. 4. Dietary [NAME] (DC) performed handwashing after using her cell phone and prior to touching cooking utensil. These failures had the potential for cross contamination (transfer of harmful bacteria from one place to another) that could lead to foodborne illness to residents who received food from the facility. Findings: During a concurrent observation and interview on 5/20/24 at 1:30 p.m. with the Dietary Supervisor (DS), DA 1 and DA 2 were observed in the kitchen with hairnets not covering all their hair. DA 1 had a bun on top of her head and approximately 4 inches of hair was exposed and not covered by her hairnet. DA 2 had bangs hanging on her forehead 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, staff failed to allow one of five sampled residents (Resident 4) to exercise their rights and preferences for care when Certified Nursing Assistant (CNA 4) turned off Resident 4's bedside light without asking permission to do so, and against Resident 4's wishes. This deficient practice had the potential to cause psychosocial distress and frustration for Resident 4, and removed the resident's autonomy to perform tasks of their choice when and how they wanted. Findings: A review of Resident 4's admission Record indicated the facility admitted Resident 4 on 5/23/2023. Resident 4's admitting diagnoses included major depressive disorder, lack of coordination, and schizoaffective disorder (a mental health disorder comprised of a combination of schizophrenia symptoms [hallucinations or delusions] and mood disorder symptoms [depression or mania (being abnormally upbeat, jumpy or wired)]). A review of Resident 4's H&P, dated 12/15/2023, indicated Resident 4 was able to make his needs…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, staff failed to report an alleged incident of staff-to-resident abuse for one of five sampled residents (Resident 4) following an incident between Resident 4 and Certified Nursing Assistant (CNA) 4 on 5/7/2024. This deficient practice had the potential to cause a delay in the notification of necessary State and local agencies and the timeliness of their investigations, and increased the potential for additional staff-to-resident abuse incidents to occur as CNA 4 worked 11 additional shifts until he was suspended pending an investigation into the alleged abuse. Findings: A review of Resident 4's admission Record indicated the facility admitted Resident 4 on 5/23/2023. Resident 4's admitting diagnoses included major depressive disorder (persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), lack of coordination, and schizoaffective disorder (a mental health disorder comprised of a combination of schizophrenia symptoms…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure one of four sampled residents (Resident 1), was not physically abused by Resident 2 (perpetrator), as evidenced by: 1. Resident 1 was punched in the face with a closed hand by Resident 2, while smoking on the smoking patio. This failure resulted in Resident 1 feeling scared and helpless. Findings: During a review of Resident 1's admission record (Face Sheet), the admission record indicated Resident 1 was admitted to the facility on [DATE], and was readmitted on [DATE], with diagnoses including cellulites (a red, swollen, and painful area of the skin that is warm and tender to touch) of left lower limb, bipolar (a mental illness that can affect the thoughts, mood and behavior), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and difficulty walking (a loss of balance, where one has difficulty in taking steps). During a review of Resident 1's history and physical (H&P),…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement their abuse policy and procedure (P&P). This violation put Residents 1 at risk of further physical abuse. Findings: During a review of the facility's P&P titled, Resident-to-Resident Altercation, dated November 1, 2015, indicated the facility acts promptly and conscientiously to prevent and address altercations between residents. During a review of the facility's P&P titled, Abuse-Reporting and Investigations dated 1/3/24 indicated the following to protect the health, safety, and welfare of facility residents by ensuring that all reports of resident abuse, mistreatment, neglect, exploitation, injuries of an unknown source, and any suspicion of crimes are promptly reported and thoroughly investigated. During a review of Resident 1's admission Record (Face Sheet), dated February 29, 2024, the face sheet indicated Resident 1 was admitted to the facility on [DATE], and was readmitted on [DATE] with a diagnoses including cellulites…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to develop a comprehensive care plan (a document that outlines the facility's plan to provide personalized care to a resident based on the resident's needs) with interventions that included monitoring and follow-up care for four of six residents (Residents 3, 4, 5 and 6) after a resident-to-resident