Virgil Rehabilitation & Skilled Nursing Center

Based on observation, interview, and record review, the facility failed to provide a Physical Therapy (PT, profession aimed in the restoration, maintenance, and promotion of optimal physical function) Evaluation for one of four sampled residents (Resident 14) with ROM limitations, after identifying a decline in range of motion (ROM, full movement potential of a joint) on 5/14/2025, to obtain a baseline measurement, adjust the splint to the right knee, set a goal for the splint wear tolerance (amount of time a person could wear a splint before experiencing discomfort or skin irritation), monitor the skin, and train the RNA on applying the splint establish goals for the splint. As a result, a right knee extension (straightening) splint (material used to restrict, protect, or immobilize a part of the body to support function, assist and/or increase range of motion) was placed on Resident 14 without a PT Evaluation, placing Resident 14 at risk of developing additional ROM limitations and skin integrity (health and condition of the skin) issues. Findings: During a review of Resident 14'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.

Based on observation, interview, and record review, the facility failed to ensure to cap (cover) the enteral feeding (a way to deliver liquid nutrition directly into the stomach or small intestine through a soft, flexible tube) tube for one of two sampled residents (Resident 14) reviewed for enteral feeding. This failure had the potential for Resident 14's enteral tube feeding to become contaminated (the presence of unwanted or harmful substances that make something impure, unsafe, or unsuitable for its intended use, often by making it dirty) and increased the risk of infection.Findings:During a review of Resident 14's admission Record, the admission Record indicated the facility originally admitted Resident 14 on 11/18/2022 and readmitted Resident 14 on 1/8/2026 with diagnoses that included esophagitis, unspecified bleeding (the tube connecting your mouth to your stomach is inflamed, irritated, or swollen, causing it to bleed), gastrointestinal bleeding (bleeding in the tube-like system running from the mouth to your butt), aphasia (a disorder that makes it difficult to speak),…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, and record reviews, the facility failed to: 1. Clarify one of six sampled residents (Resident 31's) physician order for famotidine (a medication used to reduce the amount of acid produced by the stomach) dated 12/24/2025, which did not indicate a frequency (number of times) for taking the medication. 2. Ensure one of six sampled residents (Resident 80's) lidocaine patch (a medication in the form of a patch used to treat inflammation and pain) was available in stock at the facility. These deficient practices had the potential to cause medication errors for Resident 31 and inadequate pain relief for Resident 80 and placed both residents at risk for adverse health consequences such as acid-reflux, and decline in resident's mental, physical, functional or psychosocial status due to inadequate pain management.Findings: 1. During a review of Resident 31's admission Record (a document containing demographic and diagnostic information), dated 2/5/2026, the admission record indicated the facility…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 infection control measures necessary to prevent the spread of infections by failing to ensure the staff wore full personal protective equipment ([PPE] equipment worn to minimize exposure to hazards that cause serious workplace injuries and illnesses), including use of a face mask to cover both nose and mouth, during influenza ([flu] illness that infect the nose, throat, and lungs, causing sudden fever, cough, sore throat, body aches, and fatigue) season in accordance with the facility's policy and procedures titled Respiratory Virus Prevention and Control Plan, updated on 11/21/2025. These deficient practices had the potential to result in the spread of disease and illness throughout the facility, which could result in severe respiratory illness, hospitalization and/or death.Findings: During an interview on 2/5/2026 at 8:24 a.m. with the Infection Prevention Nurse (IPN), the IPN stated facility staff needed to wear face masks while inside the facility due to the current flu and Coronavirus disease…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 four sampled residents (Resident 1 and 2) who were fall risk, were provided with ordered and care-planned safety devices to reduce the risk of accidents. For Resident 1, the facility failed to ensure Resident 1's 's wheelchair had footrests and alarm as ordered by physician, and for Resident 2, the facility failed to ensure Resident 2 had footrests applied as recommended by Physical Therapy. These deficient practices had the potential to result in injury for Resident 1 and 2, during wheelchair transfer by facility staff.1.During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnosis of degeneration of brain, dementia (progressive impaired ability to think, remember or make decisions that interferes with doing everyday activities), weakness, and bilateral osteoarthritis (OA- is the most common form of arthritis, a degenerative joint…

