Westlake Convalescent Hospital

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide a dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) emergency kit (e-kit, collection of supplies that you might need during a time of emergency) at bedside for one of seven sampled residents on dialysis (Resident 85). This failure had the potential for Resident 85 to receive delayed intervention in managing complications such as bleeding.Findings:During a review of Resident 85's admission Record, the admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses that included, but not limited to end stage renal disease with dependence on dialysis, diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), gastroesophageal reflux disease (GERD - a condition in which stomach acid flows back up into the esophagus (food pipe) causing heartburn), hypertension (HTN-high 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 that its medication error rate was less than five percent (%). Two errors out of 29 opportunities contributed to an overall error rate of 6.9 % affecting one of four residents observed for medication administration (Resident 31). The errors noted were as follows:1. Attempted administration of approximately 7.5 milliliters (mL) of vitamin C (a vitamin supplement) liquid, instead of 5mL as per physician's orders.2. Attempted administration of approximately 7.5mL of levetiracetam (a medication used to treat seizures) liquid, instead of 5mL as per physician's orders.The deficient practice of failing to administer medications in accordance with the physician's orders increased the risk that Resident 31 may have experienced medical complications that could result in hospitalization.Findings:During a review of Resident 31's admission Record (a document containing diagnostic and demographic information), dated 7/17/25, the admission record…

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 residents observed for medication administration (Resident 31) was free of significant medication errors (an observed or identified incident in the preparation or administration of medications that causes the patient discomfort or jeopardizes their health or safety) when on 7/16/2025 Licensed Vocational Nurse 3 (LVN 3) was observed attempting to administer 7.5 milliliters (mL) of levetiracetam liquid (a medication used to treat seizures) instead of 5mL ordered by the physician.The deficient practice of failing to administer medications in accordance with the physician's orders increased the risk that Resident 31 may have experienced medical complications resulting in hospitalization.Findings:During a review of Resident 31's admission Record (a document containing diagnostic and demographic information) dated 7/17/25, the admission record indicated he was admitted to the facility on [DATE] and most recently readmitted 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 ensure the call light (a device that alerts healthcare providers that the patient needs assistance) was within reach for one of one sampled resident (Resident 22).This deficient practice had the potential to result in delay in meeting Resident 22's need for assistance.Findings:During a review of Resident 22's admission Record, the admission Record indicated the resident was admitted to the facility on [DATE] with the most recent readmission on [DATE], with diagnoses that included, but not limited to chronic respiratory failure (a condition where the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body), diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), schizophrenia (a mental illness that is characterized by disturbances in thought), Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure that a resident with an indwelling catheter (a flexible plastic tube inserted into the bladder that remains there to provide continuous urinary drainage) received proper care and services for three of five sampled residents (Resident 20, 57, and 64) as evidenced by: -For Resident 20 the facility staff did not empty the indwelling catheter urinary collection bag (designed to collect urine drained from the bladder via a catheter) as ordered by the physician. -For Resident 57 the facility failed to maintain the resident's urinary catheter bag below the level of the bladder. -Fore Resident 64, there was no assessment for indwelling catheter removal. These deficient practices had the potential to result in urinary tract infection (UTI-an infection involving any part of the urinary system, including urethra, bladder, ureters, and kidney) and had a potential to lead to urosepsis (a potentially life-threatening complication of urinary tract…

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 and interview, the facility failed to store Tuberculin purified protein derivative (Tuberculin PPD- used in skin test to help diagnose tuberculosis [ infection caused by bacteria Mycobacterium tuberculosis]), according to manufacturer's recommendation. -Label Latanoprost (eye drops used to increase the outflow of fluid from the eye) with an open date. -Discard multi-dose of Clearlax (a medication used to treat occasional constipation) and Reguloid (a medication used to treat constipation) after 60 days of opening. This deficient practice had a potential for the residents to receive medications with improper efficacy due to improper storage condition of medications. Findings: During medication storage observation and concurrent interview on 6/21/2024 at 12:29 PM, with Registered Nurse (RN) 2, one open vial of Tuberculin PPD with expiration date 12/2025, and open date 5/29/2024, was observed in the medication refrigerator. RN 2 stated the label on the vial indicated to refrigerate until opened. RN 2 stated Tuberculin PPD medication had to be stored in the…

