Windsor Gardens Convalescent Hospital

Based on interview and record review, the facility failed to provide the necessary care and treatment for one of one sampled resident (Resident 96) by failing to: a. Reassess Resident 96's ongoing use of Bactrim (a prescription antibiotic combination used to treat bacterial infections) and sacubitril-valsartan (medication for congestive heart failure [CHF-a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling]), and notify the physician that the electronic medical records (EMR) system triggered a drug-drug interaction (DDI) alert (an alerts that appear on the screen by flagging potential adverse reactions or duplicate therapies during the prescribing process. These alerts appear during medication search or processing allowing clinicians to cancel or override them) due to concurrent use of Bactrim and sacubitril-valsartan. This combination of medications can significantly increase the risk of hyperkalemia, a condition caused by dangerously high elevated levels of potassium (an essential mineral and electrolyte that helps 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 ensure a resident's eyeglasses were kept in working condition for one of three sampled residents (Resident 11). This failure resulted in Resident 11 not being able to see adequately and expressing feeling of frustration from not being able to enjoy his preferred activity.During a review of Resident 11's admission Record, the admission record indicated that Resident 11 was initially admitted to the facility on [DATE], with diagnoses including cerebrovascular disease (loss of blood flow to a part of the brain), alcoholic cirrhosis (permanent scarring that damages the liver and interferes with its functioning), and atrial fibrillation (afib- an irregular and very rapid heart rhythm that and can lead blood clots in the heart).During a review of Resident 11's Minimum Data Set (MDS - a resident assessment tool) dated 03/12/2026, MDS indicated that Resident 11's cognitive (mental action or process of acquiring knowledge and understanding) skills…

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 re- assessment was done each time Resident 6 has a fall and implementation of fall prevention interventions, including timely post-fall reassessment and revision of the care plan, for 1 of 1 sampled resident (Resident 6) who was identified as high risk for falls.This deficient practice has a potential for Resident 6 to have recurrent falls , sustaining injury from fall compromising residents safety.During a review of Resident 6's admission Record (Face Sheet), the admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses including hypertension (a condition characterized by persistently elevated blood pressure, which can increase the risk of cardiovascular complications), atherosclerotic heart disease (a condition where plaque builds up in the arteries, reducing blood flow to the heart), benign prostatic hyperplasia (BPH - a non-cancerous enlargement of the prostate that can cause urinary…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to ensure adequate documentation of intake and output for one (Resident 8) out of one sampled residents who are on hemodialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed).This deficient practice had the potential to cause fluid overload (excess water in the body) or dehydration (insufficient water in the body) for Resident 8.Findings:During a review of Resident 8's admission record, the admission record indicated Resident 8 was originally admitted on [DATE] with diagnoses including, but not limited to polyneuropathy (disease or dysfunction of one or more nerves, typically causing numbness or weakness in the hands and feet); end stage renal disease (ESRD- irreversible kidney failure); chronic (systolic) congestive heart failure (CHF- a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling); and adult failure to thrive…

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 resident's head of the bed was elevated to at least 30 degrees during feedings as ordered for one of three sampled residents (Resident 3), who was receiving nutrition through a gastrostomy tube (G tube, a flexible tube surgically inserted through the abdomen into the stomach for the administration of nutrition, fluids, and medications). This failure had the potential to increase the risk of aspiration (accidentally inhaling food, liquids, stomach acid, or saliva into lungs) in the resident.Findings: During a review of Resident 3's admission Record (face sheet), dated 4/15/2026, the face sheet indicated Resident 3 was initially admitted to the facility on [DATE], and re-admitted on [DATE], with diagnoses including but not limited to Parkinsonism (a general term for brain disorders that cause slowed movements, stiffness, and tremors), dementia (a general term for loss of memory, language, problem-solving and other thinking…