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

Based on interview and record review the facility failed to report the elopement (when a resident leaves/escapes from a facility without a physician's order and without the staff knowing) from the facility of one out of three sampled residents (Resident 1) to the California Department of Public Health (CDPH), Ombudsman (an official appointed to investigate individuals' complaints against maladministration), and to the local law enforcement no later than 2 hours after Resident 1 went out on pass on 10/7/2025 at 12:50 PM and did not return to the facility, as per the facility's policy and procedures (P&P) titled Elopement, dated 1/2025. This failure resulted in the facility waiting until 10/8/2025 at 3 PM to notify CDPH, local law enforcement, and the Ombudsman, delaying the onsite inspection and investigation. This failure also Placed the resident at risk for worsening medical conditions, delayed care, being assaulted, accidents, injuries, and even death. During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 6/11/2025…

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

Based on interview, and record review, the facility failed to develop an individualized person-centered care plan (a plan of care that summarizes a resident's health conditions, specific care and services facility staff need to provide a resident to promote healing and prevent a worsening of a condition, and current treatments) to meet the resident's needs for one of three sampled residents (Resident 1). By failing to create and initiate a care plan for Resident 1's out on pass (temporary leave for a non-medical reason, such as a family visit or holiday meal) physician's order as indicated in the facility's Policy and Procedures (P&P) titled Out on Pass Policy and Procedures, dated 4/2024 and the facility's P&P titled Care Plans - Comprehensive, dated 1/2025 . These deficient practices had the potential for the residents to receive inadequate care and/or supervision which could affect the residents' quality of care and cause the resident harm.During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 6/11/2025 with diagnoses…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure one out of three sampled residents (Resident 1), who required supervision with walking, was assessed as risk for elopement (when a resident leaves/escapes from a facility without a physician's order and without the staff knowing), and was under Hospice (compassionate care for people who are near the end of life) care, did not leave the facility unsupervised while out on pass (temporary leave for a non-medical reason, such as a family visit or holiday meal) on 10/7/2025 at 12:50 PM. By failing to: 1. Conduct an IDT (IDT, a team of health care professions, which include the facility's medical director, Director of Nursing (DON), social worker, registered nurse, and other staff as needed who work together to establish plans of care for residents) meeting in collaboration with the Hospice agency to assess Resident 1's ability to participate in activities outside the facility (unsupervised) as indicated in the facility's Policy and Procedures titled…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to follow its policy and procedures (P&P), titled Out on Pass Policy and Procedure dated 4/2024 and P&P titled Physician orders and Telephone Orders with a review date of 1/2025, for one of three sampled residents (Resident 1) allowed to go out on pass (temporary leave for a non-medical reason, such as a family visit or holiday meal). By failing to ensure: 1. Resident 1's physician completed a medical evaluation of a resident's condition and reviewed the appropriateness of the resident's ability to safely leave the facility unsupervised and without direct access to facility staff. This failure resulted in Resident 1 leaving the facility unsupervised on 10/7/2025 at 12:50 PM and eloping (aka elopement: a patient or resident leaving a healthcare facility without permission and without being properly discharged ) from the facility. Placing the resident at risk for worsening medical conditions, delayed care, being assaulted, accidents, injuries, and even…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 care and services for two of five samples Residents (Residents 1 and 4) in accordance with professional standards of practice in order to meet resident's physical, mental, and psychosocial needs by failing to:1. Notify the physician about ineffective treatments for a generalized body rash as indicated in the Resident 1 care plan titled, alteration in skin as manifested by generalized body rash, initiated 7/29/2025.2. Implement a care plan for a rash on the left inner thigh for Resident 4 to monitor for effectiveness of the treatment.These deficient practices resulted in significant physical and psychosocial distress for both residents (Residents 1 and 4), including intense itching, insomnia, anxiety, depression, and reduced participation in daily activities. 1. During a review of Resident 1's Record of admission indicated, Resident 1 was admitted to the facility on [DATE] with diagnoses including hemiplegia (paralysis of one side…

