View Park Convalescent Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to: maintain a sanitary environment by failing to adhere to infection control measures in one out eight bathrooms (room [ROOM NUMBER]) These deficient practices had the potential to expose Residents in room [ROOM NUMBER] to to disease causing pathogens (germs) from bodily fluids and waste that could result in, poor patient outcomes, medical complications, and unnecessary hospitalization. During a facility tour on 4/15/25 at 8 AM room [ROOM NUMBER] bathroom was observed to have: 1. Three visibly soiled towels hanging on the towel rack. 2. A used coffee cup with residue inside and a water pitcher and cup place on a shelf above the bathroom sink. During an interview on 04/15/25 at 08:13 AM, Certified Nurse Assistant (CNA) 1 stated the dirty towels, coffee cup and, water pitcher are not supposed to be in the bathroom because of infection control, CNA1 stated she does not know who left the towels in the Resident's communal bathroom and proceeded…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 at least 80 square feet (sq. ft.) per resident in 20 of 40 resident rooms (rooms 101, 102, 103, 104, 105, 106,107,109,110,114,116,118,120,121,122,134, 137, 138, 141). This deficient practice had the potential to result in inadequate space for nursing care and privacy and safety of residents. Findings: During a record review, the facility Request for Room Size Waiver letter submitted by the Administrator, dated 4/16/2025, indicated 20 resident rooms in the facility did not meet the requirement of at least 80 square feet per resident per federal regulation. The letter also indicated all rooms have more than adequate space for resident privacy. The letter further indicated the following rooms provided are less than 80 sq.ft. per resident: Room Room Sq. Footage # of beds 101 201.965 sq.ft. 3 102 201.965 sq.ft. 3 103 201.965 sq. ft. 3 104 206.4 sq.ft. 3 105 210.15 sq.ft. 3 106 204.44 sq.ft. 3 107 236.665 sq. ft. 3 109 204.25 sq.ft. 3 110 205.145 sq.ft. 3 114 204.25 sq.ft. 3 116 204.25 sq.ft. 3 118 204.25…

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

Based on interview, and record review, the facility failed to ensure the assessment entries on the Minimum Data Set (MDS- a resident assessment tool) related to insulin was accurately documented to reflect the resident's insulin status for one of three sampled residents (Resident 80). This deficient practice had the potential to negatively affect Resident 80's plan of care and delivery of necessary care and services. Findings: During a record review, Resident 80's admission Record indicated the facility initially admitted Resident 80 on 11/15/2024 and readmitted Resident 80 on 2/7/2025 with diagnoses including congestive heart failure (CHF - a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), hypertension (HTN - elevated blood pressure) and diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). During a record review, Resident 80's Minimum Data Set (MDS- a resident assessment tool), dated 2/19/2025, indicated Resident 80 was cognitively intact (when a person has no…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 assist one out of 19 sampled residents (Resident 3) in obtaining dentures. This failure had the potential to effect the resident's nutritional status and weight. Findings: During a record review, Resident 3's admission Record indicated the facility admitted the resident on 11/17/2019 and re-admitted the resident on 7/16/2022, with diagnoses including Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), muscle wasting (weakening, shrinking, and loss of muscle) and atrophy (decrease in size and strength of the muscle) and anemia (a condition where the body does not have enough healthy red blood cells During a record review, Resident 3's Minimum Data Set (MDS - a resident assessment tool) dated 2/5/2025, indicated the resident had moderately impaired cognition. The same MDS further indicated Resident 3 was independent with eating and required substantial to total assistance with toileting, dressing and personal hygiene. During a record review, Resident 3's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure staff implemented infection prevention and control program by not wearing proper personal protective equipment (PPE - equipments including gloves, masks, gowns, face shields used to prevent spread of infection) when entering an isolation room (a type of hospital room that keeps patients with infectious illnesses away from other patients). There was an outbreak of influenza (Flu - is a contagious respiratory illness caused by influenza viruses) in the facility. This deficient practice had the potential for further spread of influenza risk of infections due to a break in infection control protocol during infectious disease outbreak. Findings: During record review, Resident 1's Minimum Data Set (MDS-a resident assessment tool) dated 1/3/2025 indicated Resident's cognitive function (the ability to think and make independent decisions) was severely impaired. Resident 1 was not able communicate needs or wants, in addition does not make…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1), had an order for nothing by mouth (NPO-an acronym for the Latin phrase nil per os, which translates to nothing by mouth) as well as fingerstick blood sugar checks every six hours for a resident that as a NPO order and is on a gastrostomy (Gtube-a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems) feeding. This failure had the potential to result in inaccurate blood sugar monitoring for someone that is not taking nutrition by mouth and affect the care and services received. Findings: A review of Resident 1 ' s admission Record dated 11/19/24, indicated Resident 1 was admitted to the facility on [DATE], with diagnoses including, type two diabetes (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) hypertension (high blood pressure), heart failure (a condition where the hear…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to report an allegation of abuse to (California Department of Public Health (CDPH) within two hours for one of three sampled residents (Resident 1). This deficient practice resulted in a delayed onsite investigation of by CDPH with a potential of further altercation between Resident 1 and Resident 2 Findings During a review of Resident 1's Face sheet (admission Record), indicated Resident 1 was re-admitted to the facility on [DATE], with a diagnoses of acute kidney failure (when your kidneys suddenly stop working properly), and essential hypertension (a type of high blood pressure that occurs when there is no identifiable cause). During a review of Resident 1's History and Physical (H&P) dated 6/29/2024, indicated Resident 1 had the capacity for medical decision making. During a review of Resident 2's Face Sheet, indicated Resident 2 was admitted to the facility on [DATE] with diagnoses including dementia (impaired thinking, remembering, or reasoning that…

