View Heights Conv Hosp

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the Minimum Data Set (MDS, a resident assessment tool) was accurately coded following a fall for one of one sampled resident (Resident 57). This deficient practice created the potential for Resident 57 to not receive the necessary care and interventions to prevent further falls and possible injuries.Findings: During a review of Resident 57's admission Record, the admission Record indicated Resident 57 was admitted to the facility on [DATE]. Resident 57's diagnoses included schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior). During a review of Resident 57's Minimum Data Set (MDS, a resident assessment tool), dated 2/25/2026, the MDS indicated Resident 57 had moderate cognitive impairment (a significant decline in memory, language, or reasoning that interferes with daily life, such as managing finances or complex tasks). The MDS indicated Resident 57 was independent for all activities of daily living (ADLs,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop a care plan for psychotropic medications (medications that affect the mind, emotions, and behavior) for one of five residents sampled for unnecessary medication review (Resident 18). This deficient practice had the potential to result in Resident 18 not receiving non-pharmacological (non-medicinal) interventions to address his lack of sleep, for which staff were administering Trazodone (a prescription medication, with sedative properties, typically used to treat major depressive disorder [a serious, common mood disorder characterized by at least two weeks of persistent, severe low mood, sadness, or loss of interest in activities]).Findings: During a review of Resident 18's admission Record, the admission Record indicated Resident 18 was admitted to the facility on [DATE]. Resident 18's diagnoses included schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior). During a review of Resident 18'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 revise the comprehensive care plan and interventions for one of two sampled residents (Resident 30) after the resident experienced a significant weight loss. This deficient practice had the potential to result in Resident 30 not receiving individualized and updated nutritional interventions to address significant weight loss, placing the resident at risk for continued weight loss, nutritional decline, and further decline in health status.Cross Reference F637 and F692Findings: During a review of Resident 30's admission Record, the admission Record indicated Resident 30 was admitted to the facility on [DATE]. Resident 30's diagnoses included schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior) and bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs). During a review of Resident 30's Minimum Data Set ([MDS]- a resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow physician orders for orthostatic (measures changes in blood pressure and heart rate when moving from lying down to standing up) blood pressure monitoring and recording by failing to accurately obtain, document, and evaluate orthostatic blood pressure readings for three of three sample residents (Resident 57, Resident 124, and Resident 2).This deficient practice had the potential to place Residents 57, 124, and 2 at risk for undetected orthostatic hypotension, dizziness, syncope (fainting), falls, injury, delayed medical intervention, and adverse cardiovascular complications related to changes in blood pressure upon position changes.Findings: 1. During a review of Resident 57's admission Record, the admission Record indicated Resident 57 was admitted to the facility on [DATE]. Resident 57's diagnoses included schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior). During a review of Resident 57's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure appropriate nutritional interventions were implemented and evaluated for one of two sampled residents (Resident 30) after the resident experienced significant weight loss. This deficient practice had the potential to place Resident 30 as risk for further weight loss and could lead to harm. Cross Reference F637 and F657 Findings: During a review of Resident 30's admission Record, the admission Record indicated Resident 30 was admitted to the facility on [DATE]. Resident 30's diagnoses included schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior) and bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs). During a review of Resident 30's Minimum Data Set ([MDS]- a resident assessment tool), dated 2/8/2026, the MDS indicated Resident 30's cognitive skills for daily decision making (the ability to think and process…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, observation, and record review, the facility failed to ensure the physician orders for metoprolol tartrate ([treats increased heart rate] medication administered for tachycardia [abnormally high resting heart rate]) included heart rate parameters (specific, clinical rules (like dose ranges, lab results, or symptom thresholds) that dictate how, when, or if a drug should be safely) prior to administration for one of one sampled resident (Resident 121).This deficient practice placed Resident 121 at risk for adverse cardiovascular complications, including bradycardia (slow heart rate), hypotension (low blood pressure), dizziness, syncope (faintness), and potential decline in condition related to the unsafe administration of Metoprolol without clear physician guidance.Findings:During a review of Resident 121's admission Record, the admission Record indicated Resident 121 was admitted to the facility on [DATE]. Resident 121's diagnoses included schizoaffective disorder (a chronic mental health…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 Lisinopril (a medication used to treat hypertension ([HTN- high blood pressure) was administered within the ordered parameters (specific, measurable, and objective clinical criteria set by a healthcare provider that dictate when a medication should be given, withheld, or adjusted) for one of one sampled residents (Resident 60). This deficient practice increased Resident 60's risk of hypotension (low blood pressure) and bradycardia (slower heart rate) that could cause dizziness, fainting, weakness, or sudden cardiac arrest (when the heart suddenly and unexpectedly stops pumping).Findings: During a review of Resident 60's admission Record, the admission Record indicated Resident 60 was admitted to the facility on [DATE] with diagnoses including hypertension (low blood pressure). During a review of Resident 60's Minimum Data Set ([MDS] - a resident assessment tool), dated 3/23/2026, the MDS indicated Resident 60's cognition (the ability to think…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 Resident 89's discontinued trazadone hydrochloride (HCl) (drug used to treat depression and anxiety disorders) was removed from one of three inspected medication carts (North Station Medication Cart 2) and properly disposed.2. Ensure an expired bottle of Rybelsius (drug used to help lower blood sugar and slow digestion) was removed from one of three inspected medication carts (North Station Medication Cart 2) and labeled with the resident's name.3. Ensure three different medications were not transferred into another container found in one of three inspected medication carts (North Station Medication Cart 2).4. Ensure Resident 121's Ozempic [(generic name - semaglutide) injectable medication used to treat diabetes and chronic weight management by reducing appetite and increasing feelings of fullness] prefilled pen was stored in accordance with manufacturer's specifications and per facility policy.These deficient practices had 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 nine sampled residents observed during dining observations (Resident 105) received meals in accordance with their preferences when: 1. Resident 105's diet order was not updated following the Registered Dietician's (RD) recommendations for double portions of protein on 4/7/2026. 2. Resident 105 was provided with milk and fish for lunch on 5/5/2026, which were documented as food items he disliked. 3. Staff did not follow Resident 105's diet order for double portions of protein during lunch on 5/6/2026. These deficient practices had the potential to negatively impact Resident 105's meal intake and placed him at risk of not receiving the nutrients and calories needed to maintain a stable body weight. These deficient practices also negatively impacted Resident 105's overall satisfaction during meals.Findings:a. During a review of Resident 105's admission Record, the admission Record indicated Resident 105 was admitted to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the residents' Public Guardian ([PG]- a court-appointed public official responsible for managing a person's financial assets and making medical decisions) information was reviewed and updated in the medical record for two of two sampled residents (Resident 109 and Resident 105).This deficient practice had the potential to result in delayed communication with Resident 109 and 105's PG and may affect timely notification, consent, and involvement in Residents 109 and 105's care planning and treatment decisions.Findings: 1. During a review of Resident 109's admission Record, the admission Record indicated Resident 109 was admitted to the facility on [DATE]. Resident 109's diagnoses included schizophrenia (a mental illness that is characterized by disturbances in thought). During a review of Resident 109's Minimum Data Set ([MDS]- a resident assessment tool), dated 3/18/2026, the MDS indicated Resident 109's cognitive skills for daily decision making…