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

Based on observation, interview and record review, the facility failed to ensure staff followed food production recipes and fortified diet (diet to increase caloric intake) guidelines during lunch service when: -Fortified diets (diet enriched to increase caloric content) were not prepared and were not served to 10 residents who were on fortified diet. -Six residents on pureed diet (foods that do not require chewing and are easily swallowed. All foods should be smooth and pureed to the consistency of pudding) did not receive the pureed lettuce, tomato, and pickles with their meal per the menu. This deficient practice had the potential to result in meal dissatisfaction for residents on puree diet, decrease caloric intake and unintentional weight loss for residents who were on fortified diet. Findings: a. During the tray line observation on 6/22/2024 at 11:35 AM, residents who were on fortified diet the Dietary Aide (DA) 1 communicated the fortified diet orders during lunch service but [NAME] 1 who was serving the food did not add any additional food items per fortified menu. 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.

Based on observation, interview and record review, the facility failed to ensure safe and sanitary food storage practices when: -Two previously cooked and frozen roast pork was thawing in the walk-in refrigerator with no pull out or thaw date. -One large turkey thawing in the walk-in refrigerator labeled with the wrong thaw date. -The walk-in freezer had ice buildup on the freezer ceiling, condenser, and pipes. Icicles hanging from the ceiling above food. There was a large deep pan in the freezer filled with solid ice and water leaking from above. These deficiencies had the potential to result in harmful bacteria growth, cross contamination (transfer of harmful bacteria form one place to another) and inappropriate storage of food and had the potential to affect 30 out 63 residents who eat food from facility kitchen. Findings: During an observation in the kitchen on 6/21/2024 at 5:15 PM, there was one previously cooked and frozen roast pork wrapped in foil with date of 6/13/2024 stored in the walk-in refrigerator. There was another previously cooked and frozen roast pork with dates…

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 call light was within reach for one of five sampled residents (Resident 22). This deficient practice had the potential to result in the resident not being able to call nursing staff for assistance when needed. Findings: A review of the admission Record indicated the facility admitted Resident 22 on 5/25/2016, with diagnoses including hemiplegia (paralysis of one side of the body), blindness of the left eye, dependence on the wheelchair, type 2 diabetes (a long-term condition in which the body has trouble controlling blood sugar and using it for energy), and schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly). A review of Resident 22's Minimum Data Set (MDS, a standardized assessment and care screening tool) dated 6/9/2024, indicated the resident had moderately impaired cognition (a person's ability to think, learn, remember, use judgement, and make decisions) skills for daily decision making. The MDS indicated Resident 22 required supervision or touching…

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 a current copy of the resident's advance directive (AD, a written instruction, recognized under State law, relating to the provision of health care when the individual is unable to make decisions for themselves) was in the resident's medical chart for one of three sampled residents (Resident 40). This deficient practice had the potential for the facility to not honor the resident's medical decisions regarding end-of-life treatment. Findings: A review of Resident 40's admission Record indicated the facility admitted the resident on 12/15/2023, with diagnoses including chronic respiratory failure (a condition that occurs when the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body), end stage of renal disease (final , permanent stage of chronic kidney disease, where kidney function has declined to the point that the kidneys can no longer function on their own), and dementia (decline in mental ability severe enough to interfere with daily functioning/life). A review of…

