West Pico Terrace Healthcare & Wellness Centre LP

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that one out of three sampled residents (Resident 10) was free from physical restraint by failing to ensure the physician's order for bilateral bed siderails was in placed and the proper use of use rails are appropriate according to facility's policy and procedure. This deficient practice had the potential to result in entrapment and injury with the use of restraints. Cross Reference F656 Findings: During record review, the admission Record indicated Resident 10 was originally admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses including cerebral infarction (lack of blood flow resulting in severe damage to some of the brain tissue), Parkinson's disease (a chronic brain disorder that causes movement problems, and can also affect mental health, sleep, and pain), Type II Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) and muscle wasting and atrophy…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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) in writing at the time of transfer to the hospital for one of three sampled residents (Resident 38). This deficient practice denied Resident 38 or the Responsible Party (RP) of being informed of resident's right to have the facility hold and reserve his bed while absent from the facility. Findings: During record review of Resident 38's admission Record (Face Sheet) indicated Resident 38 was initially admitted to the facility on [DATE], and was readmitted on [DATE], with diagnoses including metabolic encephalopathy (brain damage that causes severe confusion and forgetfulness), bladder cancer and chronic kidney failure (a condition in which the kidneys suddenly can't filter waste from the blood). During record review of Resident 38's Bed Hold Agreement form, dated 12/6/24 indicated the form had…

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

Based on interview and record review, the facility failed to complete a change of condition (COC -a sudden deviation from person/patient's baseline in physical, cognitive, behavioral or function) in accordance with the facility's policy and procedures (P&P) titled Change of Condition Notification reviewed 6/20/2024 for one out of six residents (Resident 23) This deficiency practice had the potential to result in the delay of care for Resident 23. Findings: During record review, Resident 23's admission Record indicated the facility admitted Resident 23 on 7/3/2023 with diagnoses including dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough), personal history of transient ischemic attack (TIA - a temporary blockage of blood flow to the brain) and cerebral vascular accident (CVA- Stroke) without residuals, and hypertension (HTN - elevated blood pressure). During record review of Resident 23's Minimum Data Set (MDS - resident assessment tool) dated 1/10/2025, indicated Resident 23 had cognitive impairment (when a person has trouble…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 immediately develop and implement a baseline care plan according to their Policy and Procedures (P&P) in accordance with the facility's policy and procedures (P&P) titled Comprehensive Person-Centered Care planning revised 11/2018 for one of four sampled residents (Resident 6), by failing to: 1. Address the inclusion of activity programs that are tailored to Resident 6's interests and to Resident 6's cognitive, physical/functional and social abilities to stimulate and facilitate Resident 6's social engagement. 2. Outline a personalized treatment strategy for Resident 6's hearing loss within 48 hours of admission. These deficient practices had the potential to negatively affect the delivery of necessary care and services for Resident 6. Findings: During record review, Resident 6's admission Record indicated the facility admitted Resident 6 on 11/23/2024 with diagnoses including dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough), generalized weakness (a feeling 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 a comprehensive care plan (CP) that met the care/services based on the resident's individual assessed needs for one of six sampled residents (Resident 10), by failing to ensure that a comprehensive CP was developed with the use of Resident 10's bilateral (both) bed siderails, when Resident 10 was hospitalized on [DATE], 7/22/2024, and 12/27/2024. This deficient practice had the potential to result in a negative impact on residents' health and safety, as well as the quality of care and services received. Findings: A review of the admission Record indicated Resident 10 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis including cerebral infarction (lack of blood flow resulting in severe damage to some of the brain tissue), Parkinson's disease (a chronic brain disorder that causes movement problems, and can also affect mental health, sleep, and pain), Type II Diabetes Mellitus (DM-a 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.