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

Based on observation, interview, and record review, the facility failed to ensure Licensed Vocational Nurse (LVN) 4 performed hand hygiene in between residents during medication preparation. This deficient practice had the potential to place all residents at risk of infection.Findings:During an observation on 5/6/2026 at 8:00 a.m., in the South Back Nursing Station, Licensed Vocational Nurse (LVN) 4 was observed touching a paper bag filled with medications for a new admission. LVN 4 then prepared medications for another resident without performing hand hygiene.During an interview on 5/6/2026 at 9:33 a.m. with LVN 4, LVN 4 stated he did not perform hand hygiene after touching the paper bag and before preparing medications for the next resident. LVN 4 stated he should have performed hand hygiene before proceeding to the preparation of the next resident's medications. LVN 4 stated he did not know where the paper bag had been and could not consider it clean. LVN 4 stated failure to perform hand hygiene placed residents at risk of infection.During an interview on 5/7/2026 at 9:42 a.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 observation, interview, and record review, the facility failed to ensure privacy curtains were in place for one of one sampled residents (Resident 15).This deficient practice had the potential to not honor Resident 15's right to privacy. Findings:During a review of Resident 15's admission Record, the admission Record indicated Resident 15 was admitted to the facility on [DATE]. Resident 15's diagnoses include schizophrenia (a mental illness that is characterized by disturbances in thought), hyperglyceridemia [abnormally high levels of triglycerides (a type of fat) in the blood], and nicotine dependence [chronic condition characterized by a physical and psychological compulsion to use nicotine (an addictive chemical found in tobacco)].During a review of Resident 15's Minimum Data Set (MDS- a resident assessment tool) dated 4/18/2026, the MDS indicated Resident 15 was cognitively (ability to think and understand) intact. The MDS indicated Resident 15 was independent for eating, toileting 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 notify the physicians and residents' conservators (a person or organization legally appointed to manage the affairs, finances, or property of someone deemed incapable of doing so) of a change of condition following a resident's allegation of sexual abuse for three of three sampled residents (Resident 1, Resident 2, and Resident 3), after Resident 1 alleged Resident 2 and Resident 3 sexually abused her. These deficient practices limited the involvement of Resident 2 and Resident 3's conservators in care decisions and had the potential to result in a delay in timely safety interventions, placing residents at risk for harm. Findings: a. During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was initially admitted to the facility on [DATE]. Resident 1's diagnoses included schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior). During a review of Resident 1's Minimum Data Set (MDS- a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop and implement interventions for two of three sampled residents (Resident 2 and Resident 3), after Resident 1 alleged Resident 2 and Resident 3 sexually abused her. These deficient practices resulted in a delay of the implementation of safety measures and monitoring for Resident 2 and Resident 3, which placed residents at risk for harm.Findings: a. During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was initially admitted to the facility on [DATE]. Resident 1's diagnoses included schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior). During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool), dated 1/18/2026, the MDS indicated Resident 1's cognition (process of thinking) was moderately impaired. The MDS indicated Resident 1 was able to carry out activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting 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 maintain resident clinical records that was complete, accurate and readily accessible for one of three sampled residents (Resident 1), who went Out on Pass (OOP, a temporary, authorized leave from a long-term care facility, allowing residents to leave and return for continued treatment) on 10/18/2025.This failure had the potential for Resident 1 to have gone OOP without proper assessment and placed the resident's safety in jeopardy while OOP which can lead to accidents and hospitalizations.Findings:During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was originally admitted to the facility on [DATE] with diagnosis of schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior) and alcohol dependence. The admission Record indicated Resident 1 had a public guardian (a legally appointed official authorized by a court to care for a person who is unable to manage their own affairs due 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 a resident's responsible party (RP 1) was notified following the resident's involvement in a physical altercation with another resident and of an interdisciplinary team (IDT) conference for one out of three sampled residents (Resident 1). This deficient practice resulted in RP 1 not being informed of Resident 1's physical altercation with Resident 2 on 7/25/2025 nor informed of an IDT conference following the incident on 7/28/2025, placing Resident 1 at risk for uncoordinated care and decisions without input from RP 1.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 that included schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), hypertension (high blood pressure), and diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 lump (abnormal bumps or swellings on or under the skin) at the back of neck of one of four residents (Resident 1), was assessed timely and reported to the resident's physician. This deficient practice had the potential to result in the delay of care and services necessary to treat Resident 1's back of neck lump and had the potential to cause worsening condition of the lump. Findings:During a concurrent observation and interview on 7/17/2025 at 9:30 a.m. with Resident 1, Resident 1 stated he had a lump (mass) at the back of his neck. The lump was observed like the size of a pea, did not look swollen and was not red. Resident 1 stated a family member (FM)1 saw the lump and probably informed the nurse.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 schizoaffective disorder (a mental illness that can affect thoughts, 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, facility staff failed to ensure one of four sampled residents (Resident 2) was monitored for verbal and physical aggression, as ordered by the physician. This deficient practice created the risk for Resident 2, who hit another resident in the face on 4/16/2025, to commit repeat physical aggression towards other facility residents with possible physical injury and psychosocial harm. 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 was most recently readmitted on [DATE]. Resident 1 ' s admitting diagnoses included schizophrenia (a mental illness that is characterized by disturbances in thought). During a review of Resident 1 ' s Minimum Data Set (MDS, a resident assessment tool), dated 3/9/2025, the MDS indicated Resident 1 did not have impaired cognition (difficulties with thinking, learning, remembering, and making decisions). 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.