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

Based on observation, interview, and record review, the facility failed to accommodate communication needs for one of five sampled residents (Resident 59) by failing to keep a Korean communication board (a tool that includes pictures that help residents communicate their healthcare and every-day needs to facility staff) that help residents at bedside within the resident's reach. This deficient practice had the potential for Resident 59 to not be able to communicate their needs to the facility staff. Findings: A review of Resident 59's admission Record indicated the facility admitted the resident on 7/20/2023, with diagnoses that included osteomyelitis (an infection in the bone), type 2 diabetes (a long-term condition in which the body has trouble controlling blood sugar and using it for energy), hyperlipidemia (high levels of cholesterol in the blood), muscle weakness, and metabolic encephalopathy (a problem in the brain caused by a chemical imbalance in the blood). A review of Resident 59's Minimum Data Set (MDS, a standardized assessment and care screening tool) dated 4/30/2024,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide oral care for one of three sampled residents (Resident 2), who was totally dependent upon staff for all activities of daily living (ADLs - essential and routine activities include eating, dressing, getting into or out of a bed or chair, taking a bath or shower, and using the toilet), was unable to breathe independently and was ventilator (a machine that helps one breathe) dependent. This deficient practice had the potential to place Resident 39 at risk for ventilator associated infection. Findings: A review of Resident 2's admission Record indicated the facility admitted Resident 2 on 6/20/2018 and readmitted on [DATE], with diagnoses including epilepsy (a brain condition that causes recurring seizures[a sudden, uncontrolled burst of electrical activity in the brain]), and chronic respiratory failure ( a condition in which your lungs have a hard time loading your blood with oxygen or removing carbon dioxide). A review of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement accident risk and hazard interventions for two of five sampled residents (Residents 2 and 20). These deficient practices had the potential to place Residents 2 and 20 at risk for injuries. Findings: a. A review of Resident 2's admission Record (Face Sheet) indicated the facility admitted the resident on 6/20/2018, and readmitted on [DATE], with diagnoses including epilepsy (a brain condition that causes recurring seizures[a sudden, uncontrolled burst of electrical activity in the brain]), and chronic respiratory failure ( a condition in which your lungs have a hard time loading your blood with oxygen or removing carbon dioxide). A review of the Minimum Data Set (MDS - a standardized assessment and care screening tool) dated 5/2/2024, indicated Resident 2's cognition was severely impaired (never/rarely made decisions) and was totally dependent upon staff for all activities of daily living (ADLs -essential and routine activities…

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 change Resident 2's oxygen tubing every seven days per the residents care plan and physician order for one of three sampled residents (Resident 2). This deficient practice had the potential to cause complications associated with oxygen and mechanical ventilation therapy including infection or respiratory distress. Findings: A review of the admission Record indicated the facility admitted Resident 2 on 6/20/2018, and readmitted on [DATE], with diagnoses including epilepsy (a brain condition that causes recurring seizures [a sudden, uncontrolled burst of electrical activity in the brain]), and chronic respiratory failure (a condition in which your lungs have a hard time loading your blood with oxygen or removing carbon dioxide). A review of the Minimum Data Set (MDS - a standardized assessment and screening tool) dated 5/2/2024, indicated Resident 2's cognition was severely impaired (never/rarely made decisions) and was totally dependent…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the physician completed in person visits in a timely manner for one of three sampled residents (Resident 3), by failing to: -Ensure the physician initial face-to-face visit was made by a physician within 30 days after Resident 3s admission. -Ensure Physician visits were alternated with a Nurse Practitioner visits (NP- a nurse who is qualified to treat certain medical conditions without the direct supervision of a doctor) every 60 days after the first 90 days of Resident 3`s admission. These deficient practices had the potential to result in an undetected decline in medical, health, or psychosocial condition and can lead to a delay in necessary care, treatment, and services. Findings: A review of Resident 3's admission Record (Face Sheet) indicated the facility originally admitted the resident on 5/16/2023, and readmitted on [DATE], with diagnoses including epilepsy (a brain condition that causes recurring seizures [a sudden, uncontrolled burst…