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

Based on interview and record review the facility failed for one of three sampled residents (Resident 1), to inform about Medicare co pay upon admission. This deficient practice caused the Resident 1's representative (RR) to be surprised by a bill and violated their right to be informed. Findings: A review of Resident 1's admission record indicated the facility admitted Resident 1 on 1/8/2025 with diagnoses including pneumonia (an infection/inflammation in the lungs), adult failure to thrive (FTT- a decline caused by chronic diseases and functional impairments which can cause weight loss, decreased appetite, poor nutrition, and inactivity), dementia (a progressive state of decline in mental abilities) and anxiety (condition of chronic worry and fear). A review of Resident 1's Minimum Data Set (MDS- a resident assessment) dated 1/15/2025 indicated Resident 1's cognition was not intact. Resident 1 required maximal assist (helper does more than half the effort to complete the activity) with toileting, bathing, dressing. A review of Resident 1's physician order dated 1/24/2025 indicated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one sampled resident (Resident 21) had proper documented representation to make medical decisions, as there was no conservatorship application when Resident 21 was deemed non competent. This deficient practice caused an increased risk in the resident receiving care without proper documented representation. Findings: A review of Resident 21's admission record indicated the resident was admitted to the facility on [DATE] with diagnoses including epilepsy (condition involving the brain that makes people more susceptible to having recurrent unprovoked seizures [a burst of uncontrolled signals between brain cells]), Parkinson's disease (condition that causes nerve cells in the brain to die), and dementia (condition that makes someone unable to remember, think clearly, or make decisions while doing everyday activities). A review of a notice of referral receipt from the Department of Mental Health (DMH), provided by the Social Services Assistant (SSA),…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 comprehensive care plans for one of six sampled residents (Resident 35 and Resident 6). For Resident 35, who had a urinary tract infection (UTI-an infection involving any part of the urinary system, including urethra, bladder, ureters, and kidney), there was no care plan developed with individualized approaches. For Resident 6, the renal insufficiency care plan was not reviewed quarterly and the intervention was not implemented. These deficient practices had the potential to result in a delay or lack of delivery of care and services. Findings: a. A review of Resident 35's admission Record indicated that resident was admitted to the facility on [DATE] with diagnoses of, but not limited to benign prostatic hyperplasia (when prostate gland enlarges, putting pressure on the urethra), sepsis (a life-threatening blood infection), and acute kidney failure (a sudden loss of kidney function). A review of Resident 35's Annual 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the oxygen care plan for two of five sampled residents (Resident 35 and Resident 38), was reviewed and revised quarterly to reflect the resident's current status and interventions being provided to the resident. This deficient practice placed both residents at risk of unrecognized change of condition or delay in necessary intervention. Findings: a. A review of Resident 35's admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses including respiratory failure with hypoxia (low oxygen level in the blood stream), acidosis (a condition in which there is too much acid in the body fluid), and heart failure (when the heart is unable to pump enough blood and oxygen to the body's organs). A review of the At Risk for Difficulty Breathing care plan revised on 12/1/2023, indicated Resident 35 had respiratory failure and the interventions included to elevate the head of the bed and provide oxygen as ordered. A review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one sampled resident (Resident 69) received proper oral care. The failure had the potential for Resident 69 to experience bad breath, infection, and lack of eating. Findings: A review of Resident 69's admission record indicated the resident was admitted to the facility on [DATE] with a diagnoses including reduced mobility, muscle weakness, and age-related physical debility (quality or state of being weak, feeble, or infirm). A review of Resident 69's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 11/26/24 indicated the resident was alert and oriented. and required substantial / maximal assistance with eating, oral hygiene, and personal hygiene. During observation on 12/23/24 at 10:22 AM in Resident 69's room, the resident was lying in bed watching TV. Resident 69 indicated by shaking her head yes that she liked the care. Resident 69 indicated by shaking her head yes that she had her call light within…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 35) received two liters of oxygen continuously, per the physician's order. This deficient practice had the potential to result in respiratory distress (difficulty breathing) for Resident 35. Findings: A review of Resident 35's admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses including respiratory failure with hypoxia (low oxygen level in the blood stream), acidosis (a condition in which there is too much acid in the body fluid), and heart failure (when the heart is unable to pump enough blood and oxygen to the body's organs). A review of Resident 35's care plan revised on 12/1/2023, indicated the resident was at risk for difficulty breathing related to respiratory failure. The interventions included to elevate the head of the bed and provide oxygen as ordered. A review of the Physician's Order Summary Report dated 1/9/2024, indicated to