Based on observation, interview and record review, the facility did not provide a diet that met the nutritional needs for all facility residents by: 1. Not ensuring residents received a breakfast that offered a nutritional value. 2. Not ensuring a system was in place to ensure meal substitutes and alternatives provided were of equal or nutritive value for all facility residents. These deficient practices had the potential to impact resident's nutritional status and could result in all residents sustaining undesired weight loss and malnutrition. Findings: 1. During an observation on 2/13/2025 at 7:11 a.m. in the kitchen, a mc muffin sandwich without meat was served to the residents. The mc muffin sandwich contained only scrambled eggs. During an interview on 2/13/2025 at 7:20 a.m. with Dietary Supervisor (DS), the DS stated they were serving a vegetarian mc muffin sandwich for breakfast. The DS stated the mc muffin sandwich did not come with meat and that made it a vegetarian sandwich. During an interview on 2/13/2025 at 7:39 a.m. with Dietary [NAME] (DC) 2, DC 2 stated she was a…

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

Based on interview and record review, the facility failed to employ a dietary supervisor (DS) that met the qualifications of having an associate's degree or higher in food service management or in hospitality, was a certified dietary manager, certified food service manager or had national certification for food service management and safety. This deficient practice had the potential to affect 146 residents residing in the facility by potentially not receiving the nutritional assistance and guidance they needed to attain their highest practicable well-being. Findings: During a review of the Dietary Supervisor's (DS) Food Card certificate, dated 12/5/2023, the certificate indicated the DS was recognized for successfully completing the food Handler basic course. During a review of the DS's school transcript, dated Spring 2025, the transcript indicated the DS was enrolled in Introduction of food service work and Food production management. During an interview on 2/11/2025 at 8:30 a.m. with Dietary [NAME] (DC) 1, DC 1 stated the DS began working as the facility's dietary supervisor in…

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

Based on observation, interview and record review, the facility did not ensure dietary staff followed the dietary menus for 146 residents out of 146 sampled residents by failing to: 1. Ensure dietary staff provided a breakfast sandwich with sausage. 2. Ensure the Dietary Supervisor (DS) checked the food before it was provided to residents. These deficient practices had the potential to impact resident's nutritional status and placed all residents at risk for unintentional weight loss. Findings: During an observation on 2/13/2025 at 7:11 a.m. in the kitchen, breakfast sandwich without meat was served to the residents. The breakfast sandwich contained only scrambled eggs. During an interview on 2/13/2025 at 7:20 a.m. with the DS, the DS stated they were serving a vegetarian (diet with no meat) breakfast sandwich. The DS stated the breakfast sandwich did not come with meat and that made it a vegetarian sandwich. During a concurrent observation and interview on 2/13/2025 at 7:39 a.m. with Dietary [NAME] (DC) 2, DC 2 stated she was serving residents a sandwich with scrambled eggs for…

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

Based on observation, interview, and record review the facility failed to ensure safe and sanitary food storage practices in the kitchen that affected 146 residents out of 146 sampled residents when: 1. The walk -in refrigerator contained lettuce with no in date (the date when the food was placed in the refrigerator), no use by date (date the food item must be consumed by) and cheese with no use by date. 2. The dry storage room did not have a thermometer to monitor room temperature. 3. The walk-in refrigerator had three bags of expired spinach. 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 illnesses in all residents who received food from the kitchen. Findings: During the initial kitchen tour observation on 2/11/2025 at 8:31 a.m., the walk-in refrigerator was observed with a bag of cheese without a use by date, bags of spinach that were expired and lettuce that was not labeled and undated. During the initial kitchen tour observation on…

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

Based on interview and record review, the facility failed to include the selection of a venue that was convenient to both parties in the Arbitration Agreement (an agreement between the facility and the resident where they would resolve any disputes through a neutral person rather than going to court). This deficient practice had the potential to cause bias in venue selection process for residents who enter into a binding arbitration agreement and want to resolve a dispute. Findings: During a concurrent interview and record review on 2/13/1015 at 12:57 p.m., with the Administrator (ADM), the facility's Resident-Facility Arbitration Agreement, undated, was reviewed. The ADM stated the facility had updated the Resident-Facility Arbitration Agreement to indicate a section for the selection of a venue that was convenient to both parties, however, the Resident-Facility Arbitration Agreement currently utilized was not the updated version. The ADM stated the facility's administration was responsible for providing the updated Resident-Facility Arbitration Agreement to the Admissions…