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 enforce its own policy related to a safe, sanitary environment and infection control for two of five sampled residents (Resident 10 and 29) by failing to: -Ensure staff members perform hand hygiene between glove changes for Resident 29. -Ensure to label Resident 10's Intravenous catheter (a thin plastic tube inserted into a vein using a needle) and to lock the needleless system after completion of antibiotic infusion. These deficient practices had the potential to transmit infectious microorganisms and increase the risk of infection for Residents 10 and 29. Findings: a. A review of the admission Record indicated the facility admitted Resident 29 on 2/23/2024, and re-admitted the resident on 3/28/2024, with diagnoses including sepsis (a life-threatening condition in which the body responds improperly to an infection. The infection-fighting processes turns on the body, causing the organs to work poorly), chronic kidney disease (kidneys are damaged 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 follow up on insurance authorization to have a modified barium swallow study (MBSS- an exam that looks at how you swallow different liquids and foods using real time x-ray called fluoroscopy) in a timely manner for one of three sampled residents (Resident 1). This deficient practice may have caused a delay in service subsequently causing Resident 1 to become angry and refuse meals. Findings: A review of the facility admission Record indicated Resident 1 was admitted on [DATE] with diagnoses including Hemiplegia and Hemiparesis following Cerebral Infarction affecting the left side (weakness on the left side of the body after a stroke), Chronic Obstructive Pulmonary Disorder (COPD-condition involving constriction of the airways and or difficulty breathing), Dysphagia (difficulty swallowing), Encounter for Attention to Gastrostomy (g-tube: surgically inserted tube into the stomach through the abdominal wall for feeding), Unspecified severe…

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 conduct a weekly skin evaluation and assessment follow up of the sacrococcyx and left lower leg pressure injury (bedsore, the breakdown of skin integrity due to pressure, occurs when a bony prominence is under persistent contact with an external surface) for one sampled resident (Resident 1). Resident 1 did not receive a weekly assessment follow up and debridement on 8/31/2023 to evaluate the pressure injuries. This deficient practice caused an increased risk in harm to the resident. Findings: A review of the medical record indicated Resident 1 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including chronic respiratory failure, dependence on ventilator, end stage renal disease, gastrostomy, anemia in chronic kidney disease, dependence on renal dialysis and diabetes mellitus, dysphagia, and unstageable and peripheral vascular disease (PVD). According to a review of the Minimum Data Set (MDS - a standardized assessment…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the environment remained free of accident hazards for four of 28 sampled residents (Resident 32, 46, 108, and 56) by failing to: -Ensure the wheelchair brakes were locked while assisting Resident 46 with transfers from standing to sitting in the wheelchair. -Prevent Resident 32 from slipping out of the wheelchair while wearing ankle foot orthoses (AFO, brace applied to the leg to hold the foot and ankle in the correct position). -Remove an unsecured television from Resident 108's rolling bedside table. -Post appropriate signage outside Resident 56's doorway to indicate the presence of oxygen in accordance with the facility's policy. These deficient practices had the potential to result in injury to the residents and place the facility at risk for fire hazards. Findings: a. A review of Resident 46's Facesheet (admission record), dated 3/30/2022, indicated Resident 46 was originally admitted to the facility on [DATE] with diagnoses…

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

Based on observation, interview, and record review, the facility failed to ensure six of six Restorative Nursing Aides (RNA, nursing aide program that helps residents to maintain their function and joint mobility) demonstrated competency for the provision of range of motion (ROM, full movement potential of a joint) exercises. One of six RNAs did not provide adequate passive range of motion (PROM, movement of a joint through the range of motion with no effort from resident) exercises to one of 16 sampled residents (Resident 42). This deficient practice had the potential for 47 residents with physician's orders for RNA services to receive ROM exercises to experience a decline in ROM, which increased the likelihood of developing contractures (chronic loss of joint motion associated with deformity and joint stiffness). Cross reference F688 Findings: A review of Resident 42's admission Record indicated the facility admitted Resident 42 on 11/15/2021 with diagnoses including chronic respiratory failure (airways carrying air to lungs become narrow and damaged, limiting air movement in the…

