Vista Del Sol Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to:1. Implement the recommendations of the facility's Registered Dietician (RD - a food and nutrition expert who has completed extensive training to help people manage their health through eating)according to the facility's policy and procedures (P&P) titled Assisted Nutrition and Hydration, dated 1/2025 when Registered Dieticians (RD - a food and nutrition expert who has completed extensive training to help people manage their health through eating) for one of three sampled residents (Resident 7).This deficient practice had the potential to cause worsening weigh loss and possibly hospitalization for Resident 7.2. Ensure that staff changed enteral feeding formula (a method of delivering liquid nutrition directly into the stomach or small intestine when a person cannot eat or swallow safely) and the enteral feed tubing (a flexible tube for delivering nutrient-rich liquid formula directly into the stomach or small intestine) after 24 hours for one of one…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 supplemental oxygen (O2) administration for one of four sampled residents (Resident 25), the facility failed to : This deficiency had the potential for Resident 25 to experience undesired health effects related to the administration of oxygen not limited to hypoxia (a dangerous medical condition where body tissues or organs do not receive enough oxygen, potentially causing severe damage or death within minutes), hospitalization and death. Findings: During a review of Resident 25's admission record (face sheet - a document containing demographic and diagnostic information) indicated Resident 25 was admitted to the facility on [DATE] and re-admitted on [DATE] with the following diagnoses: acute kidney failure), type 2 diabetes mellitus (a disorder characterized by difficulty in blood sugar control and poor wound healing), anemia (a condition marked by a lack of healthy red blood cells or hemoglobin, reducing…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 and interview, the facility failed to implement Health insurance portability and Accountability Act (HIPAA - protect sensitive health information from being shared without knowledge or consent) and to provide care in a manner that promoted and enhanced the resident's quality of life, dignity, respect and individuality for and ensure that care for one of three sampled Residents (Resident 54) according to the facility's policy and procedure (P&P) titled Dignity and Respect, dated 1/2025. This deficient practice resulted in the violation of HIPPA and dignity rights for Resident 54.Findings: A review of Resident 54's admission Record indicated the facility admitted Resident 54 on 4/17/2026 with diagnoses including dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough), diabetes (DM - a disorder characterized by difficulty in blood sugar control and poor wound healing), and major depressive disorder (persistent low mood, deep sadness, or a loss of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure two of two staff (Certified Nursing Assistant (CNA) 1 and Licensed Vocational Nurse (LVN) 1) practiced infection control standards according to the facility facility's policy and procedures (P&P) titled Standard Precautions, dated 12/2025 when:1.CNA 1 did not remove a gown (personal protective equipment-PPE) when exiting a resident's isolation room (a specialized, private room designed to separate a patient from others to control the spread of infections or protect vulnerable patients).2. LVN 1 did not disinfect (the process of using chemicals or physical agent to kill/destroy bacteria and other very small living things that cause disease) the blood pressure machine ( a device to monitor/check blood pressure) between residents. This deficient practice had the potential to spread infection in the facility leading to hospitalization.Findings: A review of Resident 6's admission Record indicated the facility admitted Resident 6 on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the licensed nursing staff failed to offer the influenza (flu) vaccine as required or appropriate to one of five sampled residents (Resident 38). This deficient practice placed Resident 38 increased risk of acquiring and transmitting the flu to other residents in the facility. Findings: A review of Resident 38's admission Record indicated the resident was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses of Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), difficulty swallowing and high blood pressure. A review of Resident 38's Minimum Data Set (MDS- a resident assessment tool) dated 4/10/2026, indicated the resident's cognition (ability to think and reason) was severely impaired. A review of Resident 38's Immunization Report, dated 5/4/2026, indicated Resident 38 last received the flu vaccine on 3/25/2025. During a concurrent interview and record review on 5/1/2026…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 licensed nursing staff failed to offer the Coronavirus Disease (COVID-19) vaccination to two of five sampled residents (Resident 2). This deficient practice placed Resident 2 at a higher risk of acquiring and transmitting the COVID-19 to other residents in the facility. Findings: A review of Resident 2's admission Record indicated the facility originally admitted the resident on 9/8/2021 and readmitted on [DATE], with diagnoses of dementia (a progressive state of decline in mental abilities), pressure Ulcer/injury Stage 4 (Full-thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage, or bone) and gastro-esophageal reflux disease (GERD- frequent heartburn). A review of Resident 2's Minimum Data Set (MDS - a resident assessment tool) dated 3/11/2026, indicated Resident 2 had severely impaired cognition (never/rarely made decisions). The MDS indicated the resident is dependent for toileting and personal hygiene. A review of Resident 2's Immunization…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 Certified Nurse's Aide (CNA) 3 reported the alleged violation of abuse to the facility Administrator (Admin) within 2 hours of receiving report of abuse allegation f for one of three sampled residents (Resident 1) according to facility policy and procedures titled, Reporting of Alleged Violations with a review date of 01/2025. This deficient practice of failing to