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

Based on observation, interview, and record review, the facility failed to follow its policy and procedure (P&P) titled Water Temperature Policy For Facility Laundry and Preventative Maintenance Policy by failing to: 1. Monitor the washer water temperature on 2/14/2025. 2. Clean the dyer lint trap (a mesh filter located inside a dryer that caught lint and fabric fibers from clothes during the drying cycle) on 2/14/2025. This deficient practice had the potential to increase the risk of infection which could increase the morbidity (the amount of disease in a population) and mortality (the state of being subject to death) among 146 residents residing in the facility. Findings: 1. During a concurrent observation and interview on 2/14/2025 at 9:21 a.m. with the Maintenance Supervisor (MS), in the facility's laundry room, there were no monitors on the washer indicating the water temperature. The MS stated the water temperature needed to be between 125-165 degrees Fahrenheit (°F, a measurement of temperature). The MS stated the facility was unable to read the water temperature of the…

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

Based on observation, interview, and record review, the facility failed to accommodate residents in the dining room during mealtimes by not ensuring: 1. The dining room offered enough space for all residents to sit down at the same time for mealtime. 2. Residents were sent to not their rooms to wait until a seat became available. 3. Residents were asked to form a line to wait for a seat to become available. This deficient practice had the potential to affect Resident's self-esteem and self-worth. Findings: During an observation on 2/11/2025 at 12:10 p.m., in the dining room, the dining room was observed having 40 chairs. During an observation on 2/11/2025 at 12:22 p.m., in the dining room, residents were observed forming a line at the entrance of the dining room. Residents were in line waiting for a seat to become available. During an observation on 2/12/2025 at 12:07 p.m., in the dining room, an identified resident walked into the dining room, looked around the room for a place to sit and remained standing in the middle of the dining room because he could not find an empty seat.…