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

Based on observation, interview, and record review, the facility failed to store food under sanitary conditions and maintain the kitchen in a sanitary manner as evidenced by: -Food products stored past labeled use by dates. -Unlabeled plastic bag with hot dogs in kitchen freezer. -Kitchen floor with dirty particles, dust, and white substance. These deficient practices caused an increased risk to cross-contaminate food with pathogens (germs) that could expose residents receiving food from the kitchen; and place them at risk for developing food borne illness (food poisoning) leading to symptoms including an upset stomach, stomach cramps, nausea, vomiting, diarrhea, and fever which can lead to hospitalization and/or death. Findings: During an observation of the kitchen's walk-in refrigerator, on 3/29/2022 at 8:53 a.m., during the initial tour of the kitchen, a plastic jar of 1/8 Crinkle-Cut thin dill chips was labeled with an open date of 5/3/2021. The use by date indicated 10/29/2021 was observed. During a concurrent interview, the Dietary Supervisor (DS) confirmed the use by date 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 did not implement appropriate infection control practices to prevent the transmission of communicable diseases by failing to: a. Ensure staff had access to a handwashing station in Resident 58 room, who was currently under transmission-based precautions (the second tier of basic infection control and are to be used in addition to Standard Precautions for patients who may be infected or colonized with certain infectious agents for which additional precautions are needed to prevent infection transmission). b. Properly disinfect a cloth gait belt (assistive device placed around a person's waist to assist with safe transferring between surfaces or while walking) and front wheeled walker (FWW, an assistive device with two front wheels used for stability when walking) between residents' use for Resident 53, 26, and 46. These deficient practices had the potential to transmit infectious microorganisms and increase the risk of infection for residents and…

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

Based on observation, interview, and record review, the facility failed to provide resident with dignity and respect by not sitting when assisting the resident with meal and eating at eye-level for one of 28 sampled residents (Resident 22). This deficient practice had the potential for Resident 22 to feel less respected as a person, which could negatively impact the resident's sense of dignity. Findings: A review of Resident 22's admission Record indicated the facility re-admitted Resident 22 on 11/18/2021, with diagnoses including seizure disorder (burst of uncontrolled electrical activity between brain cells that causes temporary abnormalities in muscle tone or movements like stiffness, twitching or limpness) and gastroesophageal reflux disease (digestive disorder that occurs when acidic stomach juices, or food and fluids back up from the stomach into the throat). A review of the Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 1/12/2022, indicated Resident 22's cognitive skills of daily decision making were moderately impaired but required limited…

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 residents health information was protected by not posting a sign above each resident's bed disclosing medical information regarding their dialysis access for two of three sampled residents (Resident 18 and Resident 42). This deficient practice had the potential of exposing residents medical information to staff who were not providing care to these resident and to visitors. Findings: a. A review of Resident 18's admission Record (Face Sheet) indicated the facility originally admitted the resident on 12/14/2021, and readmitted on [DATE], with diagnoses including chronic respiratory failure (inability to breath effectively) and end stage renal (inability of the kidney to remove waste product from the blood stream) disease. A review of Resident 18's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 3/20/2022, indicated Resident 18's cognitive skills of daily decision making were severely impaired 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 provide a homelike environment with adequate lighting for two of 28 sampled residents (Resident 22 and 32). This deficient practice had the potential to place Resident 22 and 32 at risk for choking hazards while being assisted with meals and decreased the residents' alertness to adequately eat, which increases their potential for weight loss. Findings: a. A review of Resident 32's admission Record indicated the facility re-admitted Resident 32 on 4/24/2019. Resident 32's diagnoses included but was not limited to gastroesophageal reflux disease [digestive disorder that occurs when acidic stomach juices, or food and fluids back up from the stomach into the throat), acute embolism and thrombosis (types of blood vessel blockage) of deep veins in the lower extremity (leg), and dependence on wheelchair. A review of Resident 32's Minimum Data Set (MDS, a standardized assessment and care -screening took), dated 1/30/2022, indicated Resident 32's…