Based on observation, interview, and record review, the facility failed to revise the enteral feeding care plan to meet the individual needs for one of two sampled residents (Resident 22). This deficient practice had the potential to prevent Resident 22 from receiving care to address specific needs, which could lead to a decline in her nutrition. Findings: A review of Resident 22's admission Record indicated the facility admitted Resident 22 on 10/9/24 with diagnoses including cerebrovascular accident (CVA-stroke, loss of blood flow to a part of the brain) dysphagia (difficulty swallowing) and heart failure (a disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling). A review of Resident 22's Minimum Data Set [MDS - a resident assessment tool] dated 1/8/25 indicated the resident had severely impaired cognition (never/rarely made decisions) and was totally dependent upon staff for eating, oral hygiene, toileting hygiene, lower body dressing and personal hygiene. The MDS also indicated Resident 22 had a feeding tube. A review of Resident…

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

Based on interview and record review, the facility failed to notify the physician when they were unable to collect urine sample for urinalysis, culture and sensitivity (UA [a test to check if the urine has an infection, kidney problem, diabetes or liver disease] and C&S [test to find germs & the type of antibiotics they respond to]) for one of three sampled residents (Resident 23) per physician's orders. This deficient had the potential to result in the delay of the appropriate instructions needed from the physician to prevent infection and hospitalization. Findings: A review of Resident 23's admission Record indicated the facility admitted Resident 23 on 7/3/2023 with diagnoses including dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough), personal history of transient ischemic attack (TIA - a temporary blockage of blood flow to the brain), and cerebral vascular accident (CVA- Stroke) without residuals, and hypertension (HTN - elevated blood pressure). A review of Resident 23's Minimum Data Set (MDS - a resident assessment tool)…

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

Based on interview and record review, the facility failed to provide outside services as required by physician orders in accordance with the facility's policy and procedures (P&P) titled Referral to Outside Services revised on 12/1/2013, by failing to refer one of four sampled residents (Resident 6) to an audiologist (a healthcare professional that specializes in evaluating and treating hearing problems, like hearing loss). This deficient practice had the potential to negatively affect the delivery of necessary care and services for Resident 6. Findings: A review of Resident 6's admission Record indicated the facility admitted Resident 6 on 11/23/2024 with diagnoses including dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough), generalized weakness (a feeling of weakness in most parts of the body), and adult failure to thrive (a noticeable decline in health). A review of Resident 6's physician order dated 11/23/2024, indicated audiology (a medical study of hearing and balance, and treatment of related disorders) consult 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, observation, and record review, the facility failed to maintain a safe, functional and comfortable environment for one of six sampled residents (Resident 4), by failing to ensure the exit pathway was clear of geriatric (relating to old people, especially with regard to their healthcare) recliner chairs (geri-chair - large, padded chairs with wheeled bases, and are designed to assist seniors with limited mobility) and clutter. This failure had the potential to place Resident 4 at risk of fire hazards injury and accidents. Findings: A review of the admission Record indicated Resident 4 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis including pneumonia (lung infection that inflames air sacs with fluid or pus), acute respiratory failure (condition in which your blood does not get enough oxygen or has too much carbon dioxide), hemiplegia and hemiparesis (total paralysis of the arm, leg, and trunk on the same side of the body) following cerebral infarction…

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

Based on observation, interview, and record review, the facility failed to ensure one of two sampled residents' (Resident 22) enteral feeding (refers to any method of feeding that uses the gastrointestinal (stomach/intestines) tract to deliver nutrition and calories) bottle was changed after 24 hours. This deficient practice had the potential for the residents to develop tube feeding associated complications such as infection. Findings: During record review, Resident 22's admission Record indicated the facility admitted Resident 22 on 10/9/24 with diagnoses including cerebrovascular accident (CVA-stroke, loss of blood flow to a part of the brain) dysphagia (difficulty swallowing), and heart failure (a disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling). During record review, Resident 22's Requires Tube Feeding care plan, initiated 10/9/24, indicated the resident had dysphagia. The care plan indicated a goal was for the resident to not have side effects or complication related to tube feeding. The interventions indicated staff were…

