Western Convalescent Hospital

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure Minimum Data Sets (MDS, a resident assessment tool) were coded accurately for two of 23 sampled residents (Resident 40 and Resident 65).Resident 40's MDS, dated [DATE], did not reflect his use of continuous oxygen therapy, and receipt of intermittent suctioning and tracheostomy care (the routine cleaning and maintenance of a surgically created opening in the neck (stoma) and the inserted breathing tube).Resident 65's MDS, dated [DATE], did not reflect his venous ulcer (slow healing open sore that typically develop on lower leg that is caused by poor blood circulation).These deficient practices resulted in the transmission of inaccurate data to the Centers for Medicare and Medicaid Services (CMS) regarding Resident 40's and 65's health status and increased the potential for these residents to not receive the care and services they needed. Findings: 1. During a review of Resident 40's Face Sheet, the Face Sheet indicated Resident 40…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a care plan was developed for one of 23 sampled residents (Resident 40) when Resident 40 did not have a care plan in place for his as needed use of melatonin (an over the counter or prescription pill used to improve sleep issues).This deficient practice prevented staff from having resident-specific non-drug interventions to aid Resident 40's sleep and monitor the effectiveness of his of melatonin.Findings:During a review of Resident 40's Face Sheet, the Face Sheet indicated Resident 40 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 40's diagnoses included metabolic encephalopathy (a general term for altered brain function or structure caused by an underlying systemic condition).During a review of Resident 40's Minimum Data Set (MDS, a resident assessment tool), dated 4/21/2026, the MDS indicated Resident 40's cognition (ability to think and process) was severely impaired. The MDS indicated Resident 40 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 ensure a physician order for gastrointestinal referral (formal request by a physician to send a patient to a gastroenterologist [a medical doctor who specializes in diagnosing, treating, and preventing disease of the digestive system] for testing and work-up) was completed for one of one sampled resident (Resident 98).This deficient practice had the potential to put Resident 98 at risk for worsened gastrointestinal symptoms and delayed diagnosis of underlying medical condition.Findings:During a review of Resident 98's Face Sheet, the Face Sheet indicated Resident 98 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 98's diagnoses included gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems) tube placement, anemia (a condition where the body does not have enough healthy red blood cells), and Diabetes Mellitus (DM, a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure two of five sampled residents (Resident 104 and Resident 120) received care in accordance with professional standards of practice when:1. Resident 104 was not monitored for 72 hours after a change of condition ([COC] -any sudden, clinically significant deviation from a patient's normal baseline in their physical, cognitive, behavioral, or functional health status).2. Resident 120's abnormal heart rate was not reported to the physician in a timely manner.These deficient practices had the potential for Resident 104's skin rash (a noticeable change in the color, texture, or appearance of your skin) to worsen due to not being monitored and delayed physician intervention for Resident 120. Findings: 1. During a review of Resident 104's Face Sheet, the Face Sheet indicated Resident 104 was admitted to the facility on [DATE]. Resident 104's diagnosis included chronic obstructive pulmonary disease (COPD, a chronic lung disease causing…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide a safe and hazard-free environment for three of three sampled residents (Residents 76, 110, and 37) when:1. Staff did not provide padded side rails as indicated in Resident 76's and 110's respective care plans.2. Staff failed to provide fall mats, as ordered by the physician, for Resident 37.These deficient practices increased the potential for Residents 76 and 110 to sustain avoidable injuries and complications related to missing siderail padding in the event of a seizure (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness) and increased the potential for Resident 37 to sustain fall-related injuries. Findings: 1. During a review of Resident 76's Face Sheet, the Face Sheet indicated Resident 76 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 76's diagnoses included seizures (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 interview and record review, the facility failed to ensure interventions were carried out to prevent malnutrition for one of seven sampled residents (Resident 40) when the facility failed to carry out Resident 40's physician orders for checking prealbumin levels (a specific protein level used to assess acute changes in nutritional status, particularly protein-calorie malnutrition) and a thyroid panel (a group of blood tests used to evaluate how well the thyroid gland is working and to diagnose disorders like hypothyroidism [slowed metabolism] or hyperthyroidism [excessive thyroid hormone that can result in unexplained weight loss]) following Resident 40's 39 pound (lb., a unit of weight measurement) weight loss.These deficient practices resulted in a delay in care, creating the potential for Resident 40's weight loss to worsen and for delayed identification of the reason for Resident 40's weight loss.Findings:During a review of Resident 40's Face Sheet, the Face Sheet indicated Resident 40 was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide respiratory care consistent with professional standards of practice for one of five sampled residents (Resident 40) when:Resident 40 received oxygen therapy at five (5) liters per minute (L/min, a unit of flow rate) without humidification (a method for moistening inhaled oxygen).Respiratory Therapist (RT) 1 did not clarify Resident 40's oxygen order with the ordering provider.These deficient practices placed Resident 40 at risk for discomfort related to irritation of the airways and placed Resident 40 at risk of not receiving oxygen as intended by the physician.Findings:During a review of Resident 40's Face Sheet, the Face Sheet indicated Resident 40 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 40's diagnoses included presence of a tracheostomy (a surgical procedure that creates an opening in the neck and directly into the windpipe) and chronic respiratory failure (a long-term condition…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to follow the physician orders for oxygen administration for one of five sampled residents (Resident 104).This deficient practice caused Resident 9 not to receive the correct oxygen administration.Findings:During a review of Resident 104's Face Sheet, the Face Sheet indicated Resident 104 was admitted to the facility on [DATE]. Resident 104's diagnosis included chronic obstructive pulmonary disease (COPD, a chronic lung disease causing difficulty in breathing), osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage), and anemia (a condition where the body does not have enough healthy red blood cells).During a review of Patient 104's History and Physical (H&P), dated 2/18/2026, the H&P indicated Resident 104 did not have the capacity to understand and make decisions.During a review of Resident 104's Minimum Data Sheet (MDS, a resident assessment tool), dated 2/18/2026, the MDS indicated Resident 104's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a resident was provided with medically related social services (services provided by the facility's staff to assist residents in attaining or maintaining their mental and psychosocial health) for an outside gastrointestinal (formal request by a physician to send a patient to a gastroenterologist [a medical doctor who specializes in diagnosing, treating, and preventing disease of the digestive system] for testing and work-up) referral for one of one sampled resident (Resident 98).This deficient practice had the potential to put Resident 98 at risk for delayed medical interventions that would affect her quality of lifeFindings:During a review of Resident 98's Face Sheet, the Face Sheet indicated Resident 98 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 98's diagnoses included gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people…