report the alleged violation of abuse had the potential to result in delayed investigation by California Department of Public Health (CDPD) of the abuse in the facility and failure to protect Resident 1 from further abuse. Findings: During a review of Resident 1's admission record (face sheet - a document containing demographic and diagnostic information) indicated Resident 1 was admitted to the facility on [DATE] with the following diagnoses: unilateral primary osteoarthritis, right knee, generalized muscle weakness (lack of physical or muscle strength), major…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 implement its abuse prevention program policy and procedure by failing to verify potential candidate's background check for a history of abuse, neglect, or mistreatment prior to the employee start working in the facility for one Certi ed Nursing Assistant (CNA 1).This failure had the potential for mistreatment, neglect, misappropriation of property, and abuse of residents.Findings:During a concurrent interview and record review on 9/16/2025 at 2:01 p.m. with the Director of Staff Development (DSD) of CNA 1 file, it indicated CNA 1 was hired on 1/7 2025. CNA 1 had been working with a registered sex offender background record and that did not match the CNA's name or date of birth matching with their California identi cation card. The DSD stated that the pre-employment veri cation process should have accurate and stated the CNA's name and date of birth before the employee's start date. The DSD stated, she was unsure how the document indicating a registered sex offender ended up in the CNA's employee le.During an interview with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to investigate allegations of sexual abuse (non-consensual sexual contact of any type or sexual harassment), for one of three sampled residents (Resident 3) and report to California Department of Public Health (CDPH), Ombudsman (a representative that helps families and residents in long-term care facilities by investigating and resolving complaints and serving as an advocate), and to the local law enforcement within 2 hours, failed to suspend the individual involved in the abuse allegations.This deficient practice had the potential to place other facility residents at risk for abuse, and delay required onsite inspection by CDPH. A review of Resident 3's admission record indicated Resident 3 was admitted to the facility on [DATE] with a diagnosis including reduced mobility (having difficulty moving around easily or freely, affecting your ability to perform daily tasks like walking, standing), unspecified altered mental status (thinking, awareness, or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to revise fall interventions to prevent repeated falls for one of four residents (Resident 1). Resident 1 was at risk for fall. As a result, Resident 1 suffered an unwitnessed fall on 6/07/2025 and was transferred to a general acute care hospital (GACH - a health facility having professional responsibility and an organized medical staff that provides 24-hour inpatient care) for further evaluation and care. The deficient practice also had the potential for Resident 1 to sustain serious injury and death. Findings: During a record review, the admission Record indicated Resident 1 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including unspecified dementia (a condition in which a person loses the ability to think, remember, learn, make decisions, and solve problems), displaced fracture of the neck of the femur (thigh bone), lack of coordination, and difficulty walking. During a record review, Resident 1's 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 observation, interview, and record review, the facility failed to implement its policy titled Abuse Prevention Program reviewed 8/2024, for one of two sampled residents (Resident 1), when on 4/8/2025 at 11:55 AM Resident 1 accused Certified Nursing Assistant 1 (CNA1) of sexual abuse (non-consensual sexual contact/touching of any type or sexual harassment), CNA1 was not immediately removed from providing direct care (including incontinent care) to residents and continued to have access Resident 1. As a result of this deficiency, Resident 1 was not protected from the potential of further harm or retaliation from CNA1 after being identified as a perpetrator. Findings: A review of Resident 1's admission Record indicated the facility admitted the resident on 11/21/2022 and re-admitted on [DATE] with diagnoses that included functional quadriplegia (someone who has developed paralysis from the neck down, including legs, and arms, usually due to a spinal cord injury but has regained some level of independence…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 investigate and report allegations sexual abuse (non-consensual sexual contact/touching of any type or sexual harassment), for one out of two sampled residents (Resident 1) to the Department of Public Health, Ombudsman (an official appointed to investigate individuals' complaints against maladministration), and to the local law enforcement in accordance with the facility's policy and procedures (P&P) titled Abuse Investigation and Reporting reviewed 8/2024. By failing to report a sexual abuse allegation to the State Survey Agency (SSA) within 2 hours after the allegation occurred on 4/9/2025. This deficient practice had the potential to delay of an onsite inspection by the California Department of Public Health and law enforcement to ensure Resident 1's circumstance were investigated. This deficient practice also had the potential to place Resident 1 at further risk for abuse. Findings: A review of Resident 1's 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to: 1. Date the nasal canula (N/C- a plastic tube connected to an oxygen source that delivers 2-6 L/min of oxygen through prongs placed into each nostril) for two of four sampled residents, Residents 23 and 21 2. Date nebulizer (a medical device used to administer medication in the form of a mist inhaled into the lungs) tubing for Residents 23 and 21 3. Cover nebulizer mask after use for Residents 23 and 21 4. Date humidifier for Resident 23 These failures could have resulted in Resident 23 and Resident 21 acquiring an infection. Findings: 1. During record review, the admission Record for Resident 23 indicated the resident was readmitted