provide…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 carvedilol (a medication used to treat high blood pressure) bubble pack (a medication card containing tablets or capsules provided by pharmacy to the facility) hold parameters (parameters instructed by physician to follow to administer or not to administer high blood pressure medication to resident based on blood pressure reading) for blood pressure matched accurately with the hold parameters for blood pressure in facility's physician order, affecting one of four sampled residents (Resident 36) during medication pass observation. -Ensure metformin (a medication used to treat Diabetes Mellitus [DM - a disorder characterized by difficulty in blood sugar control and poor wound healing]) was administered within one hour of the prescribed time of administration, as per facility's policy and procedure (P&P) titled, Administering Medications, dated 1/2023, affecting one of four sampled residents (Resident 8) during medication pass…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 a medication error rate of less than 5% (percent) during medication pass for one of four sampled residents (Resident 8). Resident 8 was not administered metformin (a medication used to treat Diabetes Mellitus [DM - a disorder characterized by difficulty in blood sugar control and poor wound healing]) within one hour of the prescribed time and was not provided Visine-A solution ([generic name - naphazoline-pheniramine eye drops], a medication used to treat irritation and dry eyes) in accordance with the physician's orders. These deficient practices caused a medication administration error rate of 6.67%, exceeding the five (5) percent threshold. Findings: A review of Resident 8's admission Record indicated the facility originally admitted Resident 8 on 1/1/2009 and readmitted Resident 8 on 7/14/2009 with diagnoses including Type II Diabetes Mellitus without complications. A review of Resident 8's Minimum Data Set (MDS, a federally mandated assessment tool), dated 11/20/2024, indicated the resident'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 storage and/or labeling of Resident 19's lorazepam (a controlled substance [a medication with a high potential for abuse] used to treat anxiety [a medical condition described by feeling of fear or uneasiness]) 2 milligrams (mg - a unit of measurement for mass) per milliliters (mL - a unit of measurement for volume) concentrate per manufacturer's requirements in one of two inspected medication carts (Station 3 Medication Cart). This deficient practice had the potential to result in Resident 19 receiving lorazepam that had become expired, ineffective, or toxic due to improper storage and labeling possibly leading to anxiety and/or hospitalization due to health complications. Findings: A review of Resident 19's admission Record indicated the facility originally admitted the resident on [DATE] and readmitted on [DATE] with diagnoses including encounter for palliative care (a care to provide comfort and improve quality of care for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain infection control practices for one of four sampled residents (Resident 8) by failing to ensure sanitary environment in resident care areas. Resident 8's male urinal was full of urine and stored on the bedside cart along with other resident's belongings. This deficient practice had the potential to result in transmission of infectious microorganisms and increase the risk of infection for Resident 8. Findings: A review of Resident 8's admission Record indicated the facility originally admitted the resident on 1/1/2009 and readmitted on [DATE] with diagnoses including Type II Diabetes Mellitus ([DM] - a disorder characterized by difficulty in blood sugar control and poor wound healing) without complications and encounter for screening for other viral diseases. A review of Resident 8's Minimum Data Set (MDS, a federally mandated assessment tool), dated 11/20/2024, indicated the resident's cognition was intact and required clean up…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure rooms meet the requirement of no more than 4 beds per room for four sampled resident rooms (room [ROOM NUMBER], 218, 219, and 312). This deficient practice had the potential to affect the delivery of care and safety of the residents. Findings: During observation and interview on 11/27/24 at 3:14 PM with Resident 44, Resident 44 was in a room with 4 beds, stated he had enough space for privacy and family to visit. Resident 44 stated his roommate was not in the room but his roommate was able to come in and out freely. During an interview on 11/27/24 at 3.21 PM, Certified Nurse Assistant (CNA) 1 stated she was assigned to room [ROOM NUMBER] and 308. CNA 1 stated she felt there was enough space for her to perform her duties in each room. CNA 1 stated especially in room [ROOM NUMBER] because she used the Hoyer lift (electronically operated patient lift for the safe lifting of heavier patients) for Resident 44, and she could get the lift…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 the call light (an alerting device for nurses or other nursing personnel to assist a patient when in need) within reach of the resident for two of the two sampled residents (Resident 12, 39). This deficient practice had the potential to result in the residents not being able to summon a health care worker for help as needed. Findings: A review of Resident 12's admission record indicated Resident 12 was admitted to the facility on [DATE] with diagnoses that included Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements such as shaking, stiffness, and difficulty with balance and coordination), diabetes type 2 (a long-term medical condition in which the body does not use insulin [a hormone that lowers the level of sugar in the blood] properly), and muscle weakness. A review of Resident 12's history and physical, dated 4/27/2023, indicated Resident 12 had fluctuating capacity to understand and make…