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

Based on observation, interview, and record review the facility failed to ensure kitchen staff were routinely trained and evaluated for competency skills when: 1. One of one staff was not following the manufacturer's guidelines when checking the concentration of the QUAT sanitizing (a chemical used for disinfection) solution. 2. Staff was not able to verbalize the facility Resident's food from home policy. These deficient practices had a potential to result to cross-contamination (a transfer of bacteria from one object to another), ineffective dish machine, and unsanitized dishes that could lead to food borne illness (an illness caused by contaminated food and beverages) for 77 of 77 medically compromised residents who received food and ice from the kitchen. Findings: 1. During a concurrent demonstration of the Quat sanitizer testing process and interview with DA 1 (Dietary Aid 1) on 4/3/2024 at 10:08 AM, DA 1 filled the red bucket with a premix (mixture of water and quat sanitizer) Quat sanitizer then pulled out a test strip and dipped the test strip in the solution for eight (8)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen failing by: 1. Improper Storage of Food A. Unlabeled, undated pasta, ranch dressing and expired cheese dated 2/12/2024. B. Uncovered, unlabeled and undated bacon slices. C. Unlabeled, undated, and expired food inside the resident's refrigerator. Staff's parmesan cheese, drink, and Italian dressing in the resident's refrigerator in the activity room 2. Poor air circulation for Freezer three (3) and four (4). 3. Equipment Cleanliness/Cross-contamination A. Dirt debris in the Freezer 3's bottom shelves. B. Refrigerator 2's vent had dust. C. Refrigerator 1's roof and bottom shelves had black dirt debris. D. Dry storage shelves had dust buildup. Crate used for scoop storage was on the floor in the dry storage. Cans stored in the dry storage area had dirty and food debris. Staff water bottle was stored in the dry storage area. Air-condition vent had dust…

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

Based on observation, interview, and record review, the facility failed to dispose garbage and refuse properly when: A. One (1) of two (2) black dumpster (a large trash container designed to be emptied into a truck) and one (1) of one (1) blue dumpster were not covered for unknown amount of time. B. The trash area was not maintained free from trash, soiled gloves, and other dirt debris. This deficient practice had a potential for the trashes to attract flies, insects, rats, and other animals to the dumpster area, bringing diseases to 77 of 77 facility residents. Findings: During an observation of the garbage area located outside the facility's kitchen at 4/2/2024 2:05 PM, one (1) of two (2) black trash bin and one (1) of one (1) blue trash bin were not completely closed with covers/lids. The blue trash bin was overflowing with cardboard boxes. During a concurrent observation of the garbage area and interview with Maintenance Supervisor (MS) on 4/2/2024 at 2:08 PM, MS stated he was responsible of maintaining the cleanliness of the garbage areas. MS stated there were soiled gloves on…

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

Based on observation, interview, and record review, the facility failed to maintain sanitary conditions in the food services department when: 1. Two (2) cockroaches (a type of insect) were observed in the kitchen. 2. Multiple cockroaches (two cockroaches) were observed on the floor underneath the dish washing sink area. This deficient practice had the potential to result in food contamination, causing food borne illnesses (illness caused by consuming contaminated foods or beverages) among 77 of 77 residents who received food from the kitchen. Findings: During a concurrent observation of the facility's kitchen and interview with the Registered Dietitian 1 (RD 1) on 4/2/2024 at 11:34 AM, one (1) dead cockroach and one (1) crawling (live) baby cockroach were observed on the floor underneath the dishwashing sink. RD 1 stated RD 1 did not know what the baby one was, but it was a small insect, and it was moving. RD 1 stated the kitchen should be free of insect for food safety. During a concurrent observation of the dish machine area and interview with the Registered Dietitian 2 (RD 2) 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, facility failed to meet professional standards of quality for one of four sampled residents (Resident 3). This deficient practice had the potential to cause underdosing, overdosing and hospitalization. A review of Resident 3's admission Record indicated the resident was admitted to the facility on [DATE] and was readmitted on [DATE] with medical diagnoses that included adult failure to thrive, dementia (impaired ability to remember, think or make decisions that interferes with doing everyday activities), and hypertension (HTN -elevated blood pressure). A review of Resident 3's physicians orders (doctors written instructions to be followed), dated 12/29/2023, indicated Aspirin (medication used to reduce the risk of blood clots) tablet (a drug in solid form taken by mouth) chewable, give 1 tablet via gastrointestinal tube (G-tube -a tube inserted through the belly that brings nutrition directly to the stomach) one time a day for cardiac (heart) prophylaxis(prevent…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure one of three sampled residents (Resident 3) was free of significant medication error. This deficient practice had the potential to lead ineffective medication therapy, and result overdose or underdose, which could be fatal to Resident 3. Findings: A review of Resident 3's admission Record indicated Resident 3 was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses that included adult failure to thrive and dementia (impaired ability to remember, think or make decisions that interferes). A review of Resident 3's Physician Orders, dated 12/29/2023, indicated an active order for Aspirin (medication used to reduce the risk of blood clots) tablet (a drug in solid form taken by mouth) chewable, (to) give 1 tablet via gastrointestinal tube (G-tube -a tube inserted through the belly that brings nutrition directly to the stomach) one time a day for cardiac (heart) prophylaxis (prevent something from…