to the facility on [DATE], with diagnoses that included chronic obstructive pulmonary disease (COPD- a group of lung diseases that block airflow and make it difficult to breathe), dependence on supplemental oxygen, unspecified asthma (a chronic lung disease that causes inflammation in the airways, making it…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility's licensed nursing staff failed to ensure one out of 13 sample residents (Resident 20) received pain medication as prescribed by his physician by, failing to administer Resident 20's Aspercreme Lidocaine Patch 4% (a topical pain relief patch) for right knee pain as ordered by his physician. This deficient practice had the potential of causing unnecessary pain, mental anguish, and emotional distress by failing to attain or maintain Resident 20s highest practicable physical, mental, and psychosocial well-being. Findings: During record review, Resident 20's admission record indicated Resident 20 was admitted on [DATE] with diagnoses that included joint disorders (a disease or injury that affects a joint) right knee, contracture (scarring soft tissues that causes them to tighten and stiffen.)of the right knee , muscle weakness, Alzheimer's (brain condition that causes a progressive decline in memory, thinking, learning and organizing skills.), dementia…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 concurrent record review the facility failed to: 1. Maintain documentation and evidence of its ongoing Quality Assurance and Performance Improvement (QAPI) program; or 2. Present its QAPI plan to the Federal and/or State surveyors during recertification survey or upon request; or 3. Present QAPI evidence necessary to demonstrate compliance with these requirements; or 4. Develop, implement, and maintain an effective, comprehensive QAPI program, that addresses the full range of services the facility provides; or 5. Ensure governing body oversight of the facility's QAPI program and activities. Theses failures resulted in facility not having a comprehensive QAPI program and plan, disclosure of records and governance and leadership. Findings: During an interview and concurrent record review to complete the task titled QAPI and QAA on 2/16/2025 at 2/16/2025 at 5:39 pm, Administrator stated the QAPI and QAA contact person is Director of Nursing. During a concurrent record review, the QAPI and Quality Assessment and Assurance (QAA) documents with the Administrator,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 maintain effective systems to obtain and use of feedback and input from direct care staff, other staff, residents, and resident representatives, including how such information will be used to identify problems that are high risk, high volume, or problem-prone, and opportunities for improvement b failing to: 1. Conduct monthly and quarterly Quality Assurance and Performance Improvement (QAPI) meetings: 2. Provide proof for concerns related to how the facility obtains feedback, collects data, monitors adverse events, identifies areas for improvement, prioritizes improvement activities, implements corrective and preventive actions, and conducts performance improvement projects during QAPI meeting. These failures had the potential to result in the facility not establishing and implementing writing/revising policies and procedures, developing, and implementing appropriate plans of action to correct identified quality deficiencies, obtaining feedback, collecting, tracking, and analyzing data, monitoring and implement…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 concurrent record review, the facility failed to meet quarterly and receive reports from the Infection Prevention and on the Infection Preventionist Control Program This failure resulted in the Quality Assurance and Performance Improvement (QAPI) committee not in compliance with establishing performance and outcomes for quality of care and services delivered in the facility. Findings: During an interview and concurrent record review on 2/16/2025 at 2/16/2025 at 5:39 pm, the facility document titled QAPI and QAA was reviewed with the Administrator. The Administrator stated the QAPI and QAA contact person is Director of Nursing. During a concurrent record review, the QAPI and Quality Assessment and Assurance (QAA) documents with the Administrator, Registered Nurse Supervisor/Assistant Director of Nursing/Infection Preventionist Nurse (RNS/ADON/IPN), Director of Health Information, and Director of Social Service, there was no binder or documents on hand at the meeting in the Administrator's office. The Administrator stated, it is the responsibility of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure one of three sampled residents, Resident 10, had a care plan for Schizophrenia (a mental illness that is characterized by disturbances in thought). This deficient practice placed Resident 10 at risk of receiving inappropriate care. Findings: During record review, Resident 10's admission record indicated the facility originally admitted Resident 10 on 4/9/2024 and most recently on 1/31/2025 with diagnoses including chronic obstructive pulmonary disorder (COPD-a chronic lung disease causing difficulty in breathing), morbid obesity (severely overweight), anemia (a condition where the body does not have enough healthy red blood cells), gout (arthritis), general anxiety disorder (GAD-condition of persistent worrying) asthma (chronic condition that causes shortness of breath) major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), schizophrenia and insomnia (trouble falling asleep or staying…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 of three sampled residents, Resident 10, had care plans revised per policy and procedures titled Care Plans, Comprehensive Person-Centered. revised 3/2022. This deficient practice placed Resident 10 at risk of receiving inappropriate care. Findings: During record review, Resident 10's admission record indicated the facility originally admitted Resident 10 on 4/9/2024 and most recently on 1/31/2025 with diagnoses including chronic obstructive pulmonary disorder (COPD-a chronic lung disease causing difficulty in breathing), morbid obesity (severely overweight), anemia (a condition where the body does not have enough healthy red blood cells), gout (arthritis), general anxiety disorder (GAD-condition of persistent