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 hydrocortisone (a mild topical corticosteroid used to temporarily relieve itching, redness, and swelling) 1 percent ([%] - a drug percentage expresses the active ingredient in grams per milliliter) medication cream was properly stored for one of one sampled resident (Resident 104). 2. Clarify a pharmacy label with unclear instruction for 1 of 5 sampled residents (Resident 103) when Resident 103's amlodipine bubble pack had a label indicated to take 1 tablet by mouth via G-tube (gastrostomy tube, a flexible medical device inserted directly through the abdomen into the stomach). This deficient practice of not storing the medication after usage had the potential for Resident 104 to unsafely use the medication and had a potential for medication error for Resident 103. Findings: a. During a review of Resident 104's Face Sheet, the Face Sheet indicated Resident 104 was admitted to the facility on [DATE]. Resident 104's diagnoses…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement the physician's order for arterial and venous ultrasounds (painless, non-invasive imaging tests that use sound waves to evaluate blood flow throughout your body) in a timely manner for one of one sampled resident (Resident 65).This deficient practice had the potential to result in the delay of the identification of medical concerns, delaying the care and services necessary for Resident 65.Findings:During a review of Resident 65's Face Sheet, the Face Sheet indicated Resident 65 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 65's diagnoses included left leg above knee amputation (AKA, surgical removal of the leg above the knee joint), peripheral vascular disease (PVD, a slow progressive narrowing of the blood flow to the arms and legs), cerebral infarction (a type of ischemic stroke - occurs when a blood clot or fatty plaque blocks a blood vessel in the brain), and sepsis (a life-threatening blood…

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 five sampled residents (Resident 9) intravenous peripheral line (IV, a short, flexible catheter inserted into a small vein) dressing was changed every 72 hours to correlate with the documentation on the Medication Administration Records (MAR, a daily documentation record used by a licensed nurse to document medications and treatments given to the resident.This deficient practice of not accurately documenting the IV dressing changes had the potential to place Resident 9 at risk for infection at the insertion site.Findings:During a review of Resident 9's Face Sheet, the Face Sheet indicated Resident 9 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 9's diagnoses included osteomyelitis (inflammation of the bone or bone marrow, usually due to infection), osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage), and chronic kidney disease (is 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 treatment and care in accordance with professional standards of practice for one of three sampled residents (Resident 1), who had a gastrostomy tube (GT-a surgical opening fitted with a device to allow feedings to be administer directly to the stomach common for people with swallowing problems) and tracheotomy ( a surgical opening in the neck fitted with a tube that helps a person breathe), by failing to ensure:1.Resident 1 was not provided with a breakfast tray and did not consume food by mouth without a physician's order. 2.Licensed nurses notified the physician and documented the incident regarding Resident 1 consuming food without a physician's order on 4/21/2026. These failures had the potential to result in Resident 1 aspirating (food or liquid entering the airway or lungs), having compromised respiratory status and death. Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was initially…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure three of five sampled residents (Residents 2, 3 and 4) who were dependent (relying for support) on staff with activities of daily living, were provided good oral hygiene (the practice of keeping the mouth, teeth, and gums clean and healthy) daily. This deficient practice resulted in the residents' mouth dirty.This deficient practice placed the residents at risk for gum infections and other systemic health infection (bacteria from gum disease that can enter the bloodstream) which can jeopardize the residents' overall health condition, that can lead to hospitalizations.Findings:a). During an observation on 12/10/2025 at 9:15 a.m., in Resident 2's room, Resident 2 was in bed with head of the bed elevated. Resident 2 had thick, white secretions on the right side of the mouth. Resident 2 started to talk and observed white, thick saliva on the side of the resident's mouth and tongue. Resident 2 stated the nurses do not provide her oral…

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). Implement occupational therapy (OT- a form of therapy for those recuperating from physical or mental illness that encourages rehabilitation through the performance of activities required in daily life) recommendations of hand splints and obtain physician orders for 2 of 5 sampled residents (Resident 2 and Resident 3) to prevent contractures (a medical condition where muscles, tendons, or other tissues become permanently shortened or tightened, limiting movement and causing deformity) of hands and fingers to improve joint mobility. 2). Implement the facility's policy and procedure (P&P) titled Screening, when the Physical Therapist (PT 1) did not reassess one of five residents (Resident 8), after readmission to the facility and after Resident 8 could no longer tolerate his physician-ordered services.These failures had the potential to increase the risk of joint disability and had the potential to cause or worsen the pain.Findings: 1).…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to report one of three resident's (Resident 7) right thumb fracture (broken bone) to the California Department of Public Health (CDPH) within two hours, as indicated in the Federal regulations. This failure resulted in the delayed investigation by CDPH, placing the affected resident and other residents at risk for potential abuse and injuries.Findings:During a review of Resident 7's admission Record, the admission Record indicated Resident 7 was admitted to the facility on [DATE] and readmitted on [DATE]. The admission Record indicated Resident 7 had a history tracheostomy (a surgical opening in the neck, fitted with a device to allow air and oxygen to be administered directly to the airway), gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems), ventilator (a medical device to help support or replace breathing) dependence, and dementia (a progressive…