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 bed rails zoning was measured for Resident 12 annually or ongoing for bed safety assessments was completed for one of one sampled resident reviewed (Resident 12). This deficient practice had the potential to result in an inability to verify that the bed system remained safe for residents' use and placed the resident at risk for entrapment, injury, and harm.During a record review of Resident 12's admission Record (Face Sheet), the admission record indicated the resident was admitted to the facility on [DATE] with a diagnoses including type 2 diabetes mellitus (high blood sugar due to the body not using insulin properly) , diabetic neuropathy (nerve damage causing numbness or pain, usually in the hands and feet), essential hypertension (chronic high blood pressure without a specific cause), and muscle weakness with abnormalities of gait and mobility (reduced strength and difficulty walking or moving safely). During a record review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide behavioral health treatment and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for one of two sampled residents (Resident 13) by failing to provide an ongoing assessment, monitoring and implementing a person-centered care plan when Resident 13 stated persistent negative feelings related to trauma experience.This deficient practice had the potential to negatively affect the delivery of behavioral health care and services to Resident 13.During a review of Resident 13's admission Record, the admission record indicated that Resident 13 was initially admitted to the facility on [DATE], with diagnoses including hepatic encephalopathy (a disease in which the functioning of the brain is affected by some agent or condition a disease in which the functioning of the brain is affected by severe liver disease), schizoaffective disorder, bipolar type (a mental illness that can affect…

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 insulin (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication) rotation of injection sites for three out of three sampled residents (Resident 61, Resident 9 and Resident 57). This deficient practice had the potential to result in lipodystrophy (partial or complete loss of fat) which affects insulin absorption, potential hyperglycemia (high blood glucose) for Resident 61, 9 and 57. Findings: During a review of Resident 61's admission Record, the admission record indicated Resident 61 was admitted on [DATE] with left-sided hemiparesis/hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body), cerebral infarction (a type of brain damage due to a blockage in blood flow), and diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of the Minimum Data Set (MDS – a resident assessment tool)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the facility's pharmacist consultant's recommendation in the Medication Regimen Review (MRR), which advised adding a pain medication order for mild or severe pain, was reviewed and acted upon for one of five sampled residents (Resident 3)This failure resulted in Resident 3 not receiving recommended adjustments to her pain medication regimen, increasing the risk for Resident 3 to suffer from unmanaged pain. Findings: During a review of Resident 3's admission Record (face sheet), dated 4/15/2026, the face sheet indicated Resident 3 was initially admitted to the facility on [DATE], and re-admitted on [DATE], with diagnoses including but not limited to Parkinsonism (a general term for brain disorders that cause slowed movements, stiffness, and tremors), dementia (a general term for loss of memory, language, problem-solving and other thinking abilities), bipolar disorder (a chronic mental health condition characterized by intense extreme mood swings…

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 a medication was not left at the bedside without a physician's order for one of two sampled residents (Resident 15). This deficient practice has the potential risk for medication errors and adverse drug events. During a review of Resident 15's admission Record, the admission record indicated that Resident 15 was initially admitted to the facility on [DATE], with diagnoses including metabolic encephalopathy (a chemical imbalance in the blood affecting the brain), diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), congestive heart failure (CHF-(a condition in which the heart does not pump blood as well as it should) and muscle weakness. During a review of Resident 15's Minimum Data Set (MDS - a resident assessment tool) dated 4/01/2026, MDS indicated that Resident 15's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were…

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

Based on observation, interview, and record review, the facility failed to ensure the Dining Services Manager (DSM) had the appropriate competencies and skills to carry out duties in the kitchen when she incorrectly tested the chorine levels of the dishwasher.This failure had the potential to affect chlorine concentration. Excess chlorine on dishes could lead to chlorine poisoning, while insufficient chlorine could leave germs on the dishes, both increasing the residents' risk of serious illness or death. Findings: During a concurrent observation and interview on 4/14/2026 at 8:38 AM in the kitchen, DSM began performing a test to check the dishwasher's chlorine sanitizer levels. DSM removed a test strip from the bottle and dipped it into the liquid draining from the outlet outside the dishwasher. DSM held the strip in the liquid for 5 seconds and then removed it. DSM compared the test strip to the color guide on the bottle and interpreted the chlorine concentration as 200 parts per million (ppm). DSM stated this is the method normally used to check the dishwasher's chlorine levels.…