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

Based on interview, the facility failed to ensure mail was delivered to residents on Saturdays. This had the potential to affect all residents in the facility who received personal mail, including but not limited to 4 of 11 residents (Resident 3, Resident 4, Resident 6, Resident 10) at the resident council meeting, who verbally confirmed not receiving mail on Saturdays. Findings include: On 12/26/2023 at 2:09 PM a group of residents met to discuss the resident council. When asked whether residents received their mail on Saturdays, several residents voiced concerns they did not receive mail on Saturdays. Resident 56 stated the Social Services Designee (SSA) gives out the mail and she is not here on Saturdays. During an interview on 12/27/2023 at 2:07 PM, SSA stated the business office receives and sorts the mail. Then the business office delivers the mail to SSA for SSA to dispense. SSA further stated residents are able to get mail Monday through Friday. On Saturday, residents are unable to receive mail because the business office is closed. Mail received over the weekend is held…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 clinical records contained an advance directive (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) acknowledgement form for three out of the three sampled residents (Resident 12, 57, 269). This deficient practice had the potential to cause conflict with a resident's wishes regarding health care. Findings: 1. A review of Resident 12's admission record indicated Resident 12 was admitted to the facility on [DATE] with diagnoses that included Parkinson's Disease (a brain disorder that causes unintended or uncontrollable movements such as shaking, stiffness, and difficulty with balance and coordination), diabetes type 2 (a long-term medical condition in which the body does not use insulin [a hormone that lowers the level of sugar in the blood] properly), and muscle weakness. A review of Resident 12's history and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain residents' room temperature level between 71- and 81-degree Fahrenheit (° F) as required by the Federal regulation for one of three sampled residents (Resident 1) and three of five rooms checked during an environmental tour. This deficient practice resulted in the resident's increased level of discomfort and had the potential to negatively impact the resident's quality of life. Findings: During an observation on 12/26/2023 at 9:00 AM, Resident 1 and Resident 1's room was observed. Resident 1 was lying flat on her back, fully covered with multiple blankets. The window next to Resident 1's bed was louver styled. Several broken panes and there were gaps despite the louvers being closed were observed. During a concurrent interview, Resident 1 stated the room is too cold in the morning. She can't get out of bed because it is too cold. She likes for the room to warm up before she gets out of bed to start her day. A review of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide necessary respiratory care services for three of five sampled residents (Resident 45, 65 and Resident 269) by failing to ensure the residents oxygen tubing and humidification bottles were dated per the facility's Oxygen Administration - Resident, policy and procedure. This deficient practice had the potential to result in complications associated with oxygen therapy, including infection or respiratory distress. Findings: a. A review of Resident 45's admission record indicated the facility admitted the resident on 3/19/2022 with diagnoses that included chronic obstructive pulmonary disease (COPD - a lung disease characterized by long term poor airflow), seizures and high blood pressure. A review of Resident 45's physician orders dated 3/19/2022 indicated to administer oxygen at 2 liters per minute (lpm) via nasal canula (NC), as needed, to keep oxygen saturations greater than 92%. A review of Resident 45's oxygen therapy care plan,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 that staffing information was posted and placed in a visible and prominent place daily. As a result, the total number of staff and the actual hours worked by the staff were not readily accessible to residents and visitors. Findings: During an observation on 12/26/12023 at 8:05 A.M., the facility staffing information posted on the facility's bulletin board was from 12/22/2023. During an observation and interview on 12/29/2023 at 9:05 A.M. with the Director of Staff Development (DSD), the DSD stated the facility staffing information posted on the bulletin board was from 12/28/2023. The DSD stated that the daily staffing information for 12/23/23, 12/24/2023, 12/25/2023 and 12/26/2023 was included in the same clear sheet protector as the 12/22/2023 information but was not visible. The DSD stated the daily staffing posting should be visible. The DSD stated he did not post the updated staffing for 12/29/2023 and he will update the information. During an interview on 12/29/2023 at 10:22 A.M., the Director of…