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, for 1of 5 sample residents, Resident 2, the facility failed to:1). Ensure the intravenous (IV- administration of the medications via a catheter inserted into a vein) medication was administered completely, consistent with professional standards of practice and physician's order.2). Ensure the IV site was securely placed and did not dislodge (pulled out).This failure had the potential for the infection will not be resolved due to an incomplete dose of antibiotic medication administered.This failure had the potential to cause infection on the IV site and the potential for a missed antibiotic dose.Findings:During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including urinary tract infection (UTI-an infection of the urinary tract, which includes the kidneys, ureters, bladder, and urethra), dysphagia 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure one of 5 sampled residents (Resident 2) was administered the correct amount of oxygen (a gas considered as medication essential for life to supplement the body's oxygen supply in conditions), ordered by the physician.This failure had the potential to cause oxygen toxicity (lung damage from breathing in excessive supplemental oxygen [also called oxygen poisoning] causing the resident to cough and trouble breathing and in severe cases, can cause death) to the affected resident.Findings:During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including urinary tract infection (UTI-an infection of the urinary tract, which includes the kidneys, ureters, bladder, and urethra), dysphagia following cerebral infarction (difficulty swallowing that occurs after a stroke), and type 2 diabetes mellitus (abnormal blood…

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 residents' (Resident 8) clinical record contained complete and accurate documentation of the services resident did not receive as indicated in its policy and procedure (P&P) titled Charting and Documentation.This failure had the potential for miscommunication and had the potential that the residents would not receive the quality of care and services the resident need. Findings:During a review of Resident 8's admission Record, the admission Record indicated Resident 8 was admitted to the facility on [DATE]. The admission Record indicated Resident 8 had a history of traumatic brain injury (TBI-a disruption in the normal function of the brain that can be caused by a bump, blow, or jolt to the head), tracheostomy (a surgical opening in the neck, fitted with a device to allow air and oxygen to be administered directly to the airway), ventilator (a medical device to help support or replace breathing) dependence, and gastrostomy (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 complete the Physician Orders for Life-Sustaining Treatments (POLST - care directive during life threatening situations, an approach to improve end of life care by encouraging providers to speak with patients and create specific medical orders to be honored by healthcare workers during medical crisis) for one of seven sampled residents (Resident 2). This deficient practice placed Resident 2 at risk for delay in treatment or life sustaining procedures during in the event of an emergency.Findings: During a review of Resident 2's admission Record, the admission Record indicated, Resident 2 was initially admitted to the facility on [DATE] with diagnoses including PU Stage 4 (Full-thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage, or bone), urinary tract infection (UTI - an infection in the bladder/urinary tract), and gastrostomy tube placement (a surgical opening fitted with a device to allow feedings to be administered…