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

Based on observation, interview, and record review the facility failed to ensure medications were stored and or disposed per the facility's policy and procedures titled Disposal of Medications and Medication-Related Supplies, subtitled, Controlled Medication Disposal revised 2/20/2024, and Labelling of Medication Containers revised 2/20/2024, by failing to: 1. Safely dispose wasted medications in one of four medication carts (Medication Cart B #2). 2. Label 34 out of 36 multiuse (non-prescription medication/over the counter medication that can be used for more than one resident) with an open date (date indicating packaging opened; used to determine amount of time food can be safely consumed). These deficient practices had the potential to: 1. Result in medication diversion and access by unauthorized persons. 2. Affect medication efficacy (the power to produce the desired effect) and reduce the therapeutic (intended to treat diseases or disorders) effects of medications administered to all 84 residents in the facility. Findings: 1. During a concurrent observation of Medication Cart…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure three medications were not left with the resident who was not capable to self-administer medications for one of 18 sample residents (Resident 77). This deficient practice had the potential to result in, 1. Harm through drug interactions and/or allergic reactions, unnecessary hospitalizations, and even death for Resident 77. 2. Access to the medication by unintended person/residents. Findings: A review of Resident 77's admission record indicated Resident 77 was initially admitted to the facility on [DATE], and was readmitted on [DATE], with diagnoses that included diabetes mellitus (high sugar in the blood) and traumatic subdural hemorrhage (bleeding in the area between the brain and the skull from a head injury), atrial fibrillation (afib - an irregular and often very rapid heart rhythm), and syncope and collapse (fainting or passing out). A review of Resident 77's Minimum Data Set (MDS - a standardized assessment and care…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to ensure that advanced healthcare directive information was provided to the resident's responsible party (RP) for two of eight sampled residents (Resident 1 and Resident 3). This deficient practice resulted in violation of Resident 1 and Resident 3's representative's rights to receive information on advanced healthcare directive and to formulate advanced healthcare directive for Resident 1 and Resident 3. Findings: A review of Resident 1's admission Record indicated the resident was admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses that included Alzheimer's disease (brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks), schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves), and hypertension (HTN -elevated blood pressure). A review of Resident 1's History and Physical (H&P -complete assessment of the patient and the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide a safe environment by failing to secure/cover multiple exposed sheathed wires and connectors on the bed side rail for one of six residents (Resident 29). This deficient practice had the potential to result in injury/harm to Resident 29. Findings: A review of Resident 29's admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses that included unspecified dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), psychotic disturbance (severe mental disorders that cause abnormal thinking and perceptions), and anxiety (persistent and excessive worry that interferes with daily activities). A review of Resident 29's History and Physical Examination dated 12/26/2023, indicated, Resident 29 did not have the capacity to understand and make decisions. A review of Resident 29's Minimum Data Set (MDS - a standardized assessment…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of six Residents (Resident 288) was free from physical restraint. This deficient practice had the potential to result in lowered and or lost dignity and self-esteem and increased the risk for injury or death for Resident 288. Findings: A review of Resident 288's admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses that included anxiety disorder (persistent and excessive worry that interferes with daily activities). A review of Resident 288's Minimum Data Set (MDS - a standardized assessment and care screening tool) dated 2/19/2024, indicated the resident had moderately intact cognition (capacity to remember, learn new things, concentrate, or make decisions that affect everyday life), required assistance from staff for eating, hygiene (oral and physical), and toileting. A review of Resident 288's care plans, indicated, Resident is at Risk of Falls/Injury related to impaired 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 observation, interview, and record review, the facility failed to obtain a physician's order for a low air loss mattress (LALM - a mattress designed to distribute the patient's body weight over a broad surface area and help prevent skin breakdown) for one of six sampled residents (Resident 9). This deficient practice had the potential to harm Resident 9 and for Resident 9 not to receive appropriate treatment and interventions. Findings: A review of Resident 9's admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses that included Type 2 Diabetes (elevated blood sugar), abnormalities of mobility, and muscle weakness. A review of Resident 9's History and Physical Examination dated 7/16/2023 indicated, Resident 9 did not have the capacity to understand and make decisions. A review of Resident 9's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 3/12/2024, indicated the resident did not have intact cognition (capacity to remember, learn…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 create a patient centered care plan (a plan of care that summarizes a resident's health conditions, specific care needs, and current treatments) for two of six sampled Residents (Residents 9 and 288) by failing to: 1. Develop and implement a care plan for Resident 9's low air loss mattress (LALM: special mattress designed to distribute the patient's body weight over a broad surface area and help prevent skin breakdown). 2. Develop and implement a care plan for Resident 288's full bed length side rails. These deficient practices: 1. Had the potential to delay healing, and placed Resident 9 at increased risk for developing new pressure injuries, worsening of existing ones, and complications resulting from untreated or improperly treated pressure injuries. 