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

Based on observation, interview, and record review the facility failed to: 1. Store food in accordance with professional standards for food service safety by failing to: a. Label four gallons of Salad oil with the receiving date. b. Label ten containers of grits with the receiving date. c. Label two cans of apple juice with the receiving date. 2. Discard open canned mushrooms after three days of storage in the refrigerator. These deficient practices had the potential to result in food-borne illnesses. Findings: During a concurrent observation and interview on 12/26/2023 at 8:25 A.M., the surveyor observed four gallons of Salad Oil, 10 containers of grits, and two cans of apple juice with no receiving dates in the dry storage room. Dietary [NAME] 1 (DC 1) stated the Salad oil, grits, and apple juices should have been labeled with their receiving dates. One container of open canned mushrooms was observed in the refrigerator with an open date of 12/22/2023. DC 1 stated that the mushrooms should have been discarded on 12/25/2023. During an interview on 12/26/2023 at 12:06 P.M. with the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to observe infection control measures for two of the two sample residents (Residents 56 and 57) by failing to ensure the residents' urinals (a container used to collect urine) were labeled with residents' names and room numbers. This deficient practice had the potential to result in the contamination of the residents' care equipment and placed the residents at risk for infection. Findings: a. A review of Resident 56's record of admission indicated the facility admitted the resident on 10/27/2021 with a readmission date of 8/30/2022. Resident 56's diagnoses included chronic heart failure (a condition that develops when your heart does not pump enough blood for your body's needs), diabetes type 2 (a long-term medical condition in which the body does not use insulin [a hormone that lowers the level of sugar in the blood] properly), and chronic kidney disease (a condition in which the kidneys are damaged and cannot filter blood well). A review…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 of 38 residents rooms, room [ROOM NUMBER], 218 and 219 accommodated no more than four residents per room. The three rooms each had 5 residents in the rooms. This deficient practice had the potential to result in inadequate space to provide safe nursing care and privacy for the resident. Findings: On 12/26/2023 at 9 AM during a tour of the facility, rooms [ROOM NUMBER], were observed to have five beds per room and were occupied by interviewable and non-interviewable residents. room [ROOM NUMBER] was being used as storage and was not occupied by residents. During an interview on 12/26/23 at 9:08 AM, Resident 38 stated he has enough space despite there being five beds in the room. During an interview on 12/26/23 at 9:15 AM in room [ROOM NUMBER], Certified Nursing Assistant (CNA 1) stated there's enough room to do her work without obstruction. During the survey on 12/26/2023 to 12/29/2023, the certified nursing assistants 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 provide a bed hold notification (holding or reserving a resident's bed while the resident is absent from the facility for therapeutic leave or hospitalization) at the time of transfer to the hospital for one of three sampled residents (Resident 19). This deficient practice denied Resident 19 or her Responsible Party (RP) of being informed of her right to have the facility hold and reserve her bed while absent from the facility. Findings: A review of Resident 19's admission record indicated the facility originally admitted Resident 19 on 1/1/2009, and readmitted on [DATE], with diagnoses that included type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar [glucose]), and gastrostomy (a tube inserted through the belly that brings nutrition directly to the stomach). A review of Resident 19's Minimum Data Set (MDS - a standardized assessment and screening tool) dated 10/20/2023, indicated Resident 19 had severely…