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

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 one of three sampled residents (Resident 30), by failing to ensure the nasal cannula (NC -a connector attached to oxygen) tubing and humidifier (a device used to make supplemental oxygen moist) for oxygen (O2) therapy was changed per facility's policy. This deficient practice had the potential to cause complications associated with oxygen therapy. Findings: During record review, the admission Record indicated Resident 30 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis including acute bronchospasm (a sudden narrowing of the airways [bronchi] in the lungs, caused by the contraction of muscles lining the airways), pulmonary embolism (a blood clot gets stuck in an artery in the lung, blocking blood flow to part of the lung), Type II Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) and chronic…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to: 1. Ensure to label an open date of one of five sampled residents (Resident 19)'s ipratropium-albuterol inhalation solution (used to prevent and treat difficulty breathing, wheezing, shortness of breath, coughing, and chest tightness) inhalation solution that can expire once opened with an open date according to manufacturer guidelines. 2. Ensure Resident 30's medications were not left unattended at the bedside. These deficient practices had the potential to compromise the therapeutic effectiveness of the stored medications and cause unintended accident concerning medication use. Findings: 1. A review of the admission Record indicated Resident 19 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including metabolic encephalopathy (a chemical imbalance in the blood affecting the brain), type II Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to properly store one of five sampled residents (Resident 43)'s levalbuterol (used to prevent or relieve the wheezing, shortness of breath, coughing, and chest tightness caused by lung disease) inhalation solution medication that expires once opened according to manufacturer guidelines. This deficient practice had the potential to compromise the therapeutic effectiveness of the stored medications given to the residents because of inappropriate storage of medications. Findings: A review of the admission Record indicated Resident 43 was admitted to the facility on [DATE] with diagnoses including acute respiratory failure (condition in which your blood does not get enough oxygen or has too much carbon dioxide), congestive heart failure (CHF-a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling) and acute kidney failure (a condition in which the kidneys suddenly can't filter waste from 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 interviews and record review, the facility failed to provide pharmaceutical services, including the provision of routine antibiotics as ordered for one of the three sampled residents (Resident 1) as per physician ' s order dated 10/11/2024 at 9:48 pm for Ciprofloxacin HCI (hydrochloride) Otic (relating to or located in the region of the ear) Solution (Ciprofloxacin HCI - is a fluoroquinolone antibiotic that kills bacteria by blocking a protein they need to reproduce and repair themselves) due to suspected ear infection. for had swelling and discharge to the right ear on 10/11/2024. This failure resulted in Resident 1 not receiving the ordered antibiotic for 2 days resulting in redness, swelling, severe pain (right side of face), and a cream-colored wiggling foreign body in the right ear which required the resident be transfer to General Acute Care Hospital (GACH) on 10/20/2024. Findings: During a review of the admission record indicated Resident 1 was initially admitted to the facility on [DATE] and was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow their policy and procedure (P&P) by not allowing one of four sampled residents (Resident 1) to return to the facility from [DATE] to [DATE] after hospitalization. This deficient practice resulted in Resident 1 remaining at the hospital longer than necessary and had the potential to affect the resident ' s psychosocial wellbeing. Findings: During a review of Resident 1 ' s admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses that included acute respiratory failure (condition in which your blood does not get enough oxygen or has too much carbon dioxide), hypertension (HTN-high blood pressure), and dementia (a progressive state of decline in mental abilities). During a review of the history and physical (a term used to describe a physician's examination of a patient. In an H&P, the physician obtains a thorough medical history from the patient, performs a physical examination, and then documents their…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide care and services based on comprehensive (complete) individualized assessments and physician's orders necessary to maintain the highest practical well-being for two of five sampled residents (Resident 5 and Resident 30). By failing to: 1. Notify Resident 5's physician of the need for a follow up (repeat) Chest Xray (CXR - imaging test that looks at the lungs, heart, and ribcage) due to resident position on 12/11/2023. 2. Notify Resident 5's physician of abnormally high monocytes (white blood cells - [WBC] cells that help fight infections in the body) count of 17.6 percent (% -unit of measure. Reference range [RR] normal value was between 2.0 % to 8.0 %) on 12/12/2023. 