2. Placed Resident 288 at increased risk for unnecessary restraints, which could result in physical and emotional harm. Findings: 1. A review of Resident 9's admission Record indicated the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide activities of daily living (ADL-such as bathing, showering, toileting, and mobility) for two of six sampled residents (Residents 6 and 54) This deficient practice resulted in Residents 6 and 54 feeling angry and also had the potential to develop skin infections, skin irritation, and foul odor. Findings: 1. A review of Resident 54's admission Record indicated the resident was admitted to the facility on [DATE], with diagnoses including muscle weakness (a decrease in muscle strength), and Type 2 diabetes mellitus (elevated blood sugar). A review of Resident 54's History and Physical (H&P) dated 2/18/2024, indicated Resident 54 had the capacity to understand and make decisions. A review of resident 54's Minimum Data Set (MDS- a standardized assessment and care screening tool) dated 2/23/2024, indicated Resident 54's cognitive skills (the core skills your brain uses to think, read, learn, remember, reason, and pay attention) for daily decision…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that the settings for a Low Air Loss Mattresses (LALM - a pressure-relieving mattress used to prevent and treat pressure injuries) were correct and appropriate to the weight of one of six sampled residents (Resident 9). This deficient practice had the potential for Resident 9 to develop pressure injuries (injuries to the skin and underlying tissue, primarily caused by prolonged pressure on the skin). Findings: A review of Resident 9's admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses that included Type 2 Diabetes (a disease in which your body does not produce enough insulin needed to control sugar levels in the blood), abnormalities of mobility, and muscle weakness. A review of Resident 9's History and Physical Examination dated 7/16/2023 indicated, Resident 9 did not have the capacity to understand and make decisions. A review of Resident 9's Minimum Data Set (MDS- standardized 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure the tube feeding product/formula was not hanged for more than 48 hours per manufacturer's instructions and facility's policy and procedures for one of two sampled residents (Resident 3), These deficient practices had the potential to result in abdominal pain, vomiting, and loose bowel movement because of bacteria growth for Resident 3. Findings: A review of Resident 3's admission Record indicated the resident was admitted to the facility on [DATE] and was readmitted on [DATE] with medical diagnoses that included, adult failure to thrive (syndrome of weight loss, decreased appetite and poor nutrition, and inactivity, often accompanied by dehydration), dementia (impaired ability to remember, think or make decisions that interferes with doing everyday activities), and hypertension (HTN -elevated blood pressure). A review of Resident 3's History and Physical (H&P- physician's examination of a resident, in which the physician obtains 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 ensure five of five staff were assessed for competency upon hire and annually. This deficient practice had the potential for a knowledge, training, and certification deficit among staff, leading to inadequate or delayed resident care. Findings: During an interview with Treatment Nurse (TN) on 4/3/2024 at 12:43 PM, TN stated TN has been employed with the facility for seven years. TN stated TN did not remember the last time TN completed an annual skills competency training. TN stated staff could forget important tasks that can interfere with daily care of the residents, if an annual skills competency training was not performed. TN further stated nurses could forget how to complete certain tasks to help the residents. During an interview Certified Nurse Assistant 2 (CNA 2) on 4/3/2024 at 12:53 PM, CNA 2 stated CNA 2 has been employed with the facility for one year. CNA 2 stated CNA 2 completed annual skills competency two weeks ago with Director of Staff Development (DSD). During an interview with Registered Nurse Supervisor…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 pharmaceutical services to meet the needs of residents by failing to ensure facility policy for multi-use medications in medication cart (Medication Cart B #2). This deficient practice had the potential to cause inability of the facility to readily identify medications that have a limited time for use once opened and had the potential for poor therapeutic outcomes due unintentional administration of expired medication. Findings: On [DATE], at 10:11 a.m., during a record review of the multi-use medication containers, and a concurrent interview with Licensed Vocational Nurse 4 (LVN 4), LVN4 counted 34 multi-use open medication containers in Medication Cart B, #2, that were in-use and did not have an open for use date per facility policy. During an interview, LVN 4 stated she did not know the facility's policy for labeling multi-use medication container's, LVN4 further stated she has been employed at the facility since [DATE]. On [DATE], at 2:40PM…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 it's policy and procedures (P &P) titled, Consent for Procedures and Medical Treatment, by failing to ensure the resident representative (RP) consent was obtained prior to getting a debridement (is the medical removal of dead, damaged, or infected tissue to improve the healing potential of the remaining healthy tissue) done for one of three sample residents (Resident 1). This deficeint practice had the potential to place Resident 1 and the RP at risk for not being able to understand the benefits and reasonable risks associated with the procedure and make an informed decision. Findings: A review of Resident 1 ' s admission record indicated Resident 13 was initially admitted to the facility on [DATE], and was readmitted on [DATE], with diagnoses including, unstageable (a full thickness tissue loss where the depth of the wound is completely obscured by eschar [a dry, dark scab or falling away of dead skin, typically caused by a burn, or by 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 reviews, the facility failed to develop a comprehensive care plan for one of three sampled residents (Resident 1) for the pressure ulcers (PU- Injury to skin and underlying tissue resulting from prolonged pressure on the skin) to Resident 1 ' s Sacral coccyx (bones that complete the lower spine and help provide stability and function to the lower back and legs) upon identification on 11/6/2023. This deficient practice had the potential to result in negative impact on Resident 1 ' s wounds healing thereby affecting health and safety, as well as the quality of care and services received. Findings: A review of Resident 1 ' s admission record indicated Resident 13 was initially admitted to the facility on [DATE], and was readmitted on [DATE], with diagnoses including, unstageable (a full thickness tissue loss where the depth of the wound is completely obscured by eschar [a dry, dark scab or falling away of dead skin, typically caused by a burn, or by the bite of a mite, or as a result…