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 two sampled residents (Resident 1's) transfer to the general acute care hospital (GACH) was documented in resident's medical records. This deficient practice had the potential to place Resident 1 at risk of not receiving appropriate care and delay in communication among staff due to incomplete medical records.Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including chronic respiratory failure with hypoxia (a condition that occurs when the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body), tracheostomy (an opening created at the front of the neck so a tube can be inserted into the windpipe [trachea] to help you breathe), and gastrostomy tube placement (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a comprehensive care plan for pressure ulcer/injury (PU/PI] - localized damage to the skin and/or underlying tissue usually over a bony prominence) was developed for one of four sampled residents (Resident 2), who had multiple pressure ulcers. This deficient practice had the potential for Resident 2 not receiving the appropriate wound care interventions which could lead to infection or worsening of the wounds. Findings: During a review of Resident 2's admission Record, the admission Record indicated, Resident 2 was initially admitted to the facility on [DATE] with diagnoses including PU Stage 4 (Full-thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage, or bone), urinary tract infection (UTI - an infection in the bladder/urinary tract), and gastrostomy tube placement (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach for people with swallowing problems). During 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 ensure one of four sampled residents (Resident 2), who had multiple pressure ulcers / injury (PU/PI - localized damage to the skin and/or underlying tissue usually over a bony prominence) received care in accordance with professional standards of practice. Resident 2's PU's were not reassessed weekly including the type of the PU, location, measurement and description. This deficient practice caused an increased risk in the worsening of Resident 2's pressure ulcers and inappropriate or delayed treatment.Findings: During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was admitted to the facility on [DATE] with diagnoses including PU Stage 4 (Full-thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage, or bone), urinary tract infection (UTI - an infection in the bladder/urinary tract), and gastrostomy tube placement (a surgical opening fitted with a device to allow feedings to be administered…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure, one of three sampled residents (Resident 1), had a resident-centered, comprehensive care plan. This deficient practice placed the resident at risk for injuries and had the potential for Resident 1 ' s needs to not be met. Findings: During a review of Resident 1 ' s admission Record, the admission Record indicated, Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 1 ' s diagnoses included disorder of bone density (the amount of minerals (primarily calcium and phosphorous) contained within a specific volume of bone, and it's a measure of bone strength and thickness) and structure, contractures (a stiffening/shortening at any joint, that reduces the joint ' s range of motion) of muscles at multiple sites, functional quadriplegia (a complete inability to move due to severe disability or frailty, without any physical injury or damage to the spinal cord), and respiratory failure (the body ' s inability to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure, one out of three residents (Resident 1), was provided two-persons assist (a care technique where two caregivers work together to help a president with mobility, transfers, or other daily living activities) when providing activities of daily living ([ADLs]-routine tasks/activities such as bathing, dressing, and toileting a person performs daily to care for themselves). This deficient practice placed the resident at risk for falls and injuries. Findings: During a review of Resident 1 ' s admission Record, the admission Record indicated, Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 1 ' s diagnoses included disorder of bone density (the amount of minerals (primarily calcium and phosphorous) contained within a specific volume of bone, and it's a measure of bone strength and thickness) and structure, contractures (a stiffening/shortening at any joint, that reduces the joint ' s range of motion) 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 implement its infection control program by failing to: 1. Ensure the Laundry Aide (LA) performed hand hygiene, changed gown and gloves after sorting dirty linen and prior to handling clean linen. This deficient practice put all the residents at risk for cross contamination (movement of bacteria from one place to another) and infection. 2. Refrigerate opened food item, as indicated in the bottle container, for one of three sampled residents (Resident 93). This deficient practice had the potential for Resident 93 to experience foodborne illnesses (food poisoning). Findings: 1. During a concurrent observation and interview on 3/19/2025 at 11:54 a.m. with the LA in the laundry room, the LA was observed sorting dirty linen from the laundry chute. The LA then went to the clean area and rolled a large cart containing clean linen to the middle of the floor, without performing hand hygiene and removing contaminated gloves and gown, after sorting…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to: 1. Obtain and document informed consent (a process during which residents or caregivers are educated regarding the potential risks and benefits of medication therapy) from the resident or their responsible party (RP - a person delegated to make medical decisions for the resident in the event they are unable to do so) prior to treatment with lorazepam (a medication used to treat mental illness) and sertraline (a medication used to treat mental illness) in one of five residents sampled for unnecessary medications (Resident 83). This deficient practice have prevented Resident 83 or her RP from exercising their right to decline treatment with psychotropic medications. This increased the risk that Resident 83 could have experienced adverse effects (unwanted, uncomfortable, or dangerous effects that a drug may have) related to psychotropic medications leading to impairment or decline in her mental or physical condition or functional or psychosocial status.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the room windows were able to close in Residents 23, 55, and 102's rooms ensuring the rooms would not be cold. This deficient practice resulted in the residents being cold while in their rooms. Findings: During an initial tour on 3/18/2025 at 11:08 am, in room [ROOM NUMBER], two room windows near Resident 102's bed was open and unable to be closed. One window had a crack in the center from the top to the bottom. During an initial tour on 3/18/2025 at 11:50 am, in room [ROOM NUMBER], the room window near Resident 23's bed had red tape around three of four sides and was open and unable to be closed. During an initial tour on 3/18/2025 at 12:12 pm, in room [ROOM NUMBER], the room window near Resident 55's bed had black tape around three of four sides and was open and unable to be closed. A review of the admission Record indicated Resident 102 was admitted to the facility on [DATE] with diagnoses that included functional quadriplegia…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review the facility failed to: 1. Ensure one of six sampled residents (Residents 1) received a weekly weight per the physician's order. This deficient practice resulted in inadequate monitoring of the weight of the Resident 2. Ensure one of one sampled resident (Resident 8) had accurate orthostatic blood pressure (a form of low blood pressure that happens when standing after sitting or lying down) readings obtained to determine if the resident had orthostatic hypotension (low blood pressure). This deficient practice had the potential to result in Resident 8 to experience a delay in interventions, if the resident had been positive, for orthostatic hypotension (low blood pressure). Findings: 1). During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including hypotension (low blood pressure), diabetes (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to: 1. Ensure the low air loss mattress (a pressure relieving mattress for the management of pressure sores) was at the proper setting to maintain skin integrity for one of 25 sampled residents (Resident 96). 2. Ensure one of six sampled residents (Resident 112) had prevalon boots (cushioned boots used to eliminate pressure on the heels) applied per the physician's order. These deficient practices placed Resident 96 at risk to develop new pressure injury, poor wound healing and deterioration of current pressure ulcers. Resident 112 was at risk for new skin breakdown on the heels of her feet. Findings: a). During a review of Resident 96's admission Record, the admission Record indicated, Resident 96 was initially admitted to the facility on [DATE] and latest readmission was on 3/13/2025. Resident 96's diagnoses included pressure ulcer/injury Stage 4 (Full-thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage, or bone)…

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, interviews, and record reviews, the facility failed to provide appropriate services to prevent a decline in joint range of motion (ROM, full movement potential of a joint) for six out of 10 sampled residents (Residents 15, 2, 8, 24, 17, and 67) who had limited ROM by failing to: 1) a. Ensure the Restorative Nursing Aide (RNA, nursing aide program that help residents to maintain their function and joint mobility) staff did not put on Resident 15's right elbow splint (rigid material or apparatus used to support and immobilize a broken bone or impaired joint) and right resting hand splint for more than four hours as ordered by the physician. b. Ensure RNA treatment was completed for Resident 15 as ordered by a physician on 2/27/2025, 3/1/2025, 3/8/2025, and 3/16/2025. 2) a. Ensure RNA treatment was completed for Resident 2 as ordered by the physician on 2/27/2025, 3/1/2025, 3/8/2025, and 3/16/2025. b. Ensure Resident 2 received timely annual Rehabilitation Joint Mobility Assessments (JMA) 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 provide adequate and sufficient nursing staff to provide care for residents requiring Restorative Nursing Aide (RNA, nursing aide program that helps residents to maintain their function and joint mobility) treatments. This deficient practice had the potential for 81 residents with physician's orders for RNA to experience a decline in range of motion (ROM, full movement potential of a joint), mobility, and activities of daily living (ADL, basic activities such as eating, dressing, toileting) function. CROSS REFERENCE TO F688. Findings: During a review of the active physician's orders for residents on RNA services dated 3/19/2025, the physician's orders indicated 81 residents had physician's orders for the RNA to provide treatments and services including but not limited to, ROM exercises to upper extremities (UE, shoulder, elbow, wrist, hand) and lower extremities (LE, hip, knee, ankle, foot), application of splints (rigid material or apparatus used to support and immobilize a broken bone or impaired joint) 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.