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

Based on observation, interview, and record review, the facility failed to provide a dining experience that maintained or enhanced resident's dignity and respect during mealtimes for facility residents by not ensuring: 1. The dining room offered enough space for all residents to sit down at the same time for mealtimes. 2. All residents sitting at the same table were served food at the same time. 3. All residents received their breakfast at the same time. 4. Residents were not served food on disposable plates and bowls. This deficient practice had the potential to affect Resident's self-esteem and self-worth. Findings: 1. During an observation on 2/11/2025 at 12:16 p.m., in the dining room, staff were observed passing out food trays to residents. Not all residents sitting at the same table received their food trays at the same time. Staff passed out food trays to different residents sitting at different tables, skipping residents. During an observation on 2/11/2025 at 12:22 p.m., in the dining room, residents were observed forming a line at the entrance of the dining room. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to obtain informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered) prior to administration of psychotropic medication (medications that affect the mind, emotions, and behavior) for three of eight sampled residents (Residents 31, 16, and 347) by failing to: 1. Ensure informed consent was obtained from Resident 31's conservator (a person who has been appointed by the court to make decisions for another person who is deemed incompetent) prior to Resident 31's initial administration of Trazodone (an antidepressant [a medication used to treat depression, which is a mood disorder that causes a persistent feeling of sadness and loss of interest] and a sedative [a medication used to help an individual fall asleep]) on 7/30/2024. 2. Ensure Resident 31's Verification of Informed Consent were complete and included the frequency (how often) of administration for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the assessment entry on the Minimum Data Set ([MDS], a resident assessment tool) was accurate for one of seven sampled residents (Resident 31) when the MDS did not indicate Resident 31 was on hypoglycemic medication (medication used to lower blood sugar levels). This failure had the potential to negative affect Residents 31's plan of care and delivery of necessary care and services. Findings: During a review of Resident 31's admission Record (Face Sheet), the Face Sheet indicated Resident 31 was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses that included schizophrenia, type 2 diabetes mellitus (a disorder characterized by difficulty in blood sugar control and poor wound healing), and hyperlipidemia (a condition with too many fats in the blood). During a review of Resident 31's Minimum Data Set ([MDS], a resident assessment tool), dated 11/29/2024, the MDS indicated Resident 31's cognition…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 care plan for addressing the behavior of self-isolation, for which Cymbalta (a medication used to treat depression) was administered, was developed for one of five sampled residents (Resident 3). This deficient practice placed Resident 3 at risk of receiving unnecessary doses of Cymbalta, and subsequent side effects associated with psychotropic medications (a drug or other substance that affects how the brain works) such as nausea, drowsiness, agitation, and headache. Cross-reference F-tag F758. Findings: During a review of Resident 3's admission Record, the admission Record indicated Resident 3 was admitted to the facility on [DATE]. Resident 3's admitting diagnoses included schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior). Resident 3 did not have diagnoses of depression (a common mental health condition characterized by a persistent low mood, loss of interest or pleasure in activities, and other…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 Licensed Vocational Nurse (LVN) 1 documented medication administration accurately for one of 18 sampled residents (Resident 56), in accordance with professional standards. This failure had the potential to delay Resident 56 in reaching her care goals due to the documentation of medication that was not given. Findings: During a review of Resident 56's admission Record, the admission Record indicated Resident 56 was originally admitted to the facility on [DATE] and was most recently re-admitted on [DATE]. Resident 56's admitting diagnoses included schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior). During a review of Resident 56's Minimum Data Set (MDS, a resident assessment tool), dated 11/13/2024, the MDS indicated Resident 56 did not have cognitive impairments (problems with thinking, learning, or memory). The MDS indicated Resident 56 was independent to eat, and independent with mobility.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 quality of care was provided for two of three sampled residents (Residents 31 and 16) by failing to: 1. Clarify the monitoring of Resident 31's blood glucose (amount of sugar in the blood) prior to the administration of Insulin Glargine (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication). This deficient practice resulted in Resident 31's blood glucose being unmonitored prior to being administered Insulin Glargine on 2/8/2025, 2/9/2025, 2/10/2025, 2/11/2025, and 2/12/2025. This deficient practice also had the potential to result in Resident 31 becoming hypoglycemic (a condition when the blood sugar level drops too low) and symptomatic with dizziness, shakiness, and confusion. 2. Implement Resident 16's physician order for wound treatment to the right scalp. This deficient practice had the potential to increase the risk of infection for Resident 16, and placed 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 conduct an Interdisciplinary Care Team (IDT, a group of healthcare professionals who worked together to provide care for residents in a nursing home) conference after a witnessed fall on 12/19/2024 for one of seven residents (Resident 112). This deficient practice had the potential to increase the possibility of recurrent falls for Resident 112. Findings: During a review of Resident 112's admission Record, the admission Record indicated Resident 112 was admitted to the facility on [DATE]. Resident 112's diagnoses included schizophrenia (a mental illness that was characterized by disturbances in thought), insomnia (trouble falling asleep or staying asleep), and Post-Traumatic Stress Disorder (PTSD - a disorder in which a person had difficulty recovering after experiencing or witnessing a traumatic event). The admission Record indicated Resident 112 had a public guardian (responsible for the care of individuals who were no longer able to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure medications were administered as ordered for two of 18 sampled residents (Resident 56 and Resident 49) when: 1. Licensed Vocational Nurse (LVN) 1 administered five doses of Ozempic (a prescription injectable medication used to treat type 2 diabetes mellitus [DM, a disorder characterized by difficulty in blood sugar control and poor wound healing] in adults) to Resident 56 from an Ozempic injection pen that was 35 days beyond its use by date. 2. LVN 1 administered Metformin (a medication used to treat high blood sugar levels caused by DM) to Resident 49 greater than one hour before the scheduled administration time. These failures created the potential for Resident 56 to not achieve the desired weight loss the Ozempic was indicated for, due to decreased effectiveness of the expired medication. These failures also created the potential for Resident 49 to sustain gastric distress (a group of uncomfortable symptoms related to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure two of five sampled residents (Resident 3 and Resident 31) were free from unnecessary medications when: 1. Staff failed to monitor for the presence of self-isolating behaviors for Resident 3, and ensure a gradual dose reduction (GDR, stepwise tapering of a medication dose) was attempted for her Cymbalta (a medication used to treat depression and anxiety), which was initiated in March 2024. 2. Staff failed to provide behavior manifestations for hallucinations of Resident 31's use of haloperidol (an antipsychotic medication [a medication that affects the mind, emotions, and behavior]). These deficient practices had the potential for Resident 3 to suffer unwanted adverse effects from continued administration of Cymbalta including excessive sedation, heart problems, and tremors (involuntary, rhythmic shaking movements that can affect various parts of the body, such as the hands, arms, legs, head, or voice), resulted in the facility indicating 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 dispose of medication for one of 18 sampled residents (Resident 56) when: 1. An Ozempic (a prescription injectable medication used to treat type 2 diabetes mellitus [DM, a disorder characterized by difficulty in blood sugar control and poor wound healing] in adults) injection pen was kept in the North Station medication cart beyond its use-by date of 12/31/2024. 2. Licensed Vocational Nurse (LVN) 1 failed to label an Ozempic injection pen with the correct open date. These failures created the potential for Resident 56 to receive Ozempic with reduced potency and effectiveness, possibly causing a delay in the effectiveness of the ordered therapy. Findings: During a review of Resident 56's admission Record, the admission Record indicated Resident 56 was originally admitted to the facility on [DATE] and was most recently re-admitted on [DATE]. Resident 56's admitting diagnoses included obesity (a chronic condition characterized by an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents' food preferences were respected, alternates were provided, and food allergy was noted on the diet card (a document that listed a resident's dietary needs, including allergies, preferences, and restrictions) for three of 29 sampled residents (Resident 97, Resident 51, and Resident 81) when: 1. Resident 97 was not provided with an alternative lunch substitute on 2/11/2025, and Resident 97's preference for two quesadillas for lunch and dinner was not documented timely in the medical record. 2. Resident 51's preference for a snack of fresh fruit, was documented timely in the medical record from admission. 3. Resident 81's preference of not having beans was not honored on 2/13/2025 during lunch. 4. Resident 81's shrimp allergy was not documented on the diet card on 2/13/2025. These deficient practices had the potential to result in Resident 97 and 81's decreased meal intake, and at risk for weight loss and malnutrition. This…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow its policy and procedure (P&P) titled Nourishment Policy for two of two residents (Resident 56 and Resident 81) by failing to: a. Provide Resident 56 snacks when requested. b. Provide Resident 81 snacks. This deficient practice violated Resident 56 and 81's rights to eat as they wanted to. Findings: 1. During a review of Resident 56's admission Record (Face Sheet), the Face Sheet indicated Resident 56 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), alcohol dependence (a chronic disease where the individual craves drinks with alcohol and unable to control their drinking), and nicotine dependence (a compulsive need for nicotine, the additive chemical in tobacco products). During a review of Resident 56's Minimum Data Set ([MDS], a resident assessment tool), dated 11/13/2024, the MDS…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of three sampled residents' (Resident 21) conservator (a person who has been appointed by the court to make decisions for another person who is deemed incompetent) understood the Arbitration Agreement (an agreement between the facility and the resident where they would resolve any disputes through a neutral person rather than going to court) in a language Conservator 1 understood. This deficient practice resulted in Conservator 1 not understanding what entering a binding Arbitration Agreement meant. Findings: During a review of Resident 21's admission Record (Face Sheet), the Face Sheet indicated Resident 21 was admitted to the facility on [DATE] with diagnoses that included schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), alcohol dependence (a chronic disease where the individual craves drinks with alcohol and unable to control their drinking), and nicotine dependence (a compulsive need for nicotine,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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. Report the facility's 24 Coronavirus Disease 2019 ([COVID-19] highly contagious viral infection) positive residents to the California Department of Public Health (CDPH) confirmed cases as indicated in the All facilities Letter 23-08 ([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) dated 1/18/2023, which indicated to report outbreaks (the occurrence of cases of a disease or condition above the expected or baseline level, usually over a given period of time, in a geographic area or facility, or in a specific population) and unusual infectious disease occurrences to the local public health officer and the California Department of Public Health (CDPH) . 2.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure allegation of physical abuse by a facility staff to one of three sampled residents (Resident 2), was reported to California Department of Public Health (CDPH) within two (2) hours, as indicated in the facility's policy and procedure (P&P) titled, Reporting Abuse. This failure resulted in the delay of investigation by CDPH and placed the resident and other residents at risk for further physical abuse. Findings: During a review of Resident 2 ' s admission Record, the admission Record indicated Resident 2 was admitted to the facility on [DATE], with a diagnosis that included schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), nicotine dependence (compulsive craving to use a drug), and homelessness (unhoused or unsheltered). During a review of Resident 2 ' s History and Physical (H&P) dated 7/17/2024, the H&P indicated Resident 2 neurologic was grossly intact and symmetric. During a review of Resident 2 ' s…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure safe planning for transfer and discharge was conducted, followed up and documented for one of five sampled residents (Resident 1). This failure resulted in delayed discharge as requested by the resident and family member, and had the potential to affect Resident 1 ' s psychosocial and emotional weelbeing. Findings: During a review of Resident 1 ' s admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE], with a diagnosis that included schizoaffective disorder bipolar type (a mental illness that can affect thoughts, mood, and behavior), tobacco dependence (compulsive craving to use nicotine), and insomnia (trouble falling asleep or staying asleep). During a review of Resident 1 ' s Minimum Data Set ([MDS] a federally mandated resident assessment tool) dated 8/10/2024, the MDS indicated Resident 1 had the capacity to make self-understood and the ability to understand others. The MDS indicated Resident 1…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide services that met professional standards of quality for two of three sampled residents (Resident 1and Resident 2) when: 1. Staff did not document one-to-one (1:1, close supervision) monitoring was performed for Resident 2 at 10 PM on 8/7/2024. 2. Staff documented the same assessments for Resident 2 over different time periods on 8/7/2024 and 8/8/2024. Staff documented the same assessments for Resident 1 over different time periods on 8/7/2024. 3. Staff did not update Resident 1 and Resident 2 ' s vital signs (measurements of the body's most basic functions) when there was a change in the resident ' s condition on 8/6/2024. These deficient practices had the potential to result in serious harm such as another episode of aggression towards others, and a delay of necessary treatments. Findings: 1a. 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…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement the care plan for two of three sampled residents (Resident 1 and Resident 2), when staff did not monitor Resident 1 and Resident 2 after a physical altercation on 8/6/2024. This deficient practice had the potential for residents to not receive appropriate care, treatment, and services. Findings: 1. 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 schizoaffective disorder (a serious mental illness that affected how a person thought, felt, and behaved), tachycardia (heart was beating faster than normal, usually more than 100 beats per minute), hypertension (high blood pressure), and vitamin D deficiency (having inadequate amounts of vitamin D in body). During a review of Resident 1 ' s History & Physical (H&P), dated 9/8/2023, the H&P indicated Resident 1 was alert and oriented. During a review of Resident 1 ' s Minimum Data…