3. Ensure Resident 5 received Levofloxacin (antibiotic - medication used to treat infection) 500 milligrams (mg - unit of measurement) give 1 tablet by mouth one time a day for cough for seven days, to be started on 12/29/2023 as per physician's order. The Levofloxacin was not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide necessary care and treatment for urinary tract infection (UTI, an infection in the drainage system for removing urine) for one of three sampled residents (Resident 30) by failing to: 1. Collect a urine sample from Resident 30 on 12/17/2023 for urinalysis (UA - urine test used to check for infection or kidney problems) and culture and sensitivity (C&S -a test to diagnose germs such as bacteria or fungus [yeast or mold] per physician's orders. The urine sample was not collected until 12/20/2023. 2. Notify Resident 30's physician of abnormal positive for bacteria UA & C&S results on 12/20/2023. The physician was not notified until 12/25/2023. 3. Ensure Resident 30 received Ertapenem (used to treat certain serious infections) 1gm (gm -unit of measure) intravenously (IV - inside a vein [blood vessel]) daily for 10 days, starting 12/25/2023 as per physician's order. These deficient practices resulted in Resident 30 not receiving treatment for a UTI…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that the licensed nurse had the skills and knowledge to collect a urine sample for one of three sampled residents (Resident 30). As a result, the facility delayed in collecting urine sample for urinary tract infection (UTI, an infection in any part of the urinary system [the kidneys (organs in the body that filter waste materials out of the blood and pass them out of the body as urine, regulates blood pressure and the levels of water, salts, and minerals), ureters (Tube/s that carry urine from the kidneys to the bladder [Hollow organ that stores urine]), bladder and urethra [The tube that leads from the bladder and transports and discharges urine outside the body]) by 3 days for Resident 30. Placing the resident at risk for sepsis (a life-threatening infection in the blood that travels throughout the entire body), organ failure, and death. Cross Reference F727, F755 & F684 Findings: A review of Resident 30's admission Record indicated the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to a Registered Nurse for at least eight (8) consecutive hours a day, seven (7) days a week to ensure that Resident 30's clinical needs were met. As a result, Resident 30 did not receive Ertapenem (Antibiotic - prevent bacterial infections) 1gram (gm - Unit of measure) intravenous (IV - inside a vein) to treat urinary tract infection (UTI, an infection in any part of the urinary system [the kidneys (organs in the body that filter waste materials out of the blood and pass them out of the body as urine, regulates blood pressure and the levels of water, salts, and minerals), ureters (Tube/s that carry urine from the kidneys to the bladder [Hollow organ that stores urine]), bladder and urethra[The tube that leads from the bladder and transports and discharges urine outside the body]). Cross Reference F684, F690, F755 Findings: A review of Resident 30's admission Record indicated the resident was admitted to the facility on [DATE] and was readmitted on [DATE]…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure call light (also known as call cord, used in communicating remotely with staff to alert a staff of the need for any type of assistance) was within reach for one (1) out of 15 sampled Residents (Resident 11). This deficient practice had the potential for the resident not being able to reach staff for assistance when needed for activities of daily living (ADLs) such as hydration and toileting, which could lead to delay of care and accidents including falls. Findings: A review of Resident 11's admission Record indicated the resident was originally admitted to the facility on [DATE], with diagnoses of, but not limited to, displaced fracture of second cervical vertebra (bone break in the neck portion of a person's spine), dysphagia (difficulty swallowing), muscle weakness, and a history of falling. A review of Resident 11's Quarterly Minimum Data Set (MDS- a standardized assessment and screening tool), dated 10/30/2023, indicated the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure residents' medical records were updated to show documentation that advance directives (Written statement of a person's wishes regarding medical treatment made to ensure those wishes are carried out should the person be unable to communicate them to a doctor) were discussed and written information were provided to the residents and/or responsible parties for four of 24 sampled residents (Residents 2, 24, 29, 30, and 95). This deficient practice violated the residents' and/or the representatives' right to be fully informed of the option to formulate their advance directives and had the potential to cause conflict with the residents' wishes regarding health care for Residents 2, 24, 29, 30, and 95. Findings: A review of Resident 29's admission Record, indicated Resident 29 was admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses including fracture of neck of left femur (a break in the thigh bone), acute kidney failure (a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to follow through with the Preadmission Screening and Resident Review (PASARR- a federally required screening to help identify individuals with possible serious mental illnesses requiring a specialized follow up evaluation) recommendation to obtain a PASARR II (assessment that determines if resident's mental condition could be