Based on interview and record review, the facility failed to ensure two Licensed Vocational Nurses (LVN) knew what the purpose of checking orthostatic hypotension (a condition where blood pressure drops significantly when a person stands up from a sitting or lying position or sits up from a lying position) was for and how to obtain blood pressure readings, to determine if a resident had orthostatic hypotension. This deficient practice had the potential to place residents at risk for a delay in care and services which could result in falls or injury. Findings: During an interview on 3/19/2025 at 3:02 p.m. with LVN 4, LVN 4 stated orthostatic blood pressure is ordered for residents who are taking psychotropic (drugs that affect a person's mental state) medications. LVN 4 stated the purpose is to determine if the resident on psychotropic medication had hypotension (low blood pressure). LVN 4 stated the procedure for taking orthostatic blood pressure is done by taking the resident's blood pressure in the lying position first, and if necessary, would take the sitting blood pressure…

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 monitor blood pressure related to the use of amlodipine (a medication used to treat high blood pressure) with hold parameters (instructions in the medication order to hold the medication if the blood pressure reading is too low) between 3/23/24 and 3/31/24. The deficient practice of failing to monitor blood pressure related to the use of amlodipine increased the risk that Resident 83 could have experienced adverse effects related to receiving amlodipine when her blood pressure was too low possibly resulting in dizziness and falls with injury. Findings: During a review of Resident 83's admission Record, dated 3/20/25, the admission Recordindicated she was admitted to the facility on [DATE] with diagnoses including hypertension (high blood pressure.) During a review of Resident 83's available Care Plans (a resident-centered plan of care developed to address a resident's unique health care needs), dated 3/13/24, revised 3/27/24, the care plan indicated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to: 1. Ensure one of six sampled residents (Resident 1) was not prescribed Seroquel (a drug used to treat a mental health condition) without an appropriate diagnosis. 2. Define and monitor behaviors related to the use with lorazepam (a medication used to treat mental illness) for one of five residents sampled residents (Resident 83). These deficient practices placed Resident 1 and Resident 83 at risk of adverse effects (bad outcome). Findings: A. During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including hypotension (low blood pressure), diabetes ([DM] a disorder characterized by difficulty in blood sugar control and poor wound healing), and asthma (a chronic lung condition characterized by recurrent episodes of wheezing, shortness of breath, and coughing). During a review of Resident 1's History and Physical (H&P), dated 11/4/2024, the H&P 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure its medication error rate was less than five percent (%). Two medication errors out of 33 total opportunities contributed to an overall medication error rate of 6.06 % affecting two of six residents observed for medication administration (Residents 4 and 83). The facility failed to: 1. Administer the correct strength of cranberry (a supplement) supplement to Resident 4. 2. Administer the correct formulation of multivitamins (a vitamin supplement) to Resident 83. The deficient practices of failing to administer medications in accordance with the physician's orders increased the risk that Residents 4 and 83 may have experienced medical complications possibly resulting in hospitalization. Findings: 1). During a review of Resident 4's admission Record, dated 3/20/25, the admission Record indicated she was admitted to the facility on [DATE] and most recently readmitted on [DATE] with diagnoses including personal history of traumatic…

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 four sampled residents (Resident 8) had the correct laboratory tests done as ordered by the physician. This deficient practice had the potential to result in Resident 8 to experience a delay in services due to incomplete laboratory results. Findings: During a review of Resident 8's Face Sheet (front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated Resident 8 was originally admitted on [DATE] and readmitted on [DATE] with diagnoses that included hyperlipidemia (high levels of fats in the blood), and bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs). During a review of Resident 8's Care Plan, dated 9/20/2019, the Care Plan indicated Resident 8 was a risk for dehydration due to the use of medications for bipolar disorder and interventions included to perform laboratory tests as…

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 the lunch menu was followed on 3/18/2025 by failing to: 1. Ensure Eighteen (18) residents on a soft and bite size diet (Diet for people who are not able to bite off pieces of food safely but are able to chew bite sized pieces down into little pieces that are safe to swallow/Bite sized pieces no bigger than ½ x ½ inches) did not receive whole bread instead of bread that is cut into smaller pieces. 2. Ensure the menu included the texture modified diet (diets that are altered in texture to accommodate resident chewing or swallowing problems includes diets such as Soft and Bite size and Minced and Moist) that was ordered for residents. The menu did not indicate the serving guide for the bread at each meal. These Deficient practices had the potential to result in meal dissatisfaction, decreased nutritional intake and increased choking risk in 18 residents on a soft and bite size diet. Findings: According to the facility lunch menu on 3/18/2025, the following items would be served…

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 preparation practices were followed in the kitchen when one can opener blade was dirty with dry brown sticky residue and when the blade was worn with the potential to spread harbor harmful bacteria. This deficient practice had the potential to result in harmful bacteria growth and cross contamination (transfer of harmful bacteria from one place to another) that could lead to food borne illness in 47 out of 109 residents who received food from the facility. Findings: During an observation in the kitchen food preparation area on 3/18/2025 at 9:30 a.m. one can opener blade was noted to be dirty and worn out. The blade was stained, covered with brown residue. During a concurrent observation and interview with the Dietary Supervisor (DS) on 3/18/2025 at 9:35 a.m., the DS verified that there is only one can opener in the kitchen. The DS verified that the blade had brown sticky residue. The DS did not know what the dark brown color residue was. DS stated it could be removed with washing.…

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's policy on food from outside and brought by family-visitors did not address how to store and reheat food to ensure safe and sanitary food storage, handling and consumption. For residents who have leftover food brought from outside the facility, the facility policy does not have a procedure for safe food handling. This had the potential to cause food borne illness in residents in the facility who were served the food brought by family or visitors. Findings: During an interview with Dietary Supervisor (DS) on 3/18/2025 at 10:30 a.m. the DS stated resident's families are encouraged not to bring anything that needs to be stored. The DS stated residents can have food from outside for one meal because there is no space to store the resident's leftover food from visitors. The DS stated anything leftover will be discarded per our policy. During an interview with charge nurse (LVN2) on 3/18/2025 at 11a.m., LVN2 stated there is no refrigerator for residents at the nursing station. LVN2 stated there are some residents who…