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 Licensed Vocational Nurse (LVN) 3 accurately documented medication administration for one of one sampled resident (Resident 44). This failure had the potential to result in inaccurate medical records, medication documentation errors, and inappropriate clinical decision-making related to medication management.Findings:During a review of Resident 44's admission Record (Face Sheet) indicated Resident 44 was initially admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses including hypertensive heart disease and chronic kidney disease with heart failure, atrioventricular block (a slowed heart that occurs because of a malfunction with the heart's electrical system) and cardiomyopathies (problems with your heart muscles that can make it harder for your heart to pump blood).During a review of Resident 44's Minimum Data Set (MDS - a resident assessment tool) dated 01/2/2026 indicated Resident 44 had no cognitive…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure informed consent was obtained in a timely manner from the resident before administering influenza (an infection of the nose, throat and lungs, which are a part of the respiratory system) vaccine (a preparation that is used to stimulate the body's immune response against diseases) for two of five sampled residents (Resident 19 and Resident 20) when: 1.The informed consent for the influenza vaccine, including a discussion of the risks, benefits, and potential side effects for Resident 19, was obtained on 08/27/2025, which was 6 days prior to the administration on 09/02/2025. 2.The informed consent for the influenza vaccine, including a discussion of the risks, benefits, and potential side effects for Resident 20 was obtained on 08/27/2025, which was 21 days prior to the administration on 09/17/2025. This deficient practice violated Resident 19 and Resident 20's rights to make an informed decision by the time of administration. A. During a review…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of one sampled resident (Resident 30) has call light (a device to press, to call and ask for help) within reach.This deficient practice had the potential for Resident 30 unable to ask for help if needed.During a record review of the admission record, the admission record indicated Resident 30 was admitted to the facility on [DATE] with diagnoses of chronic systolic (congestive) heart failure and atrial fibrillation (diminished ability of heart to pump blood with irregular heartbeat), presence of prosthetic heart valve (device to replace malfunctioning heart valve to promote one way blood flow), essential hypertension (chronic high blood pressure), benign prostatic hyperplasia with lower urinary tract symptoms (enlarged prostate gland causing urgency, frequency and incomplete bladder emptying), cerebral infarction due to embolism of cerebral artery (damage to brain cells due to lack of blood supply affecting bodily functions,…

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 meet the needs of the residents in a timely manner for three of six sampled residents (Resident 1, Resident 2 and Resident 3). For Resident 1, Resident 2 and Resident 3, the facility failed to respond to the call lights and requests for assistance timely.These deficient practices resulted in Resident 1 stating she felt irritated, Resident 2 stated he .was so upset and angry and Resident 3 stated she felt staff do not treat me with respect. 1. During a review of the admission Record indicated the facility admitted Resident 1 on 7/24/25 with diagnoses including diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) and generalized muscle weakness. During a review of the Minimum Data Set (MDS, a resident assessment tool) dated 7/29/25 indicated Resident 1 was cognitively intact. Resident 1 was dependent on putting on/taking off footwear, substantial assistance with lower body dressing, supervision with…

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

Based on interview and record review, the facility failed to obtain a physician order for fingerstick to obtain the blood sugar level (BSL, measure of sugar in the blood by using a glucometer [medical device that measures the blood glucose level in the body] for one of six sampled residents (Resident 1) according to the professional standards of quality. For Resident 1, the facility failed to:1.Obtain a physician order to obtain BSL by fingerstick from Resident 1's physician. The fingerstick were done on 7/24/25, 8/2/25, 8/8/25/ 8/9/25, 8/10/25 and 8/11/25.2.Notify the physician when Resident 1's BSL results were above 189 milligrams per deciliter (mg/dL, a unit of measurement for the concentration of glucose in the blood, normal range is between 60 mg./dL to 100 mg./dL).These deficient practices had the potential for Resident 1 to suffer from hyperglycemia (high blood sugar level) and not given appropriate treatment.During a review of the admission Record indicated the facility admitted Resident 1 on 7/24/25 with diagnoses including diabetes mellitus (DM-a disorder characterized by…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the safety of one of four sampled residents Resident 1. As a result of this deficient practice Resident 1 fell on 6/19/2025 at 4:40 AM and transferred to General Acute Care Hospital (GACH). Findings: A review of Resident 1's admission record indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE] with a diagnosis including metabolic encephalopathy (a problem in the brain caused by a chemical imbalance in the blood) chronic kidney disease (kidneys cannot filter blood as well as they should), weakness (a lack of strength in the muscles), Alzheimer's disease (a progressive disease that destroys memory and other important metal functions). During a revie of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 4/22/2025 indicated brief interview for mental status (BIMS: a screen used to assist with identifying a resident's current cognition and to help determine if any…