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

Based on observation, interview and record review, the facility failed to ensure two of two ice coolers in the hallways of the facility were locked. This deficient practice had the potential to result in residents helping themselves to ice and possibly not following proper safety procedures. During an observation with concurrent interview on 1/17/24 with Registered Nurse Supervisor (RNS) 1 in front of nursing station B. An ice cooler with a padlock closure in the unlocked position was observed. The RNS stated the kitchen staff are responsible for the ice cooler. During an observation with concurrent interview on 1/17/24 with LVN 2 in the front hallway of the facility adjacent to Nursing station A. An ice cooler was observed to be unlocked. LVN 2 stated it is empty but should be locked. During an interview on 1/19/24 with MDSN, MDSN stated the ice coolers should be locked to prevent residents from helping themselves. A review of the facility's policy and procedures titled Avoidance of environmental Hazards reviewed 5/16/23, indicated This facility will strive to provide a hazard-free…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 an environment that was free of accident hazards for one of six sampled residents (Resident 2), by failing to ensure resident had bed side rails as part of the resident ' s individualized care plan for preventing falls. This deficient practice resulted in Resident 2 falling on 1/7/24 requiring transfer to the GACH (General Acute Care Hospital). Cross reference with F700 Findings: A review of Resident 2's admission Record dated 1/18/24 indicated Resident 2 was admitted to the facility on [DATE], with diagnoses including muscle weakness, blindless in on eye, low vision in other eye, myocardial infarction (heart attack) and hypertension (high blood pressure). A review of Resident 2's Minimum Data Set (MDS a standardized assessment and care screening tool) dated 11/21/23 indicated Resident 2 had mildly impaired cognition (ability to think, understand and make daily decisions). The same MDS further indicated Resident 2, was dependent or required…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 it ' s policy and procedures for bed side rails for one of six sampled residents (Resident 2), by failing to ensure Resident 2 had and order for bed side rails and a care plan was developed for bed side rails. This deficient practice had the potential to result in risk of entrapment for Resident 2. Cross reference with F689. Findings: A review of Resident 2's admission Record dated 1/18/24 indicated Resident 2 was admitted to the facility on [DATE], with diagnoses including muscle weakness, blindless in on eye, low vision in other eye, myocardial infarction (heart attack) and hypertension (high blood pressure). A review of Resident 2's Minimum Data Set (MDS a standardized assessment and care screening tool) dated 11/21/23 indicated Resident 2 had mildly impaired cognition (ability to think, understand and make daily decisions). The same MDS further indicated Resident 2, was dependent or required substantial maximal assistance from…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to 1. Ensure one of four sampled residents (Resident 1), had measures in place to prevent pressure sores (pressure ulcer/ injury or bed sore, an injury to the skin that develops over bony areas of the body from prolonged pressure to the area) from developing. This failure resulted in Resident 1 developing a new pressure sore on right heel and a re-ulceration (reopening) of previously healed pressure sore on sacrum (a triangular bone in the lower back). 2. Implement its policy and procedures for pressure sore management to take a picture of a pressure sore on admission available in the resident ' s medical chart for two of six sampled residents (Residents 2 and 5). This resulted in no pictures of pressure sores taken on admission and filed in the medical chart for review for two of two sampled residents (Residents 2 and 5). 3. Ensure Low Air Loss (LAL) mattresses (mattress designed for pressure reducing which is used to prevent and treat…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to 1. Ensure one of four sample residents (Resident 7) was not left wet for extended periods. This failure resulted in Resident 7 being left wet for over 40 minutes. 2. Ensure one of four sample residents (Resident 5) urine was assessed as being abnormal in color and transparency and reported to the medical doctor. This failure had the potential to result in Resident 7 developing a urinary tract infection (UTI, an infection in any part of the urinary system) and delay treatment. Findings: 1. During a review of Resident 7's admission Record, dated 9/6/23, the admission record indicated, the resident was readmitted to the facility on [DATE] with diagnoses including hemiplegia (paralysis) and hemiparesis (muscle weakness) of right dominant side following stroke, dysphagia, hypertension, muscle weakness, difficulty in walking, and need for assistance in personal care. During a review of Resident 7 ' s Minimum Data Set (MDS, a standardized…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety when: 1) Sanitizer concentration level in a sanitizer bucket in the kitchen was measured at 0 (zero) ppm (parts per million - Usually describes the concentration of something in water or soil). 2) Dishwasher 2 (DW 2) did not wash hands prior to handling cleaned dishes after touching soiled dishes. 3) DW 2 double-stacked dish racks while washing cups, dishes, and kitchen utensils with the dishwashing machine when the manufacturer of the dishwashing machine did not allow double-stacking of dish racks. 4) Breakfast food temperatures were not measured on 11/16/2021. 5) Roast pork was not cooled down properly and cooling temperatures were not logged on cooling log per policy. These deficient practices had the potential to result in food-borne illness (any illness resulting from the spoilage of contaminated food, bacteria-germs, viruses,…