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 99) was afforded the right to be free from physical restraint (Bed rails) by failing to: 1. Ensure Resident 99 had an order for the use of bed rails. 2. Ensure Resident 99 had a signed informed consent for the use of bed rails. 3. Ensure Resident 99 was not restrained by having four siderails up. These deficient practices had the potential to result in Resident 99 to experience restricted movement while in bed, and not fully understanding the risks and benefits associated with the use of bed rails which could lead to injury. Findings: During a concurrent observation and interview on 3/18/2025 at 10:33 a.m., with Resident 99, Resident 99 was observed lying in bed with all four bed rails up around the bed. Resident 99 stated she did not ask to have the four bed rails up and did not remember falling out of bed recently. During a review of Resident 99's Minimum Data Set (MDS - a resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of four sampled residents (Resident 46), had a diagnosis of diabetes mellitus (DM - a condition that leads to high levels of sugar in the blood), entered on the residents' Minimum Data Set (MDS- an assessment and care screening tool). This deficient practice had the potential to negatively affect Resident 46's plan of care and delivery of necessary care and services. Findings: A review of the admission Record indicated Resident 46 was originally admitted to the facility on [DATE] and re-admitted on [DATE], with diagnoses that included polyneuropathy (a condition where nerves, often in the hands and feet, are damaged or dysfunctional, leading to numbness, tingling, pain, and weakness), hypertension (high blood pressure), and fibromyalgia (a condition causing widespread musculoskeletal pain, fatigue, and tenderness). A review of the Physician's Order dated 2/1/2024, indicated to give Resident 46 Metformin HCL oral tablet 500 MG (milligram) 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 ensure an extension cord was free from safety hazards for one out of one sampled resident (Resident 96). This deficient practice had the potential to result in an unsafe environment with a fire hazard risk and a risk for fall and injury. Findings: During a review of Resident 96's admission Record, the admission Record indicated, Resident 96 was initially admitted to the facility on [DATE] and was most recently readmitted on [DATE]. Resident 96's diagnoses included pressure ulcer/injury Stage 4 (Full-thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage, or bone) of the sacrum (large, triangle-shaped bone in the lower spine that forms part of the pelvis), chronic respiratory failure (a long-term condition when the airways that carry air to your lungs become narrow and damaged), and hypotension (low blood pressure). During a review of Resident 96's Minimum Data Set (MDS - a resident assessment tool), dated…

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 its residents were free from significant medication errors by administering amlodipine (a medication used to treat high blood pressure) outside of the hold parameters (instructions in the medication order to hold the medication if the blood pressure reading is too low) a total of 81 times between 4/1/24 and 1/28/25 affecting one of five residents sampled for unnecessary medications (Resident 83.) The deficient practice of failing to administer amlodipine in accordance with hold parameters as specified in the physician order contributed to two falls resulting in injuries to Resident 83's face and hands on 4/10/24 and 6/20/24 and increased the risk that Resident 83 may have experienced other adverse effects of low blood pressure such as dizziness, possibly resulting in a decline in her quality of life. Findings: During a review of Resident 83's admission Record, dated 3/20/25, the admission Record indicated Resident 83 was admitted to 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, and interview, the facility failed to implement its infection prevention and control measures for two of four sampled residents (Residents 2 and 3) by failing to: 1.Ensure Resident 2's foley catheter ([FC] a thin, flexible tube inserted into the bladder to drain urine) bag was off the floor. 2. Ensure Licensed Vocational Nurse (LVN) 1 and LVN 2 wore Personal Protective Equipment ([PPE] clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments) while providing wound care to Resident 2, who was on Enhanced Barrier Precautions ([EBP] an approach to the use of PPE to reduce transmission of Multidrug-Resistant Organisms [MDRO] bacteria that are resistant to multiple antibiotics). 3. Ensure LVN 1 performed hand hygiene (washing hands or using an alcohol-based hand sanitizer) during wound care after cleaning stool for Resident 2 and after cleaning the wound, as well as between gloves change for Resident 3. This deficient practice had the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to provide a safe, clean, and home like environment for 2 of 4 sampled residents (Resident 2 and Resident 4). This deficient practice had the potential to result in unsanitary living conditions, illness and could negatively impact Resident 2 and Resident 4 ' s psychosocial well-being. Findings: During a review of Resident 2 ' s admission Record, the admission Record indicated Resident 2 was admitted to the facility on [DATE], with diagnoses including Stage 4 Pressure ulcer (a deep wound that has damaged the skin, muscle, or bone) of the sacral region (located at the lower end of the spine, above the tailbone) unspecified Dementia (a progressive state of decline in mental abilities) and cellulitis (a skin infection that causes swelling and redness) of the buttocks. During a review of Resident 2 ' s History and Physical (H&P) dated 12/31/2024, the H&P indicated Resident 2 did not have the mental capacity to understand and make medical decisions. During a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of four sampled Residents (Resident 2) was provided a clean homelike environment by failing to provide clean bed sheets. This deficient practice placed Resident 2 at risk for an unclean environment and had the potential for the spread of infection and physical discomfort. Findings: During a concurrent observation and interview on 12/11/2024 at 10:00 a.m. in Resident 2's room, with Certified Nurse Assistant (CNA) 1, CNA1 was observed providing activities of daily living ([ADLs] routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) care to Resident 2. Resident 2's bed was observed with brown dry spots on the bottom sheet, the top sheet with yellow stains and a white blanket dirty with brown spots. CNA 1 provided a bed bath to Resident 2 and did not change the bottom sheet. CNA 1 covered Resident 2 with the stained top sheet and blanket. CNA 1 stated the bed sheets are…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to report an allegation of abuse, for one of 8 sampled residents, (Resident 1), to the California Department of Public Health (CDPH) within two (2) hours, as indicated in the facility ' s policy and procedure (P&P), titled Abuse and Mistreatment of Residents. This failure resulted in the delayed investigation by CDPH and placed Resident 1 at risk for further abuse. Findings: During a review of Resident 1 ' s admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body), hemiparalysis (a condition that causes weakness or paralysis on one side of the body), dysphagia (difficulty swallowing) and osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage). During a review of Resident 1 ' s Minimum Data Set ([MDS] a federally mandated resident assessment tool), the MDS indicated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of 8 sampled residents (Resident 1), received toileting hygiene in a timely manner. This failure had the potential to cause resident discomfort and skin breakdown. Findings: During a review of Resident 1 ' s admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body), hemiparalysis (a condition that causes weakness or paralysis on one side of the body), dysphagia (difficulty swallowing) and osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage). During a review of Resident 1 ' s Minimum Data Set ([MDS] a federally mandated resident assessment tool), the MDS indicated Resident 1 ' s cognitive skills (thinking skills) was severely impaired (a physical or mental condition that significantly limits a person's ability to function in their daily life). The MDS…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to implement infection control practices, by failing to ensure: 1. Oxygen nasal cannulas (a small plastic tube, which fits into the person ' s nostrils for providing supplemental oxygen) were properly stored when not used, for two of eight sampled residents, (Resident 1 and Resident 2). 2. The gastrostomy tube ([GT] a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems) site was maintained clean, for two of 8 sampled residents, (Resident 7 and Resident 8). This deficiency had the potential to cause infections to the affected residents. Findings: a. During a review of Resident 1 ' s admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body), hemiparalysis (a condition that causes weakness or paralysis on 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 interview and record review, the facility failed to promptly notify the physician of a change of condition (COC) for one of three residents (Resident 1) who was observed with slurred speech (damage to the brain or nerves that cause the muscles used for speaking to become weak and uncoordinated and can be a symptom of a cerebral infarction ([stroke] loss of blood flow to part of the brain). This deficient practice resulted in delayed medical care and had the potential to result in the physical decline and death for Resident 1. Findings: During a review of Resident 1 ' s admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] and re-admitted on [DATE]. Resident 1 ' s diagnoses included hemiplegia (one-sided weakness) and hemiparesis (one-sided paralysis) following cerebral infarction, presence of cerebrospinal fluid ([CSF] clear, watery fluid that flows in and around the brain and spinal cord) drainage device ([shunt] drain excess CSF from the brain to another…