altercation where Resident 3 was hit in the back of the head with a book by Resident 4. This failure had the potential to cause a delay or lack of necessary care for Residents 3, 4, 5, and 6 following a resident-to-resident altercation. Findings: a. During a review of Resident 3's admission Record, dated 2/14/2024, the admission record indicated Resident 3 was admitted to the facility on [DATE] with the following diagnoses which included cerebral infarction (also known as a stroke; refers to damage to the tissues in the brain due to a loss of oxygen to the area), hemiplegia (paralysis [the loss of the ability to move] of one side of the body) and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure adequate supervision was provided when a resident, with a known history of striking out at peers and staff, exhibiting unpredictable episodes of verbal and physical aggression, and was arrested and issued a misdemeanor (type of offense punishable under criminal law) on 12/3/2023, was left without one-to-one supervision in the smoking patio with seven other residents for one out of seven sampled residents (Resident 1). This failure had the potential to result in Resident 1 striking out at other residents, visitors, or staff member in the facility. Findings: a. During a review of Resident 1 ' s admission Record, the admission Record indicated Resident 1 was originally admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses that included but not limited to schizophrenia (usually involves delusions [false beliefs], hallucinations [seeing or hearing things that don't exist], unusual physical behavior, and…

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

Based on interview and record review, the facility failed to ensure a competency assessment skill (a measurable pattern of knowledge, skills, abilities, behaviors, and other characteristics in performing that an individual need to perform work roles or occupational functions successfully) checks were performed upon hire for four of five randomly selected staff. This deficient practice had the potential for the facility not be able to assess the skills necessary to provide nursing services to assure resident safety and to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident will not be performed within the acceptable standards of practice. Findings: During a concurrent interview and record review on 12/15/2023 at 2:26 p.m., with the Director of Staff Development (DSD), five random employee files were checked. Registered Nurse 2 (RN 2), Licensed Vocational Nurse 4 (LVN 4), Certified Nursing Assistant 1 (CNA 1), and Certified Nursing Assistant 2 (CNA 2), did not have competency assessment skills done upon hire. DSD stated he was not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the Minimum Data Set ([MDS] resident assessment and care screening tool) was accurately coded for one of one sampled resident (Resident 86). This failure had the potential to result inaccurate care and services for the residents due to inappropriate MDS care screening and assessment tool practices. Findings: During a review of Resident 86's admission Record, the admission Record indicated Resident 86 was admitted to the facility on [DATE] with diagnoses including schizoaffective disorder (a mental illness that can affect your thoughts, mood, and behavior) and unspecified protein-calorie malnutrition (a nutritional status on which reduced availability of nutrients leads to changes in body composition and function). During a review of Resident 86's History and Physical (H&P) dated 7/22/2023), the H&P indicated Resident 86 can make needs known but can not make medical decisions. During an interview on 12/14/2023 at 8:18 a.m., with the MDS nurse 1…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement a fall risk care plan for one of eight sampled residents (Resident 42) who was at risk for falls. This deficient practice had the potential to place Resident 42 at risk for fall and injury from a fall. Findings: During a review of Resident 42's admission record, the admission record indicated Resident 42 was originally admitted to the facility on [DATE] and re-admitted on [DATE], with diagnosis that included osteoarthritis (the wearing down of the protective tissue at the ends of bones (cartilage) which occurs gradually and worsens over time), compression of the second lumbar vertebrae (occur when the bony block or vertebral body in the spine collapses) and polyarthritis (a joint disease that involves one or more signs of inflammation, pain, movement restriction, swelling, warmth, and redness). During a review of the Minimum Data Set (MDS- a comprehensive assessment tool) dated 11/28/2023, indicated Resident 42 had moderate…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 staff supervision during smoke breaks on the outside patio for one out of 8 residents (Resident 92). This deficient practice resulted in Resident 6 hitting Resident 92 over a cigarette