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

Based on observation, interviews and record review, the facility failed to employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition services as follows: 1) [NAME] 1 did not know when to discard ReadyCare (name brand) shakes. 2) Dishwasher 1 did not know which test paper to use to measure concentration of sanitizer used for sanitizer bucket. 3) Dishwasher 1 and Dishwasher 2 did not know how to manually wash dishes. These failures had the potential to result in unsafe and unsanitary food preparation and production, and a potential for food-borne illness affecting all residents who received foods from the kitchen. Findings: 1) During a concurrent observation and interview on 11/16/2021, at 8:57 a.m., with [NAME] 1, in the kitchen, [NAME] 1 stated he managed and handled the ReadyCare shakes in the 3-door upright refrigerator and labeled the shakes with the date he transferred the shakes from the freezer. He further stated he was not sure how long he could keep the shakes. A review of the ReadyCare shake label,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety when multiple food items in the refrigerators were not labeled or dated or kept beyond the use-by-date. These deficient practices had the potential to result in food-borne illness (any illness resulting from the spoilage of contaminated food, bacteria-germs, viruses, or parasites that contaminate food, as well as toxins [poisons]) among medically vulnerable residents who consumed the food prepared by the facility kitchen. Findings: During a concurrent observation and interview on 11/16/2021, at 8:35 a.m., with Registered Dietician (RD) in the kitchen, the following food items were observed either not being dated, labeled, or being kept beyond use-by-date marked on the container in the 3-door upright refrigerator: green and red bell peppers, celeries, zucchinis, garlics, wrapped cut onions, lettuces, and squashes. The RD stated cooks…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure residents' medical records were updated to indicate that advance directives (written statement of a person's wishes regarding medical treatment made to ensure those wishes are carried out should the person be unable to communicate them to a doctor) information was discussed, and written information provided to residents and or with responsible parties for six of six sampled residents (Residents 56, 57, 59, 63, 73, 78). This deficient practice violated the residents' and/or the representatives' right to be fully informed of the option to formulate their advanced directives and had the potential to cause conflict with the residents' wishes regarding health care for Residents 56, 57, 59, 63, 73, 78. Findings: 1. A review of Resident 56's admission Record indicated the resident was admitted to the facility on [DATE], with diagnosis that included Diabetes Mellitus, Kidney Failure (a condition which the kidneys lose the ability to remove waste and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure two of four sampled residents were free from physical restraints (any manual method, physical or mechanical device, equipment, or material that is attached or adjacent to the resident's body, cannot be removed easily by the resident, and restricts the resident's freedom of movement or normal access to his/her body) (Resident 21, Resident 59). a. For Resident 59, the facility failed to obtain a physician's order, implement a care plan, provide the evidence of that less restrictive interventions were attempted prior to application of restraint and the evidence of that the routinely re-assessed use of restraint was documented. b. For Resident 21, the facility failed to ensure there were an assessment, order, care plan, consent, and/or attempts of which less restrictive intervention were used prior to application of restraint. Resident 21 was sitting on her wheelchair with both her hands underneath her buttocks, with a white bed sheet…