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 Licensed Vocational Nurse (LVN) 2 had the specific competencies and skill sets necessary to identify and intervene for a one of three sampled residents who had a change of condition (COC). This deficient practice resulted in delayed care and had the potential to cause harm for Resident 1. Findings: During a review of Resident 1 ' s admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] and re-admitted on [DATE]. Resident 1 ' s diagnoses included hemiplegia (one-sided weakness) and hemiparesis (one-sided paralysis) following cerebral infarction ([stroke] loss of blood flow to a part of the brain), presence of cerebrospinal fluid ([CSF] clear, watery fluid that flows in and around the brain and spinal cord) drainage device ([shunt] drain excess CSF from the brain to another part of the body), and intracerebral hemorrhage (hematoma formed within the brain). During a review of Resident 1 ' s History and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure Midodrine10 mg ([mg] unit of measurement) (medication to treat low blood pressure) was held (not administered) in accordance with the written physician's order for one of three sampled residents (Resident 1.) This deficient practice had the potential to increase Resident 1's blood pressure beyond the normal range (normal range: 90/60 millimeters of mercury [mmHg] to 120/80 mmHg) resulting to complications like stroke. Findings: 1). During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE]. Resident 1's diagnoses included type 2 diabetes mellitus (high blood sugar) and hypotension (low blood pressure.) During a review of Resident 1's Minimum Data Set ([MDS] a standardized care screening and assessment tool) dated 7/8/2024, the MDS indicated Resident could rarely or never was able to understand and be understood by others. The MDS indicated Resident 1 was dependent and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to: 1. Ensure the resident's medical records were updated to show documentation of the 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 six (6) out of (6) sampled residents (Resident 27, 40, 82, 95, 99, and 113). 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. Findings: a. During a review of Resident 27's admission Record (Face Sheet), dated 3/21/2024, the Face Sheet indicated Resident 27 was admitted to the facility on [DATE], and was readmitted on [DATE] with a diagnoses including chronic respiratory failure…

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. Keep residents medical records confidential for 3 of 45 residents (Resident 25, 95, and 11). This deficiency violated residents privacy by failing to keep residents' medical records confidential. Findings: During a record review of Resident 95's admission Record, it indicated Resident 95 was originally admitted on [DATE], with diagnoses that included personal history of traumatic brain injury (brain dysfunction caused by outside force). During a record review of Resident 95's Order Summary Report, dated 3/24, it indicated Resident 95 receives a regular diet, puree texture, honey/moderately thick consistency, large portion for weight management, 4 ounces of pudding for lunch for 3 months. During a record review of Resident 24's admission Record, it indicated Resident 24 was admitted to the facility on [DATE] with diagnoses that included type 2 diabetes mellitus (a condition where the body has difficulty controlling blood sugar),…

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. Provide treatment and services for two of five sampled residents (Residents 9 and 82) who received gastrostomy tube feedings ([GT] tube surgically placed into the stomach for nutrient and medication administration) to ensure that feeding formula were completely labeled in accordance with the facility's policy and procedure. This deficient practice had the potential to result in Residents 9 and 82 not getting the right infusion rate of the tube feeding formula as ordered by the physician. Findings: a. During a review of Resident 9's admission Record, the admission Record indicated, Resident 9 was originally admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses including anemia (a condition that develops when your blood produces a lower-than-normal amount oof healthy red blood cells) and chronic obstructive pulmonary disease ([COPD] - a group of lung disease conditions that causes breathing difficulties). 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to: 1. Provide treatment and services for two of five sampled residents (Residents 9 and 82) who received gastrostomy tube feedings ([GT] tube surgically placed into the stomach for nutrient and medication administration) to ensure that feeding formula were completely labeled in accordance with the facility's policy and procedure. This deficient practice had the potential to result in Residents 9 and 82 not getting the right infusion rate of the tube feeding formula as ordered by the physician. Findings: a. During a review of Resident 9's admission Record, the admission Record indicated, Resident 9 was originally admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses including anemia (a condition that develops when your blood produces a lower-than-normal amount oof healthy red blood cells) and chronic obstructive pulmonary disease ([COPD] - a group of lung disease conditions that causes breathing difficulties). 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 observation, interview, and record review, the facility failed to: 1. Ensure opened food items are stored in a manner to prevent the growth of microorganisms that can cause food borne illnesses (any illness resulting from spoiled or contaminated food). This deficiency had the potential to cause food borne illnesses for resident's in the facility. Findings: On 3/19/24 at 8:20 AM, during an initial tour of the kitchen accompanied by the Dietary Service Supervisor (DSS), the following findings were observed: 1. One box of cinnamon streusel coffee cake mix was opened, with the inner packaging opened, placed into a resealable bag which was left opened, exposing the inner contents. 2. One box of iodized salt was opened and not closed properly. 3. 2 cups of undated orange juice in refrigerator #1. During an interview, on 3/19/24 at 8:50 AM, with the DSS, the DSS stated that opened containers of food need to be properly sealed to ensure the product remains fresh, to avoid contamination, and so pests can't get inside the open packages. The DSS also stated that the cups of undated…