worrying) asthma (chronic condition that causes shortness of breath) major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), schizoaffective disorder Bipolar type, (a mental illness that can affect thoughts, mood, and behavior; sometimes called…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review for one of three sampled residents, Resident 1, the facility failed to notify the attending physician of x-ray results indicating a hip fracture in a timely manner. This deficient practice delayed Resident 1 to receive the definitive (medical treatment that goes beyond emergency care to maximize recovery) care to fix the fracture and had the potential to cause Resident 1 to experience pain longer than necessary. Findings: During record review, Resident 1's admission record indicated the facility admitted on [DATE] and most recently on 1/24/2025 with diagnoses including atrial fibrillation (irregular heart beat), lack of coordination, anemia (a condition where the body does not have enough healthy red blood cells), hypothyroidism(low thyroid function), hyperlipidemia (high fat in the blood), Alzheimer's (a disease characterized by a progressive decline in mental abilities), hypertension (high blood pressure) and gastroesophageal reflux disease (indigestion/heartburn). During…

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

Based on interview and record review the facility failed to ensure the physician reviewed the monthly medication review recommendation from pharmacy for one of three sampled residents, Resident 14. This deficient practice placed Resident 14 at risk of receiving an unnecessary dose of antipsychotic (medication to treat mental health condition) medications. Findings: During record review, Resident 14's admission record indicated the facility originally admitted resident 14 on 2/22/2024 and most recently on 4/11/2024 with diagnoses including low back pain, chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and Anxiety (excessive worrying and fear). During record review, Resident 14's minimum data set (MDS - a resident assessment) dated 11/22/2024 indicated Resident 14's cognition (mental ability to make decisions 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 clinical records in accordance with accepted professional standards and practices for one out of 13 sample residents (Resident 20) by failing to accurately document the administration of Aspercreme Lidocaine Patch 4% (a topical pain relief patch) for right knee pain in Resident's electronic medication administration records (eMAR) This deficient practice had the potential to negatively impact the delivery of services. Findings: During record review, Resident 20's admission record indicated Resident 20 was admitted on [DATE] with diagnoses that included joint disorders (a disease or injury that affects a joint) right knee, contracture (scarring soft tissues that causes them to tighten and stiffen.)of the right knee , muscle weakness, Alzheimer's (brain condition that causes a progressive decline in memory, thinking, learning and organizing skills.), dementia (loss of memory, language, problem-solving and other thinking abilities),…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 that the kitchen staff met the annual Inservice training sessions and evaluation requirements on fire prevention for 8 out of 8 Kitchen staff. This deficient practice had the potential for a knowledge, and training deficit among the kitchen staff, leading to inadequate or delayed response to the fire safety of the Residents. Findings: During an interview on 10/9/2024, at 10:18 A.M., with the dietary cook (DC), the DC stated he has been working at the facility for 10 years. The DC stated he received Inservice on fire and safety upon hire and recently on the day of the fire incident that happened on 9/24/2024. The DC stated he does not recall receiving fire and safety training from the dietary supervisor (DS) any other time. During a concurrent interview and record review, on 10/9/2024, at 12:25 P.M., with the DS, the DC employee record and dietary Inservice binder were reviewed. The DS stated DC was trained on fire and safety upon hire, the day of the incident on 9/24/2024 and that there is no documented evidence of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure eight of 16 sampled residents (Resident 1, 9, 21, 23, 24, 25, 189, and 190) had Advanced 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) Acknowledgement forms (a signed acknowledgment indicating the resident and/or resident representative were provided with information regarding creating an Advanced Directive) documented in the residents' active medical record. This deficient practice had the potential for Resident 1, 9, 21, 23, 24, 25, 189, and 190 to be denied the right to request or refuse medical care and treatment. Findings: A review of Resident 1's admission Record, indicated Resident 1 was originally admitted to the facility on [DATE], and was re-admitted on [DATE] with diagnoses including diabetes mellitus (DM-a chronic condition that affects the way the body processes blood sugar [glucose]), urinary…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 2a. A review of Resident 9's admission Record indicated Resident 9 was originally admitted on [DATE] and was readmitted on [DATE] with diagnoses including unspecified severe protein-calorie malnutrition (the state of inadequate intake of food [as a source of protein, calories, and other essential nutrients] in the body), type 2 DM, and recurrent depressive disorder (when a person has experienced depressive symptoms for most of the day, for more days than not over two years). A review of Resident 9's MDS dated [DATE], indicated that Resident 9 had a severely impaired cognition (ability to think and make decisions) and required maximal assistance from staff for mobility such as rolling left to right, sit to lying, sit to stand, and toilet transfer. A review of Resident 9's Side Rail Assessment form effective dated 1/5/2024, entered by Registered Nurse 2 (RN 2) indicated, the assessment has determined the use of side rail for non-restrictive device, with benefits of side rails use for mobility aid, reminder to wait…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 care plan that meet the care/services based on the resident's individual assessed needs for six of 16 sampled residents (Resident 9, 13, 21, 31, 37, and 189) by failing to: 1. Develop a comprehensive care plan when resident had a change of condition for Residents 31 and 13. 