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

Based on observation, interview and record review, the facility failed to: 1) follow portion size as written on the menu for residents on pureed and regular diet. 2) follow menu as written for residents on puree and mechanical soft diet. As a result, 49 of 73 residents on pureed and regular diet received inaccurate portion for their meals, and 36 of 73 residents on pureed and mechanical diet received meals with unapproved substituted menu. This deficient practice had the potential for residents to receive inadequate protein and caloric intake when not following the menu, which could result in undernutrition or overnutrition and further compromise their medical status. Findings: 1) A review of the facility's document titled, Cooks Spreadsheet Fall Menus, dated 9/21/2021, 10/19/2021, and 11/16/2021, indicated food portioning as follows: a) regular portion for pureed bread should be served with a #16 scoop providing 1/4 cup; b) regular portion for regular ginger carrots should be served with a #8 scoop providing 1/2 cup; c) regular portion for regular rice pilaf should be served with a…

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

Based on observation, interview and record review, the facility failed to implement its own policy and procedure related to a safe, sanitary environment and infection control to help prevent the development and transmission of infection as evidenced by the following: 1. The facility failed to ensure proper concentration for the disinfecting product was papered and used to maintain sanitary interior surfaces in Resident 81's room against Candida auris (C. auris - a highly contagious fungal infection). 2. A pair of used disposable gloves were left in Resident 27's bed. 3. Certified Nursing Assistant 1 (CNA 1) did not perform hand hygiene before removing and delivering Resident 26's lunch tray. 4. CNA 5 removed a disposable gown from the package, placed it in her pocket, walked to the shower room, and put on the gown in the shower room before giving Resident 5 a shower. Findings: 1. During a concurrent observation and interview on 11/17/2021, at 1:15 p.m., with Housekeeping Supervisor (HS) in his office, he stated he prepared the bleach solution by mixing 1 gallon of water (i.e. 153.7…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 20 of 40 rooms (101, 102, 103, 104, 105, 106, 107, 109, 110, 114, 116, 118, 120, 121, 122, 134, 137, 138, 141, 142) met the square footage requirement of 80 square feet (sqft) per resident in multiple resident bedrooms for 47 of 80 residents. This deficient practice had the potential to negatively impact the resident's privacy and not to have adequate space for nursing care, which could impose a risk for the safety of the residents affected by the limited room space. Findings: A review of the facility's document titled, Client Accommodations Analysis, dated 11/18/2021, indicated that all rooms were compliant with the square footage requirement for multiple resident bedrooms. During an interview on 11/19/2021, at 9:00 a.m., with surveyors, they stated that space in 3-bed rooms looked too cramped. During an observation on 11/19/2021, between 9:07 a.m. and 9:18 a.m., with Maintenance Supervisor (MS), useable square footage for four…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 accommodate the residents' needs as follows: 1) Ensure the call light system (a device used by a resident to signal for assistance from the facility's staff) was within reach for 6 of 22 sampled residents (Residents 14, 27, 33, 51, 59, 79). 2) Ensure a wheelchair (WC) had a foot rest and leg rest (a device that is mounted on the lower frame of the WC to help the user rest his/her legs and feet/foot. Also, the foot/leg rest assists the user to achieve optimum sitting position, improves posture, and promote blood circulation) for one of 22 sampled residents (Resident 21). 3) Ensure that one of 22 sampled residents (Resident 21) used a WC assigned by therapy services. These deficient practices had the potential for delay by facility staff to respond to the necessary care and services, and increased the risk for skin breakdown, skin irritation, joint problems, lower extremity swelling and or falls for Residents 14, 21, 27, 33, 51, 59, 79.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 through with the Preadmission Screening and Resident Review (PASRR) recommendation to obtain a PASRR level II evaluation for one of six sampled residents (Resident 73). This deficient practice had the potential to result in inappropriate placement and unidentified specialized services for Resident 73. Findings: A review of Resident 73's admission record indicated Resident 73 was admitted to the facility on [DATE]. Resident 73's diagnoses included Schizophrenia (a chronic brain disorder. When schizophrenia is active, symptoms can include delusions, hallucinations, disorganized speech, trouble with thinking and lack of motivation), and Major Depressive Disorder (A mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). A review of Resident 73's PASRR completed on 10/13/2021, indicated the resident needed for Level II PASRR evaluation (which…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan (a process for identifying and documenting diagnoses, goals of care/treatment, and interventions needed for care/treatment of diagnoses) for one of one resident (Resident 27) for Resident 27's bed being against the wall. This deficient practice had the potential for Resident 27's needs not being met and placed the resident at risk for an injury. Findings: A review of Resident 27's admission Record, indicated Resident 27 was admitted to the facility on [DATE] with diagnoses including altered mental status (disruption in how the brain works that can cause a change in behavior), seizure (sudden, uncontrolled electrical disturbance in the brain that can cause changes in behavior, movements, and levels of consciousness), and dementia without behavioral disturbances (mental disorder in which a person loses the ability to think, remember, learn, make decisions, and solve problems. A…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to follow their policy for performing a body check for one of one resident (Resident 5). This deficient practice had the potential to not identify a skin alteration (A change resulting in something that is different from the original) and delay treatment of the skin alteration. Findings: A review of Resident 5's admission Record indicated Resident 5 was admitted to the facility on [DATE] with diagnoses including muscle weakness (lack of strength in the muscles), schizophrenia (chronic brain disorder that can cause delusions, hallucinations, and disorganized speech), and dementia with behavior disturbance (mental disorder in which a person loses the ability to think, remember, learn, make decisions, and solve problems with behavioral abnormalities such as depression, anxiety, agitation). A review of Resident 5's Minimum Data Set (MDS - a standardized resident care planning and assessment tool) dated 07/29/2021, indicated severely impaired…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide Restorative Nursing Assistance (RNA, a nursing service that helps patients gain an improved quality of life by increasing their level of strength and mobility) as ordered to one of four sampled residents (Resident 25). This deficient practice had the potential to lead to decline in Resident 25's physical strength and mobility. Findings: A record review of Resident 25's admission Record, dated 11/16/2021 indicated Resident 25 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including hypoxic ischemic encephalopathy (a type of brain dysfunction that occurs when the brain doesn't receive enough oxygen or blood flow for a period of time), generalized muscle weakness and lack of coordination. A review of Resident 25's Minimum Data Set (MDS, is a powerful tool for implementing standardized resident assessment and for facilitating care management) dated 9/3/2021, indicated the resident had a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure an environment free of accidents and hazards was provided for three of three residents (Residents 27, 14 and 5) as evidenced by: 1. Resident 27's bed was in a high position, against the wall, bilateral left siderails were up, call light was not within reach, bed wheels were not locked, and side rails (structural support attached to the side of a bed and intended to prevent a patient from falling) padded (filled or covered with a soft material for the purpose of protection). 2. Resident 14's call light was not within reach and bed side rails were not padded 3. Shower chair wheels were not locked before transferring Resident 5 from the bed to shower chair. These deficient practices could have resulted in an accident and injury to Residents 5, 14, and 27. Findings: 1. A review of Resident 27's admission Record, indicated Resident 27 was admitted to the facility on [DATE] with diagnoses including altered mental status (disruption in how…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that two of eight sampled residents (Residents 17 and 59) were provided appropriate gastrostomy tube (G-Tube - a flexible tube surgically inserted through the abdomen into the stomach for feeding, fluid, and medication administration), services by failing to: 1. Ensure a medically unnecessary G-Tube was removed timely for Resident 17. This placed Resident 17 at risk for developing avoidable complications of pain and possible infection. 2. Prevent aspiration by failing to ensure Resident 59's head of the bed was elevated during feeding. This failure placed Resident 59 at risk for aspiration (inhaling small particles of food or drops of liquid into the lungs) that can lead to lung problems such as pneumonia and placed the resident at risk for malnutrition. Findings: 1. A review of Resident 17's admission Record indicated Resident 17 was admitted to the facility on [DATE] with diagnoses including encounter for attention 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: 1. Label and date one of six sampled residents' (Resident 63) nasal cannula (device used to deliver supplemental oxygen or increased airflow to a patient or person in need of respiratory) per facility's policies. 2. Ensure one of six sampled residents (Resident 78) received continuous oxygen therapy according to physician's order. This deficient practice had the potential to cause complications associated with oxygen therapy. Findings: 1. A review of Resident 63's admission Record indicated Resident 63 was admitted to the facility on [DATE], with diagnoses including chronic obstructive pulmonary disease (COPD, a group of diseases that cause airflow blockage and breathing related problems making it difficult to breathe), acute respiratory failure (a fluid build-up in the lung air sacs making it difficult for lungs to bring oxygen back to the body's organs to function), and diabetes mellitus (a disorder where the body does not produce…