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. Develop a care plan for nasal cannula (a device used to deliver supplemental oxygen that should be placed directly on the resident's nostrils) for 2 of 3 sampled residents (Resident 3 and Resident 24). This deficient practice had the potential to result in a lack of meeting necessary care goals and addressing medical needs for Resident 3 and Resident 24. Findings: During a record review of Resident 3's admission Record, it indicated Resident 3 was admitted to the facility on [DATE] with diagnoses that included pneumonia (an infection of the lung), chronic obstructive pulmonary disorder ([COPD]- a group of diseases that causes obstruction of airflow from the lungs). During a record review of Resident 3's History and Physical (H&P), dated 1/2/24, the H&P indicated Resident 3 was recently hospitalized due to acute respiratory failure (diseases that affect your breathing) due to bacterial pneumonia (lung infection caused by bacteria).…

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 the necessary care and services were provided to prevent the reopening of a healed pressure ulcer for one of 22 sampled residents (Resident 101). This deficient practice resulted in Resident 101 obtaining a stage 4 pressure ulcer to the sacrococcyx (area of skin over the tailbone). Findings: During a review of Resident 101's admission Record (Face Sheet), the Face Sheet indicated Resident 101 was admitted to the facility on [DATE] with diagnoses of diabetes (high blood sugar), hypertension (high blood pressure), respiratory failure (unable to breath on your own), and stroke. During a review of Resident 101's baseline care plan dated 7/19/23, the care plan indicated the resident will have reduced risk of complications from incontinence. The staff will provide incontinence care every two hours and as needed. During a review of Resident 101's nursing reassessment, dated 7/19/23, the assessment indicated a head to toe assessment was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to: 1. Ensure medications were not left at the bedside for one of one sampled resident (Resident 111). This deficient practice put Resident 111 at risk for health issues related to taking too much medication. Findings: During a concurrent observation and interview on 3/19/24 at 1:28 p.m. with Resident 111, Resident 111 had Pepto Bismol (medication for upset stomach) and Preparation H (medication used to shrink swollen blood vessels) on her nightstand. Resident 111 states her brother brought it to her two to three weeks ago. During an interview on 3/21/24 at 10:17 a.m. with LVN3, LVN3 stated you must have a doctor's order for the resident to take their own medications. Resident medication is kept on the medication cart so the staff can monitor how much they take. The nurse needs to monitor how much the resident takes so they don't overdose. If the resident takes an overdose it can hurt the liver or the heart. During an interview on 3/21/24 at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to: 1. Implement infection control measures for one of four sampled residents (Resident 68) by failing to wear Personal Protective Equipment ([PPE] gown - specialized clothing or equipment worn by an employee for protection against infectious materials) prior to entering and providing care to Resident 68 on Enhanced Standard Precautions ([ESP] a resident-centered and activity-based approach for preventing Multiple Drug Resistant Organism ([MDRO]-are bacteria that have become resistant to certain antibiotics) transmission in skilled nursing facilities). This deficient practice had the potential to result in cross contamination (physical movement or transfer of harmful bacteria from one person, object, or place to another), spread of infections and placed other residents at risk for infection. Findings: During a review of Resident 68's admission Record, the admission Record indicated, Resident 68 was originally admitted to the facility on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to: 1. Implement infection control measures for one of four sampled residents (Resident 68) by failing to wear Personal Protective Equipment ([PPE] gown - specialized clothing or equipment worn by an employee for protection against infectious materials) prior to entering and providing care to Resident 68 on Enhanced Standard Precautions ([ESP] a resident-centered and activity-based approach for preventing Multiple Drug Resistant Organism ([MDRO]-are bacteria that have become resistant to certain antibiotics) transmission in skilled nursing facilities). This deficient practice had the potential to result in cross contamination (physical movement or transfer of harmful bacteria from one person, object, or place to another), spread of infections and placed other residents at risk for infection. Findings: During a review of Resident 68's admission Record, the admission Record indicated, Resident 68 was originally admitted to the facility on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow its policy and procedures in notifying the physician of an abnormal Blood sugar (BS) level (the main sugar found in blood) results in a timely manner for one of four sampled residents (Resident 1). Resident 1 ' s had blood sugar level of 435 milligrams per deciliter (mg/dl) on 8/20/2023. This deficient practice placed the resident at risk for a delay in treatment and at risk of hyperglycemia (high blood sugar) which can increased thirst, dry mouth, increase in urination, tiredness, blurred vision, and hospitalization. Findings: During a review of Resident 1's admission record, the admission record indicated Resident 1 was admitted on [DATE], with a diagnosis that included anoxic brain damage (brain injuries caused by a complete lack of oxygen to the brain,), diabetes (DM-high blood sugar), and hypertension (HTN-high blood pressure) During a review of Resident 1's history and physical (H&P) dated 8/10/2023, the H&P indicated Resident 1 does 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.