2. Develop a comprehensive care plan for the use of bed side rails for Residents 9, 21, and 189. 3. Develop and implement comfort measure (treatments used to ease pain and distress when life-prolonging options are not available) care plan for Resident 37. These deficient practices had the potential to result negative impact on the health and safety, and the quality of care and services provided to Residents 9, 13, 21, 31, 37, and 189. Cross Reference F604 Findings: 3. A review of Resident 37's admission Record, indicated Resident 37 was originally admitted to the facility on [DATE], and was re-admitted on [DATE] with diagnoses…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide an environment that is free from accident hazards in preventing avoidable accidents to one of five sampled residents (Resident 3) by failing to ensure Resident 3's medications were not left unattended at bedside during medication pass. This deficient practice had the potential to result in an unsafe medication administration to Resident 3. Findings: A review of Resident 3's admission Record, indicated that Resident 1 was originally admitted to the facility on [DATE], and was re-admitted on [DATE] with diagnoses including diabetes mellitus (DM-a chronic condition that affects the way the body processes blood sugar [glucose]), atrial fibrillation (AF-an irregular rapid heart rate that commonly causes poor blood flow) and schizophrenia (mental disorder in which people interpret reality abnormally). A review of Resident 3's Minimum Data Set (MDS - a comprehensive standardized assessment and care-screening tool), dated 1/30/2024,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 staff had the appropriate competencies to provide nursing and related services to assure safety of the residents by failing to: 1. Maintain and update basic life support/Cardiopulmonary Resuscitation (BLS/CPR) certification for two of seven sampled facility staff (Licensed Vocational Nurse 2 [LVN 2] and Certified Nursing Assistant 5 [CNA 5]). 2. Ensure Licensed Vocational Nurse 5 (LVN 5) had the specific competencies and skills sets necessary to perform safe medication administration for Resident 15. This deficient practice had the potential to place resident at risk of not getting proper immediate care in a life-threatening situation. Findings: 1. During a concurrent record review and interview with the Infection Preventionist Nurse/Director of Staff Development (IPN/DSD), on [DATE] at 12:53 p.m., LVN 2 and CNA 5 staff files were reviewed. Staff files indicated not up to date BLS/CPR for LVN 2 and CNA 5. IPN/DSD stated IPN/DSD was supposed to…

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

Based on observation, interview, and record review, the facility failed to ensure the standardized recipes for lunch menu were followed on 3/23/24 when: 1. [NAME] used small scoop size to serve Baked Ziti (pasta with tomato and cheese sauce baked and topped with breadcrumbs) for five residents on mechanical soft finely chopped (Ground) diet (consists of foods that are moist, ground, chopped or easily mashed required little chewing) while five residents were mechanical soft finely chopped diet received ½ cup of Baked Ziti instead of 1 cup. 2. 17 Residents on mechanical soft diet (ground and chopped) did not receive garlic toast bread texture in form that met their needs when they received garlic toast without additional 1-2 tsp (teaspoons) of margarine to adequately moisten the bread. This deficient practice had the potential to result in meal dissatisfaction, decreased nutritional intake and choking in 17 of 38 residents on mechanical soft diet who received food from the kitchen. Findings: According to the facility lunch menu on 3/23/24, the following items would be served on…

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

Based on observation, interview and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen when: 1. One large bowl of vanilla flavored pudding was stored on the same shelf next to raw shelled eggs and three (3) cartons of raw liquid eggs. 2. One small cup stored inside dried chicken base powder container and the cup in contact with the powdered chicken base. 3. Three (3) large containers of Vanilla flavored nutrition supplement with manufactured instruction to use within 3 days once opened were stored in the refrigerator with open dates of 1/23/24, 2/17/24, 2/21/24 exceeding safe storage period for the nutritional supplements. 4. Ice machine was not maintained in sanitary manner and the inside compartment of the ice machine was observed having gray and orange color residue. 5. Food brought to residents from outside of the facility, including leftovers stored in the resident food refrigerator were not labeled and dated. These deficient practices had the potential to result in harmful bacteria growth and cross…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to maintain accurate medical record in accordance with accepted professional standards and practices for eight of 16 sampled residents (Resident 1, 9, 21, 23, 24, 25, 189, and 190) by failing to ensure advance directive acknowledgment forms were easily accessible via residents' medical charts. These deficient practices had the potential to negatively impact the delivery of service given to Resident 1, 9, 21, 23, 24, 25, 189, and 190. Findings: 1. A review of Resident 1's admission Record, indicated that Resident 1 was originally admitted to the facility on [DATE], and was re-admitted on [DATE] with diagnoses including diabetes mellitus (DM-a chronic condition that affects the way the body processes blood sugar [glucose]), urinary tract infection (UTI-infection in the urinary system [kidneys, bladder, or urethra]) and epilepsy (a disorder in which a nerve cell activity in the brain is disturbed causing seizure [a sudden, uncontrolled electrical…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 in a manner that promoted or enhanced resident's dignity and respect by failing to ensure staff was not standing over resident while eating for one of seven sampled residents (Resident 90). This deficient practice had the potential to cause psychosocial harm and can resident's right to be treated with dignity for Resident 90. Findings: A review of Resident 9's admission Record indicated, the resident was originally admitted on [DATE] and was readmitted on [DATE], with diagnoses including unspecified severe protein-calorie malnutrition (the state of inadequate intake of food [as a source of protein, calories, and other essential nutrients] in the body), type 2 diabetes mellitus (DM-a chronic condition that affects the way the body processes blood sugar [glucose]), and recurrent depressive disorder (when a person has experienced depressive symptoms for most of the day, for more days than not over two years). 