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

Based on interview and record review, the facility failed to notify the physician when a resident exhibited an episode of touching himself inappropriately in the hallway for one out of six sampled residents (Resident 1). This deficient practice led to a delay in medical evaluation and interventions for Resident 1's hypersexual behaviors. Cross-reference F656 and F600. Findings: During a concurrent interview and record review on, 8/6/2024, at 3:16 p.m., with Registered Nurse (RN) 2, Resident 1's Behavior Plan, dated 2/17/2024, and Resident 1's Change of Condition (COC) Notes, dated 2/2024, were reviewed. The Behavior Plan indicated it was reported that Resident 1 masturbated (to pleasure oneself in a sexual way) in the doorway of his room, in a public setting on 2/17/2024. The COC notes indicated there was no change of condition notification made to the physician, psychiatrist, nor the psychologist for Resident 1's display of inappropriate sexual behavior on 2/17/2024. RN 2 stated for every change of condition, the normal process was to complete a change of condition note, and notify…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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) were free from sexual abuse from Resident 1, who had a known history of hypersexual behaviors (an intense focus on sexual fantasies, urges, or behaviors that can't be controlled), by failing to: 1. Immediately intervene and provide a safe distance between Resident 1 and Resident 2 when Resident 1 began masturbating (to pleasure onself sexually) in public. 2. Ensure the social services designee (SSD) notified and communicated with the licensed nurses when Resident 1 first exhibited hypersexual behaviors on 2/17/2024. These deficient practices resulted in Resident 1 masturbating while standing in close proximity to Resident 2 in the hallway on 7/20/2024. These failures also resulted in Resident 2 exhibiting feelings of anger as evidenced by a furrowed brow and fast breathing when speaking of the incident. Cross reference F656. Findings: 1. 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 observation, interview, and record review, the facility failed to effectively implement care plan interventions to address a resident's hypersexual (an intense focus on sexual fantasies, urges or behaviors that can't be controlled) behaviors for one out of six sampled residents (Resident 1) when the facility failed to: 1. Document and encourage Resident 1 to attend therapeutic group meetings for healthy relationships, symptom management, and impulse control. 2. Model and role play appropriate behaviors for Resident 1. 3. Notify and communicate with licensed nurses and the physician when Resident 1 exhibited his first episode of publicly and inappropriately touching himself in the hallway on 2/17/2024. These deficient practices resulted in Resident 1 sexually touching himself inappropriately as he stood in close proximity to Resident 2, as she spoke on the telephone, in the hallway (on 7/20/2024). These failures also resulted in Resident 2 exhibiting feelings of anger as evidenced by a furrowed brow and…