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

Based on interview and record review, the facility failed to provide nurse aide in-services education as required at least once every 12 months. This deficient practice had the potential for a knowledge, training, and certification deficit among the Certified Nurse Aide (CNA) staff, leading to inadequate resident care. Findings: During an interview with the Director of Staff Development (DSD), on 11/18/2021, at 12:23 p.m., the DSD acknowledged that records were not found of the past facility Staff In-Services conducted in previous years, addressing Dementia (A group of thinking and social symptoms that interferes with daily functioning) care training. The DSD provided documentation of nurse aide in-services held in 2012. A review of the 'Dementia Listening and Speaking' staff training sign-in sheet, dated 09/17/2021 did not indicate 'Length (in hours)' of the training. A review of the 'Special Needs of Residents and Socialization' staff training sign-in sheet, dated 11/02/2021 did not indicate 'Length (in hours)' of the training. During an interview with the DSD, on 11/18/2021 at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to maintain proper storage and labeling of medications as evidenced by: 1. Resident 17 having medication at the bedside in an empty tissue box, 2. A Medication Cart left unattended and unlocked in a common hallway, 3. Medications on the treatment cart were not labeled with the open date. These deficient practices had the potential for medication contamination, dispensing errors, and unauthorized access to medications, which could result in harm and/or death of residents. Findings: 1. A review of the admission record indicated Resident 17 was admitted to the facility on [DATE]. Resident 17's diagnoses included, but were not limited to, encounter for attention to gastrostomy, essential hypertension (or high blood pressure, a common condition in which the long-term force of the blood against artery walls is high enough that it may eventually cause health problems, such as heart disease), and sepsis (a life-threatening complication of 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.