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

Based on interview, and record review, the facility failed to develop an individualized person-centered care plan to meet the resident's need for one of five sampled residents (Resident 37) by failing to develop a care plan with goals and interventions for colostomy (creating a hole in the abdominal wall allows waste to leave the body) care. This deficient practice had the potential to result in inadequate care of Resident 37. Findings: A review of Resident 37's admission record indicated the facility admitted Resident 37 on 11/29/2023, with diagnoses that included gastrostomy (a tube inserted through the belly that brings nutrition directly to the stomach), and colostomy. A review of Resident 37's physician orders dated 11/29/2023, indicated to perform colostomy bag care during each shift. A review of Resident 37's Minimum Data Set (MDS - a standardized assessment and screening tool) dated 12/6/2023, indicated Resident 37 had moderately impaired cognition (decisions poor, cues/supervision required). The MDS indicated Resident 37 is dependent in eating, oral and toileting hygiene,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 titled Smoking Policy - Residents, for one of four sampled residents (Resident 43). This deficient practice placed Resident 43 at increased risk for injuries related to smoking. Findings: A review of the admission record (Face Sheet) indicated the facility admitted Resident 43 on 10/20/2021, with diagnoses that included a history of falling, and bradycardia (a slow heart rate). A review of the Minimum Data Set (MDS - a standardized assessment and care-screening tool) dated 10/19/2023, indicated Resident 43 had intact cognition (decisions consistent and reasonable). The MDS further indicated Resident 43 required moderate assistance for personal hygiene, toileting and oral hygiene, and upper and lower body dressing. During an observation on 12/27/2023 at 8:40 AM, Resident 43 was observed sitting on her wheelchair, wearing a smoking apron and smoking in the smoking patio. The Activity Aid (AA) was observed supervising…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 ensure discontinued medication was not available in the medication cart for use for one (1) of 39 sampled residents (Resident 14), There was a package of 25 tablets of hydrocodone/APAP (Norco, a potent narcotic and controlled substance to treat pain) 10/325 milligrams (mg, a unit to measure weight) in Medication Cart 1. The controlled drug record indicated Resident 14 received 1 dose of Norco on 12/24/23 around 1:30 PM. However, the Norco medication order had been discontinued on 12/21/23. Additonally, the nurse who administered the Norco dose had incorrectly documented the administration as Norco 5/325 mg (which was the active order at the time). This deficient practice had the potential to result in drug diversion and/or medication errors. (cross referrece to F760) Findings: On 12/27/23 at 8:57 AM during an interview, the licensed vocational nurse (LVN 3) stated the facility has 2 nursing stations, 2 medication rooms, and 4 medication carts. On 12/27/23 at 9:26 AM during an observation at the medication…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 there was documentation of the specific behavior exhibited when an antipsychotic (medication that alter brain chemistry to help reduce psychotic symptoms such as hallucination, delusion, and disordered thinking) was administered, as needed, to one (1) of 39 sampled Resident (65). This deficient practice had the potential to result in administering unnecessary medication, and/or a medication error. Findings: A review of Resident 65's admission record indicated Resident 65 was admitted on [DATE] for Hospice skilled nursing (providing skilled nursing care for the sick or terminally ill) care. Resident 65's diagnosis included malignant neoplasm (cancer) of the brain and malignant melanoma (a form of cancer) of the skin. A review of Resident 65's physician orders indicated an order dated 12/4/23 to administer Haldol (an antipsychotic) intramuscularly (into the muscle) 5 milligrams (mg, an unit of measuring weight) as needed for anxiety manifested by…

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

Based on interview and record review, the facility failed to ensure one (1) of 39 sampled residents were free from significant medication errors (an error in medication administration that may jeopardizes a resident's health and/or safety), as evident by failing to administer the correct dose of hydrocodone/APAP (Norco, a potent narcotic and controlled substance to treat pain) as per order, for Resident 14. (Cross reference to F755) Findings: On 12/27/23 at 9:26 AM during an observation at the medication cart 1 with LVN 2, there was a pack of Resident 14's hydrocodone/APAP (generic name for Norco, a potent narcotic and controlled substance to treat pain) 10/325 mg tablets. The controlled drug record for the Norco medication indicated the last dose given was on 12/24/23 at 1:30 PM. On 12/27/23 at 9:35 AM during a concurrent interview and a review of Resident 14's active orders, LVN 2 stated there was no active order of the Norco 10/325 mg, however, there was an active order of Norco 5/325 mg, dated 12/23/23 at 11:50 PM to give 1 tablet every 4 hours, as needed, for pain. LVN 2 also…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 1 (LVN 1) had the initial and/or annual competency for medication administration prior to administering medications to residents in the facility. This deficient practice had the potential for residents not to receive medication administration per physician orders and place the residents at risk for injury and harm. Findings: During an interview on 8/1/2023 at 6:15 AM, with Licensed Vocational Nurse 1 (LVN 1), she stated she has been working at the facility for about two months. LVN 1 stated she did not receive any competencies for medication administration since she has been working at the facility. She stated she can-not recall if she received medication administration competency within the last year. She stated no one in the facility checked to see if she had her competency for medication administration. During a concurrent record review and interview on 8/1/2023 at 10:31 AM, with Minimal Data Set Nurse (MDSN), licensed staff competency documents were reviewed. MDSN stated…

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