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 provide reasonable accommodations for resident needs and preferences for two of 16 sampled residents (Resident 30 and Resident 190) by: a. Failing to ensure Resident 30's preferences on preferences on daily activities. b. Failing to ensure Resident 190's bed and mattress was appropriate for Resident 190's height. This deficient practice had the potential to negatively impact the psychosocial well-being of the residents and may cause physical harm. Findings: A. A review of Resident 30's admission Record indicated Resident 30 was admitted to the facility on [DATE] with diagnoses including toxic encephalopathy (a disease in which the functioning of the brain is affected by some agent or condition-such as viral infection or toxins in the blood), fibromyalgia (a condition that causes pain all over the body, sleep problems, fatigue, and often emotional and mental distress) and generalized anxiety disorder (a mental health disorder characterized…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 protection of resident's medical record for one of three sampled resident (Resident 21). This deficient practice had the potential to violate Resident 21's right to privacy and confidentiality. Findings: A review of Resident 21's admission Record indicated Resident 21 was originally admitted on [DATE] and was readmitted on [DATE] with diagnoses including toxic encephalopathy (a disease in which the functioning of the brain is affected by some agent or condition-such as viral infection or toxins in the blood), chronic obstructive pulmonary disease (COPD - a group of lung diseases that block airflow and make it difficult to breathe), and muscle wasting and atrophy (characterized by a significant shortening of the muscle fibers and a loss of overall muscle mass). A review of the Minimum Data Set (MDS - a comprehensive assessment and care screening tool), dated 2/10/2024, indicated Resident 21's cognitive (mental action or process of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement its policy regarding reporting of an unusual occurrence and injury of unknown source and to submit a conclusion report of investigation within five days or in accordance with state or federal law for one of one sampled resident (Resident 26). This resulted in a delay of an onsite inspection by the Department to ensure the safety of the residents and had the potential to place residents at further risk for injuries. Cross Reference F610 Findings: A review of Resident 26's admission Record indicated the resident was originally admitted on [DATE] and was readmitted on [DATE] with diagnoses including unspecified type 2 diabetes mellitus (DM-a chronic condition that affects the way the body processes blood sugar [glucose]), unspecified sequelae cerebral infarction (lack of blood flow resulting in severe damage to some of the brain tissue), and memory deficit following cerebral infarction and unspecified dementia (loss of cognitive…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement its policy regarding reporting of an unusual occurrence and injury of unknown source within 24 hours in accordance with state or federal law for one of one sampled resident (Resident 26). This resulted in a delay of an onsite inspection by the State Agency to ensure the safety of the residents and had the potential to place residents at further risk for injuries. Cross Reference F609 Findings: A review of Resident 26's admission Record indicated the resident was originally admitted on [DATE] and was readmitted on [DATE] with diagnoses including unspecified type 2 diabetes mellitus (DM-a chronic condition that affects the way the body processes blood sugar [glucose]), unspecified sequelae cerebral infarction (lack of blood flow resulting in severe damage to some of the brain tissue), and memory deficit following cerebral infarction and unspecified dementia (loss of cognitive functioning-thinking, remembering, and reasoning). 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 provide preventive care consistent with professional standards of practice to two of two sampled residents (Residents 9 and 21), who was at risk for development of pressure injuries, by failing to: 1. Ensure low air loss mattress (LALM-a mattress designed to prevent and treat pressure wounds) was functioning and was not turned off when Resident 9 was in bed. 2. Ensure the appropriate setting of the LALM was properly set up according to physician's order (MD order) for Resident 21. These deficient practices can place Residents 9 and 21 at risk of poor wound healing of the current pressure ulcer (injury to skin and underlying tissue resulting from prolonged pressure on the skin) and possibly development of a new pressure injury. Findings: 1. A review of Resident 9's admission Record indicated Resident 9 was originally admitted on [DATE] and was readmitted on [DATE] with diagnoses including unspecified severe protein-calorie malnutrition,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 resident receives appropriate treatment and services to increase, prevent, or maintain the range of motion (ROM- the extent of movement of a joint) mobility for one of three sampled resident (Resident 190). This deficient practice had the potential to place Resident 190 at risk for further ROM decline and contracture (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints). Findings: A review of Resident 190's admission Record indicated Resident 190 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including hemiplegia and hemiparesis (loss of the ability to move in one side of the body) following cerebral infarction (lack of blood flow resulting in severe damage to some of the brain tissue) affecting left non-dominant side and muscle wasting and atrophy (characterized by a significant shortening of the muscle fibers and…