met in the nursing facility or if the individual requires specialized services) evaluation for one of three sampled residents (Resident 30). This deficient practice had the potential to result in inappropriate placement and unidentified specialized services for Resident 30. Findings: A review of Resident 30's admission Record indicated Resident 30 was admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses including diabetes mellitus (DM- a disorder in which the body does not produce enough or respond normally to insulin [a hormone that lowers the level of glucose) causing blood sugar [glucose] levels to be…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to develop and/or implement an individualized person-centered plan of care with measurable objectives, timeframe, and interventions to meet one of five sampled residents (Resident 29's) specific needs, by failing to: 1. Develop an individualized/person-centered care plan with goals and interventions for Resident 29's antidepressant (medication that helps calm the feelings of depression) medication. 2. Develop an individualized/person- centered care plan with goals and interventions to address Resident 29's risk for skin breakdown. These deficient practices had the potential to negatively affect the delivery of necessary care and services. Findings: A review of Resident 29's admission Record, indicated the resident was admitted on [DATE] and readmitted on [DATE] with medical history including fracture of neck and a fractur of the left femur (a break in the thigh bone), acute kidney failure (a condition in which the kidneys can't filter waste from 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 pressure ulcers (PU: damage to the layers of the skin caused by prolonged pressure on a part of the body; stage 1: red, warm to touch, stays red when pushed down on, stage 2: break in top layer of skin, stage 3 crater-like appearance damage to top layers and fat layers, stage 4: damage to all layers of skin, including muscle, bone may be visible) care and treatments as per physician's order for two of five sampled residents (Resident 29 and Resident 33). These deficient practices placed Resident 29 and Resident 33 at risk for worsening skin conditions, delay in healing of existing and complications resulting from untreated or improperly treated pressure ulcers which could result in systemic infections that could lead to death. Findings: a. A review of Resident 29's admission Record, indicated the resident was admitted on [DATE] and readmitted on [DATE] with medical history including fracture of neck of left femur (a break in the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide services to maintain mobility (ability to move) for two of five sampled residents (Resident 9 and Resident 30) with rehabilitation (restoring function) and mobility concerns, by failing to: 1. Apply Resident 9's left-hand splint (a long, firm object used as a support for a broken bone so that the bone stays in a particular position while it heals) as per physician's order. 2. Ensure a soft neck collar brace was applied to Resident 30 as per physician's order. This deficient practice placed Resident 9 and Resident 30 at risk for a decline in mobility and contractures (occurs when soft, connective tissue [skin, muscles, tendons, ligaments] in the body becomes very stiff and/or shortened). Findings: a. A review Resident 9's admission record indicated Resident 9 was admitted on [DATE] and readmitted on [DATE] with diagnoses including periorbital cellulitis (an infection of the eyelid), lack of coordination, muscle wasting and atrophy…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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. This deficient practice resulted in the actual staffing information not being readily accessible and available to residents and visitors. The deficient practice had the potential to cause inadequate staffing. Findings: During an observation on 1/16/2024 at 2:00 p.m., a projected, not an actual DHPPD (Direct Care Services Hours Per Patient Day) was observed posting in the main entrance of the facility. During an observation on 1/17/2024 at 2:00 p.m., a projected, not an actual DHPPD (Direct Care Services Hours Per Patient Day) was observed in posting the main entrance of the facility. During an observation on 1/18/2024 at 11:00 a.m., a projected, not an actual DHPPD (Direct Care Services Hours Per Patient Day was observed in posting the main entrance of the facility. During an interview with the director of nursing (DON) on 1/19/2024 at 2:00 a.m., 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 Pneumonia (PNA-lung infection) vaccine was offered and/or re-offered to one (1) of six (6) sampled residents (Resident 6) per facility policy and as ordered. This deficient practice placed Resident 6 at risk of acquiring and transmitting pneumonia infection. Findings: A review of Resident 6's admission Record indicated the resident was admitted on [DATE] and readmitted on [DATE] with diagnoses including Parkinson's disease (a disorder of the central nervous system that affects movement), type 2 diabetes (a chronic condition that affects the way the body processes blood sugar), lack of coordination, muscle weakness, cognitive communication deficit (difficulty with thinking), dysphagia (inability to swallow), chronic kidney disease (is a condition in which the kidneys are damaged and cannot filter blood as well as they should), myopathy (muscle disease), protein-calorie malnutrition (decreased dietary intake), acute embolism (a blockage of a…