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

Based on observation, interview, and record review, the facility failed to provide one of 28 sampled residents (Resident 32) with care and services to maintain the ability to perform activities of daily living (ADLs, tasks related to personal care) by failing to: -dress Resident 32 in appropriate clothes and assist Resident 32 out-of-bed daily in accordance with the care plan and the facility's policy, and -provide Resident 32 with a Restorative Nursing Aide (RNA, nursing aide program that helps residents to maintain their function and joint mobility) feeding program in accordance with the physician's order. These deficient practices had the potential for Resident 32 to experience a decline in overall function, endurance, strength, and mental health, which affects the resident's quality of life. Cross reference F805 Findings: A review of Resident 32's admission Record indicated the facility re-admitted Resident 32 on 4/24/2019 with diagnoses including gastroesophageal reflux disease (digestive disorder that occurs when acidic stomach juices, or food and fluids back up from the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to endure residents received treatment and care in accordance with professional standards for three of eight sampled residents (Residents 2, 11, and 58). The physician's orders were not followed these residents causing an increased risk in worsening pressure related skin injuries and the potential for increased harm and infection. Findings: A review of Resident 2's Face sheet indicated Resident 2 was admitted to the facility on [DATE] with diagnoses including Chronic Respiratory Failure (condition that results in the inability to effectively exchange carbon dioxide and oxygen, and induces chronically low oxygen levels or chronically high carbon dioxide levels), Tracheostomy (opening surgically created through the neck into the trachea (windpipe) to allow direct access to the breathing tube) status, Pressure induced deep tissue damage (serious form of pressure ulcer caused by direct pressure to the skin and soft tissue that causes ischemia) of…

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

Based on observation, interview, and record review, the facility failed to provide one of 16 sampled residents (Resident 42) with: -appropriate passive range of motion exercises (PROM, movement of a joint through the range of motion with no effort from resident) and -equipment to prevent further range of motion (ROM, full movement potential of a joint) loss in the left leg. These deficient practices placed Resident 42 at increased risk for the development of contractures (chronic loss of joint motion associated with deformity and joint stiffness), which could lead to increased pain. Cross reference F726 Findings: a. A review of Resident 42's admission Record indicated the facility admitted Resident 42 on 11/15/2021 with diagnoses including chronic respiratory failure (airways carrying air to lungs become narrow and damaged, limiting air movement in the body), dependence on ventilator (machine that mechanically assists with breathing), dependent on renal dialysis (process of filtering blood), dysphagia (difficulty swallowing), encounter for attention to gastrostomy (G-tube, tube…

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 unopened insulin (a medication used to control high blood sugar) was stored in the refrigerator per the manufacturer's requirements for one of three inspected medication carts (Sub-Acute Medication Cart 3) affecting Resident 57. -Remove expired insulin from one of three inspected medication carts (Sub-Acute Medication Cart 4) affecting Resident 18. These deficient practices increased the risk that Residents 18 and Resident 57 could have received medication that had become ineffective or toxic due to improper storage possibly leading to health complications resulting in hospitalization or death. Findings: During an observation on [DATE] at 2:11 PM of the Sub-Acute Medication Cart 3, with the Licensed Vocational Nurse (LVN 5), the following medications were found either expired, stored in a manner contrary to their respective manufacturer's requirements, or not labeled with an open date as required by their respective manufacturer's…

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

Based observation, interview, and record review, the facility failed to provide an appropriate meal for one of 28 sampled residents (Resident 32). Resident 32 consistently coughed during three meal observations which was not reported to nursing. This deficient practice placed Resident 32 at increased risk for aspiration. Cross reference F676 Findings: A review of Resident 32's admission Record indicated the facility re-admitted Resident 32 on 4/24/2019 with diagnoses including dysphagia (difficulty swallowing) gastroesophageal reflux disease (digestive disorder that occurs when acidic stomach juices, or food and fluids back up from the stomach into the throat), acute embolism and thrombosis (types of blood vessel blockage) of deep veins in the lower extremity (leg) and dependence on wheelchair. A review of Resident 32's Physician's Order, dated 4/24/2019, indicated to provide a regular, mechanical soft (texture modified for people with chewing or swallowing difficulties) fortified diet (diet enhanced to increase caloric intake), with hot chocolate at breakfast and lunch. A review of…

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