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

Based on observation, interview, and record review, the facility failed to post in a visible and prominent place daily the actual hours worked by licensed and unlicensed nursing staffing directly responsible for resident care per shift for three of three sampled days (3/23/2024, 3/24/2024, and 3/25/2024). This deficient practice resulted in the actual staffing information not being readily accessible and available to residents and visitors and had the potential to cause inadequate staffing. Findings: On 3/23/2024 at 8:50 a.m., a projected, not an actual DHPPD (Direct Care Services Hours Per Patient Day) was observed at Nursing Station 1. On 3/24/2024 at 9:32 a.m., a projected, not the actual hours was observed at Nursing Station 1. On 3/24/2024 at 9:29 a.m., a projected, not the actual hours was observed at Nursing Station 1. During an interview with Director of Infection Preventionist Nurse/Director of Staff and Development (IPN/DSD) on 3/24/2024 at 4:28 p.m., IPN/DSD stated, the facility posts and include only projection hours in the DHPPD daily and not the actual hours. DSD…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure: 1.Pharmaceutical services included procedures to ensure the medications used from the emergency kit (e-kit - secured container or secured electronic system containing drugs which are used for either immediate administration to residents or in an emergency or as a starter dose) located in Medication room [ROOM NUMBER] were ordered and replaced as soon as possible per facility's policy. 2.Ensure professional standards of practice for medication administration were used when administering medications to 1 out of 16 sampled residents (Resident 15). On 3/24/2024 at 9:28 a.m., LVN4 was observed crushing Apixaban 2.5mg (anticoagulant used to reduce the risk of stroke and blood clots), Proscar 5mg daily, metoprolol (used alone or in combination with other medications to treat high blood pressure) 25mg, aspirin (used to treat mild to moderate pain, inflammation, or arthritis. It also lowers your risk of heart attack) 81 mg, and Loratadine…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 do a Gradual Dose Reduction (GDR, an attempt to decrease or discontinue psychotropic [acting on the mind] medication after no more than three months from the start date of the psychotropic medication, unless clinically contraindicated) for 2 of 16 sampled residents (Residents 10 and 21). These deficient practices had the potential to result in overuse of an antipsychotic medication, without monitoring for the effectiveness and/or ineffective of the medication and can lead to adverse (negative) drug reactions. Findings: A review of Resident 21's admission Record indicated the resident was originally admitted on [DATE] and was readmitted on [DATE] with diagnoses including schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly), anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety or fear that are strong enough to interfere with one's daily activities), and major depressive disorder…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and record reviews, the facility failed to staff did not crush medications together for five of 31 opportunities during medication administration for one of 16 sampled residents (Resident 15). This deficient practice resulted in medication error of 16 percent (%). Mmedication error rate should be less than 5%. Cross Reference F755 Findings: A review of Resident 15's admission record indicated Resident 15 was admitted to the facility on [DATE] with diagnoses including Benign Prostatic Hyperplasia (BPH- a condition in men in which the prostate gland is enlarged and not cancerous), secondary hypertension (when the pressure in your blood vessels is too high [140/90 mmHg or higher] and is caused by another medical condition), and hyperlipidemia (also known as dyslipidemia or high cholesterol, means you have too many lipids (fats) in your blood). A review of Resident 15's Minimum Data Set (MDS- a standardized assessment and care screening tool), dated 2/9/2024, indicated, Resident 15 had mildly…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 two sampled residents (Resident 34's) Levalbuterol hydrochloride (HCL) (Xopenex-medication being given via inhalation [inhaling medication in the form of gas or vapor] used to treat or prevent bronchospasm [when muscles that line the airways in the lungs becomes tighten) Nebulizer was disposed of within two weeks after opening per manufacturer's policy. This deficient practice had the potential to compromise the safety and effectiveness of medication, resulting in medication errors when administered to Resident 34, and placed the resident at risk for respiratory difficulty. Findings: A review of Resident 34's admission Record, indicated the resident was admitted to the facility on [DATE], with diagnoses including encephalopathy (a disease in which the functioning of the brain is affected by some agent or condition-such as viral infection or toxins in the blood), urinary tract infection (UTI-infection in the urinary system…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 update the Facility Assessment (FA) annually to reflect staffing plan to meet the resident care needs by ensuring that Activity Director (AD) and Social Service Director (SSD) were included in the facility's staffing plan. This deficient practice may result in the facility failure to identify specific factors that would require a change to the assessment and had the potential to affect the resident care and decline in quality of care. Findings: During a concurrent interview and record review with the Director of Nursing (DON) on 3/25/2024 at 7:33 p.m., FA was reviewed. FA indicated both AD and SSD were not in the staffing plan as a part of assessment. DON stated and verified missing staffing plan for AD and SSD. DON stated it is importance to have both AD and SSD staffing addressed in the FA. DON also stated FA is an overview of what resources that the facility can provide to the residents and both AD and SSD should be in the staffing plan. A review of facility's policy and procedures (P&P), titled, Facility 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.