while unsupervised. Findings: During a review of Resident 92's admission record, the admission record indicated Resident 92 was admitted to the facility on [DATE], with diagnoses that included fracture of base of neck of left femur (a crack in the thigh bone), Type 2 Diabetes (A chronic condition that affects the way the body processes blood sugar (glucose) and Gastro-Esophageal Reflux Disease (A digestive disease in which stomach acid or bile irritates the food pipe lining). During a review of the Minimum Data Set (MDS- a comprehensive assessment tool) dated 11/14/2023, indicated Resident 92 was cognitively intact with daily decision making and required partial assistance with toileting, bathing and lower body dressing. During review of Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure physician ordered medications were given in a timely manner for one of four sampled residents (56). This failure had the potential for the residents' prescribed treatments to be ineffective. Findings: During an observation, at station one on 12/13/2023, from 9:12 a.m. to 9:30 a.m., of Resident 56's morning medication administration (med pass). At station one medication cart, Licensed Vocational Nurse 1 (LVN 1) did not administer the morning dose of Folic Acid (a water-soluble vitamin belonging to the B-complex group of vitamins important in red blood cell formation and for healthy cell growth and function) tablet, one tablet by mouth. During a review of Resident 56's physician notes dated 8/1/2022, at 9:25 a.m., indicated Folic acid 1mg, give one tablet by mouth one time a day for supplement. During a review of Resident 56's admission record, the admission Record indicated Resident 56 was admitted to the facility on [DATE] with diagnoses…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility staff failed to: 1. Label four medications with an open date for a floor stock or house supply in medication cart three. 2. Label Resident 45's Ipratropium-Albuterol Inhalation Solution (a medication that is inhaled, prescribed for conditions that cause difficulty breathing) with an opened date. This deficient practice had the potential to result in the prolonged use and loss of strength of the floor stock medications and inhalation solution and can lead to ineffective treatment of respiratory symptoms. Findings: During a concurrent observation and interview on 12/13/2023 at 10:26 a.m. with Licensed Vocational Nurse 2 (LVN) at medication cart three. LVN 2 stated there was no open date for one bottle of acetaminophen, one bottle of docusate sodium, one bottle of aspirin, and one bottle of sodium chloride tablet. LVN 2 stated she will change the bottle to a new one and put a date. LVN 2 stated it is important to put the date on the bottle once you…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 staff members personal beverages were not stored in one of 2 kitchen refrigerators. This deficient practice had the potential to result in cross contamination. Findings: During an observation of the tour of the kitchen, on 12/12/23, at 8:42 a.m., the following was observed: 1. 1 half empty Evian water bottle. 2. 1 2-liter Crush strawberry soda with ¼ of beverage remaining in the bottle. During a concurrent observation and interview, on 12/12/23, at 8:45 a.m., with the Dietary Supervisor (DS), DS stated there should not be any personal employees' beverages any kitchen refrigerator. DS stated all employees have an employee refrigerator for their designated beverages and food. DS further stated the risk of putting personal beverage items in the kitchen refrigerator could result in cross contamination for the residents. A review of the facility's policy, titled Infection Control- Policies and Procedures, dated on 1/1/2012, indicated to maintain a safe, sanitary and comfortable environment for personnel, residents,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 treat one of three sampled residents (Resident 1) with respect and dignity when Resident 1's personal possessions and clothing were left outside in the open at the back of the facility's building. This failure had the potential for Resident 1's personal possession at risk of being stolen, lost, pest infestation, exposure to rain or sun, and resulted in Resident 1 being upset and having feelings of being treated unfairly. Findings: During an observation on 9/22/2023, at 3:10 p.m., outside of Resident 1's room, Resident 1 was wheeling herself back to her room in a wheelchair. During an interview on 9/22/2023, at 3:10 p.m., Resident 1 stated, her personal possessions and clothes were left outside when she came back from the hospital to the facility. Resident 1 further stated her clothes outside were wet from the rain and the staff have not helped her bring her personal possessions in. During an observation on 9/22/2023, at 3:51 p.m., in another resident's room window with a screen near the activity's storage…

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