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

Based on observation, interview, and record review the facility failed to ensure a safe and sanitary food storage practice in the kitchen that affected 143 residents out of 143 sampled residents when: 1. The dry storage room contained opened food items with no use by date (date the food item must be consumed by) and the storage room did not have a temperature gauge to control temperature of the room. 2. The refrigerator contained opened food with no use by date. The refrigerator had bins of beans and salsa that were expired. The refrigerator had a bag of sausages that were expired. 3. The walk-in freezer's water pipe had hard ice buildup and inside of freezer door, over the top part of freezer door walkway, freezer floor, and the freezer's ceiling had ice buildup. The outside of the freezer door had brown rust on it. The freezer's door did not close. The walk-in freezer's floor was covered in ice causing it to be unsafe to walk into freezer. 4. The ice machine was not cleaned per facility's policy. 5. The resident nourishment refrigerator was not cleaned per facility's policy and it…

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

Based on interview and record review, the facility failed to include the selection of a venue that was convenient to both parties in the arbitration agreement (a contract that gives up the right to have disputes decided in a court of law before a jury and instead both parties agree to a private process where one or several individuals can make a decision about the dispute). This deficiency had the potential to cause bias in the venue selection process for residents who enter into a binding arbitration agreement at the facility. Findings: During a concurrent interview and record review on 2/8/2024 at 5:43 p.m., with the Administrator (ADM) and the Director of Nursing (DON), the facility's Resident-Facility Arbitration Agreement was reviewed. The ADM was asked if the arbitration agreement included a convenient venue selection for both parties involved in the dispute. After the ADM and the DON reviewed the arbitration agreement, both the ADM and DON agreed that the arbitration agreement did not include a convenient venue selection for both parties. The ADM stated that he would have the…

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

Based on observation, interview, and record review, the facility failed to maintain the kitchen's freezer in a safe operating condition. The walk-in freezer's water pipe had hard ice buildup inside of the freezer door, over the top part of the freezer's door walkway, freezer floor, and the freezer's ceiling had ice buildup. The outside of the freezer door had brown rust on it. The freezer's door did not close. The walk-in freezer's floor was covered in ice causing it to be unsafe to walk into freezer. This failure had the potential to result in harmful bacteria growth and cross contamination that could lead to foodborne illness in residents that are medically compromised residents due to the potential of food exposure to fluctuating temperatures. Findings: During an observation during the initial kitchen tour on 2/5/2024 at 9:38 a.m., in the walk-in freezer, observed the outside of the freezer door with areas of rust. Observed the top of the doorway filled with ice, the floor in the freezer had ice, boxes of food had a layer of ice, the ceiling of the freezer was covered in ice and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide accurate and safe pharmaceutical services for one of three nurses' stations (North) and for one of five residents (Resident 29) when: 1. Prepoured medications (medications prepared prior to administration) in the North nurses' station were not secured and left unattended. 2. Resident 29 was administered medication when his systolic blood pressure ([SBP] maximum blood pressure during contraction of the ventricles) did not meet the medication parameters (when a medication is not administered based on a specific condition). 3. Resident 29's Order Summary Report and Medical Administration Record (MAR) indicated incorrect parameters for medication fludrocortisone acetate (medication for low blood pressure) tablet 0.1 milligrams (mg, unit of measurement) and nursing staff did not correct the order. These failures had the potential for residents in the North nurses' station retrieving and consuming medications not intended for them.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 following when one of two medication rooms (Medication Room A) and one of three medication carts (South Front Medication Cart) were inspected: 1. The expired Injectable and Sublingual (medications that dissolve under the tongue) emergency kit ([e-kit]- an emergency supply of medications) was removed from usage and returned to the pharmacy. 2. The Injectable and Sublingual Drugs emergency kit was securely fastened. 3. Ozempic (weekly injection that helps lower blood sugar) was labeled with the open and discard by date for four of four residents (Residents 7, 55, 77, and 111). These failures had the potential to result in the administration of an ineffective dose of Glucagon (a medication used to prevent a resident's blood sugar from dropping too low) in the event of an emergency and the possible loss of the medications stocked in the e-kit. These failures also had the potential to result in the administration of expired Ozempic…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 obtain informed consent (process in which patients are given important information about a medical procedure or treatment including possible risks and benefits) prior to initiation and administration of psychotropic medication (medication that affects the mind, emotions, and behavior) for two of five sampled residents (Resident 3 and 51). This failure resulted in the removal of Resident 3's Public Guardian's (PG, a person who has been appointed by a court to make decisions for another person who is deemed incompetent) and Resident 51's conservator's (a person who has been appointed by the court to make decisions for another person who is deemed incompetent) right to make decisions about the care and treatments the residents received in the facility. Findings: a. During a review of Resident 3's admission Record (Face Sheet), the admission Record indicated Resident 3 was initially admitted to the facility on [DATE] and readmitted to the facility on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to keep resident valuables inside of the social services office to ensure the accountability and protection of resident valuables for one out of one sampled resident (Resident 34). This failure had the potential to result in the theft, loss, or bartering (exchanging of goods) of Resent 34's pearl necklace and rings. Findings: During a review of Resident 34's admission Record, the admission Record indicated Resident 34 was originally admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses that included but not limited to schizoaffective disorder (mood disorder) and chronic kidney disease (loss of kidney function). During a concurrent observation and interview, on 2/6/2024, at 12:15 p.m., with Licensed Vocational Nurse (LVN) 1, in the medication storage room, the discontinued medication bin was observed. There was an envelope found in the discontinued medication bin. The envelope contained a pearl necklace and two rings,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 Licensed Vocational Nurse (LVN) 4 signed the Medication Administration Record (MAR) immediately and accurately after administering medications for two of 18 residents (Residents 52 and 108). This failure resulted in LVN 4 documenting the administration of Atropine (medication that can be used for excessive drooling) when Resident 52 refused. This failure also had the potential to result in double administration of medication to Resident 52 and 108 that could lead to mental or mood changes or excessive sedation (decrease in consciousness where the resident cannot be aroused). Findings: a. During a review of Resident 52's admission Record (Face Sheet), the admission Record indicated Resident 52 was admitted to the facility on [DATE] with diagnoses that included but not limited to schizophrenia (a severe mental illness that causes disturbed or unusual thinking, loss of interest in life, and strong or inappropriate emotions),…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 resident (Resident 93) out of 7 sampled residents was seen and assessed by an optometrist (healthcare provider that examine, diagnose, and treat diseases and disorders that affect eyes and vision). This deficient practice potentially caused a delay in treatment for Resident 93. Findings: During a review of Resident 93's admission Record, the admission record indicated Resident 93 was originally admitted to the facility on [DATE] with diagnoses including schizophrenia (a mental disorder characterized by disruptions in thought processes, perceptions, emotional responsiveness, and social interactions). During a review of Resident 93's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 12/10/2023, the MDS indicated Resident 93's cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision making was moderately impaired. The MDS indicated Resident 93 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 follow up on a dental referral for one of seven residents (Resident 90) when Resident 90 had a referral to see an oral surgeon. This failure had the potential to result in the delay in treatment and placed Resident 90 at risk for infection, pain, and degraded self-esteem. Findings: During a review of Resident 90's admission Record (Face Sheet), the admission Record indicated Resident 90 was admitted to the facility on [DATE] with a diagnosis of schizophrenia (a severe mental illness that causes disturbed or unusual thinking, loss of interest in life, and strong or inappropriate emotions). During a review of Resident 90's Minimum Data Set (MDS, a standardized assessment and screening tool), dated 12/7/2023, the MDS indicated Resident 90 was able to understand and be understood by others. The MDS indicated Resident 90's cognition (process of thinking) was intact. During a review of Resident 90's Medication Review Report, dated 2/1/2024 to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to honor the food choices and vegan diet (practice of abstaining from eating any food derived from animals and animal products) preference for one of one sampled resident (Resident 138). This deficient practice had the potential to impact the resident's nutritional status, quality of life and food dissatisfaction and insufficient food intake. Findings: During a review of Resident 138's admission Record, dated 2/7/2024, the admission record indicated Resident 138 was admitted to the facility on [DATE] with the following diagnoses which included schizoaffective disorder (a mental illness that affects mood and has symptoms of hallucinations and/or delusions), diabetes mellitus, (a condition that results in too much sugar circulating in the blood, insomnia (persistent problems falling and staying asleep), and gastro-esophageal reflux disease (GERD - a chronic digestive disease where the contents of the stomach refluxes and irritates the…