Based on interview, and record review, for two of 16 sampled residents (Residents 34 and 139), the facility failed to: 1. Implement its protocol for antibiotic (a substance used to kill bacteria and to treat infections) use. 2. Monitor actual antibiotic use by failing to initiate a surveillance log These deficient practices had the potential for Residents 34 and 139 to develop resistance (not effective to treat infection) to antibiotics from unnecessary and inappropriate antibiotic use. Findings: During a concurrent interview and record review of the antibiotic stewardship binder with the Infection Preventionist Nurse (IPN) on 3/24/24 4:10 a.m., the IPN confirmed and stated that the antibiotic surveillance log was not initiated to outline the antibiotics Residents 34 and 139 were receiving, including the dose, the frequency and how may times the residents had completed. The IPN stated that having a complete log in place was important because the log shows the trend and will also determine if the antibiotic order is not appropriate. The IPN stated staff may not know if 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.

Based on observation, interview and record review, the facility failed to ensure 10 out of 20 resident rooms met the square footage requirement of 80 square feet (sq. ft.) per resident. This deficient practice had the potential to result in inadequate useable and safe living space for the residents to move freely and for nursing staff to provide care to the residents. Findings: The facility submitted a written request for a continued room waiver on 3/24/2024. On 3/24/2024, the facility administrator (ADM) provided a copy of the Client Accommodation Analysis. A review of the Client Accommodation Analysis indicated 10 out of 20 rooms do not have at least 80 square feet per resident. The room waiver request and Client Accommodation Analysis indicated the following: Room # Beds Sq.Ft. Sq.Ft per resident 104 3 198.9 66.30 105 3 198.9 66.30 106 3 198.9 66.30 107 3 198.9 66.30 108 3 198.9 66.30 109 3 198.9 66.30 116 3 224.2 74.73 117 3 218.4 72.80 119 3 206.7 68.90 120 3 212.5 70.83 The minimum requirement for a 3-bedroom should be at least 240 sq. ft. per federal regulation. During 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 nutritional care and services to one of two sample residents (Resident 2) by failing to ensure implementation and modification of interventions consistent with Resident 2 ' s needs and goals per registered dietitian (RD) recommendations. This deficient practice placed Resident 2 at risk for further weight loss. Findings: A review of Resident 2's admission Record indicated Resident 2 was admitted to the facility on [DATE], with diagnoses including left femur fracture (a break, crack or crush injury of the thigh bone), supraventricular tachycardia arrest (SVT-a condition when heart beats rapidly due to a problem with the heart ' s electrical impulse) and malnutrition (lack of sufficient nutrients in the body). A review of Resident 2's Minimum Data Set (MDS - a comprehensive standardized assessment and care-screening tool), dated 11/20/2023, indicated Resident 2 has moderately impaired cognition (mental action or process of acquiring knowledge and…

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

Based on interview and record review, the facility failed to maintain the fire alarm system (system of devices that detects the presence of fire and alerts the appropriate agencies when the system is triggered) protecting 40 out of 40 residents in the facility in good working condition such that the fire alarm system does not send false alarms. This deficient practice has the potential for the facility to not respond to a true alarm of an active fire, or for facility staff to experience alarm fatigue (when signals activate so often that staff ignore or actively silence them) which may contribute to the spread of a fire during a true fire emergency affecting the safety of residents, staff, and visitors to the facility. Findings: During an interview on 11/17/2023 at 4:07 p.m., with the Social Worker (SW), the SW stated that the facility was on fire watch (a procedure where staff continually walks around the entire facility looking for fire, smoke, and other signs of fire) because the fire alarm system was sending false signals (signals that indicate that there is a fire when there is…

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