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

Based on observation, interview and record review, the facility failed to provide at least 80 square feet (sq. ft. -unit of measure) per resident in three (3) out of (23) resident rooms. Those three rooms consisted of two and/or three beds each. This deficient practice had the potential to result in inadequate useable living space for the residents and working space for the staff. Findings: A review of the Request for Room Size Waiver letter, dated 1/19/2024, submitted by the Administrator, indicated there are eight rooms not meeting the requirement of 80 square feet per resident according to federal regulation. The letter indicated that the room sizes would not interfere with the daily nursing care or safety of the residents. The letter also indicated there would be enough space to provide for each resident's care, dignity and privacy in those rooms which are in accordance with the special needs of the residents. The letter further indicated the spaces would not have an adverse effect on the residents' health and safety or impede the ability of any resident in the rooms to attain…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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: 1.Residents' notice of proposed transfer/discharge's notification was sent to the Office of the State Long-Term Care Ombudsman (public advocate) on a timely manner for one of four sampled residents, Resident 5 2. The documentation was completed and recorded the reasons for the transfer or discharge in the resident ' s medical record for one of four sampled residents, (Resident 7). This deficient practice denied the residents additional protections from being inappropriately discharged for Resident 5 and an incomplete documentation of the discharge process for Resident 7. Findings: A. A review of the admission Records indicated Resident 5 was admitted to the facility on [DATE] and was discharged to home on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD - a group of lung diseases that block airflow and make it difficult to breathe), fibromyalgia (a condition that causes pain all over the body, sleep problems, fatigue,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 safe and effective discharge for one of four sampled residents (Resident 1). Resident 1 who was discharged home on 8/1/23, the facility failed to ensure home health services (medical care that can be provided at home) and durable medical equipment (DME, medical equipment and supplies ordered by a healthcare provided for routine and long-term use) were arranged as ordered by the physician. This deficient practice resulted in Resident 1 not provided the necessary care and health services needed after discharge from the facility. Findings: During a review of Resident 1 ' s admission Record indicated the facility admitted Resident 1 on 6/13/23 with diagnoses including fracture of the left femur (break in the thigh bone), osteoarthritis of the hip (inflammation of the hip causing pain, swelling) and difficulty in walking. During a review of Resident 1 ' s Minimum Data Set (MDS, standardized care and screening tool) dated 6/20/23 indicated Resident…

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