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

Based on interview and record review, the facility's Quality Assessment and Assurance (QAA - develops and implements appropriate plans of action to correct identified quality deficiencies) Committee failed to meet at least quarterly. This deficient practice had the potential to increase the risk of an unsafe environment for all residents and staff members. Findings: During a concurrent interview and record review on 2/8/2024 at 5:17 p.m., with the Administrator (ADM) and the Director of Nursing (DON), the facility's last QAA documentation was reviewed. The QAA documentation indicated that the last QAA meeting was held on October 4, 2023. The ADM stated that the QAA meetings should be held quarterly, and that the facility should have had a meeting in January 2024. The ADM stated that the facility was running behind with their quarterly QAPI meetings. During a review of the facility's Quality Assurance Performance Improvement (QAPI - a systematic, interdisciplinary, comprehensive and data-driven approach to maintaining and improving safety and quality in nursing homes while involving…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 effective infection prevention measures for one of nine residents (Resident 64) when Licensed Vocational Nurse (LVN) 5 did not wear gloves and handled Resident 64's medication with her bare hands. This failure had the potential to result in the transmission of infectious microorganisms and increase the risk of infection. Findings: During a review of Resident 64's admission Record (Face Sheet), the admission Record indicated Resident 64 was admitted to the facility on [DATE] with diagnoses that include but not limited to paranoid (a pattern of behavior where a person feels distrustful and suspicious of other people) schizophrenia (a severe mental illness that causes disturbed or unusual thinking, loss of interest in life, and strong or inappropriate emotions) and hereditary spherocytosis ( an inherited disease that changes the shape of and decreases the life of red blood cells). During a review of Resident 64's Minimum Data Set…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to monitor prescribed antibiotics (medications used to treat infections) and notate antibiotic usage in the Infection Prevention Control Surveillance Log (a tool used to monitor all antibiotics and infections) for three out of seven sampled residents (Residents 71, 130, and 139). This failure had the potential to result in the continued administration of unnecessary and inappropriate medications (incorrectly prescribed antibiotics for an infection), increased antimicrobial resistance (decrease of antibiotic effectiveness), unmonitored spread of infection, and physician notification delay regarding the worsening of symptoms during antibiotic treatment. Findings: During a review of the facility's Infection Prevention Control Surveillance Log, the following dates and residents were listed: 1. October 2023: Resident 9 and Resident 109 were identified to have an active infection and be prescribed antibiotics. 2. November 2023: No residents were…

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