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 follow the menu and provide residents a variety of food options when: 1. Resident 25, who did not want fish, received boiled diced chicken instead of baked chicken per menu. 2. Resident 28, who was on vegan plant-based diet, did not receive vegan options and vegan menu was not prepared. 3. Six residents who were on the renal diet (a diet intended for residents with impaired kidney function. The purpose is to provide adequate nutrition, prevent protein loss and manage fluid and electrolyte balance) received peas instead of oven French fries per menu. These deficient practices had the potential to result in inadequate nutrition status and meal dissatisfaction when the menu was not followed and updated to reflect the needs of the residents. Findings: 1. During a review of the facility lunch menu for the regular diet on 3/1/2025, the menu indicated the following items would be served: Regular diet: Breaded fish fillet 1 each; oven French fries ½ cup; buttered carrots ½ cup; chocolate cake/icing 1square; Milk;…

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: 12 residents on pureed diet received the correct pureed diet texture (foods that do not require chewing and are easily swallowed. Food should be smooth .consistency of pudding) as ordered when the cook served thin and soupy carrots instead of pureed carrots that was homogenous (of the same kind; alike), cohesive and had a pudding like consistency. This deficiency had the potential to result in meal dissatisfaction and increased choking and aspiration risk for residents on pureed diet. Findings: During an observation of the tray line service for lunch on 3/1/2025 at 11:56AM, residents who were on pureed diet received carrots that was soupy and thing liquid consistency. During a concurrent observation and interview with [NAME] (Cook 1), [NAME] 1 said she added liquid to the carrots and blended until smooth. During an interview with [NAME] 1 and Dietary Supervisor (DS) on 3/1/2025 at 12:45PM, [NAME] 1 stated she agreed that the carrots had liquid consistency. [NAME] 1 stated she should have used less…

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 in the kitchen when one can opener blade was dented and stained with dried brown residue. 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 out of residents who received food from the facility. Findings: During an observation in the kitchen food preparation area on 2/28/2025 at 6:30PM, one can opener blade was observed worn and dented. The blade was not smooth to touch, was stained, covered with brown residue and metal shavings. During a concurrent observation and interview with Dietary Supervisor (DS) on 2/28/2025 at 6:35PM, the DS verified that there were metal shavings around the blade and the blade had dents. DS stated can opener needs to be washed. The DS stated she was new and did not know when the last time the blade was changed. The DS stated she will immediately replace the blade to prevent cross…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to: -Obtain 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 in two of five residents sampled for unnecessary medications (Resident 26 and Resident 10). -Obtain informed consent from the resident or RP after increasing the dose of aripiprazole (a medication used to treat mental illness) in one of five residents sampled for unnecessary medications (Resident 43). The deficient practices of failing to obtain informed consent prior to initiating treatment or increasing the dose of psychotropic (medications that affect brain activities associated with mental processed and behavior) medications could have prevented Residents 26, 10, and 43 from exercising their right to decline treatment with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of six sampled residents (Resident 27) had the call light within reach. This deficient practice placed the resident at risk for not receiving needed care and placed the resident at risk for falls. Findings: During a review of Resident 27's admission Record, the admission record indicated Resident 27 was initially admitted to the facility on [DATE] and was readmitted on [DATE]. Resident 27's diagnoses included chronic kidney disease (a long-term condition where the kidneys gradually lose their ability filter waste products and excess fluid from the blood), dementia (a progressive state of decline in mental abilities), and contractures (tightening of muscles, tendons, skin and other tissues that limits mobility) to left hand. During a review of Resident 27's History and Physical (H&P), dated 8/30/2024, the H&P indicated, Resident 27 could not make medical decision but could make needs known. During a review of Resident 27'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 interview and record review, the facility failed to document for one of six sampled residents (Resident 10) when the nicotine smoking patch (used to help people to stop smoking cigarettes) was removed after usage. This deficient practice had the potential to ineffectively give the proper dosage of medication to Resident 10. Findings: During a review of Resident 10's admission Record, the admission record indicated Resident 10 was admitted to the facility on [DATE]. Resident 10's diagnoses included encephalopathy (brain disorder disease or damage that affects your brain's function or structure), schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), and post-traumatic stress disorder ([PTSD]- a disorder in which a person has difficulty recovering after experiencing or witnessing a traumatic event). During a review of Resident 10's Minimum Data Set (MDS, a resident assessment tool), dated 1/7/2025, the MDS indicated Resident 10's cognition (ability to learn, reason,…

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 accurately complete the minimum data set (MDS - a comprehensive resident assessment tool) assessment Section I (active diagnoses), dated 11/21/24, by failing to include a diagnosis of schizophrenia (a mental illness characterized by hearing or seeing things that are not there), depression (a mental illness characterized by depressed mood, difficulty sleeping, or lack of interest in usually enjoyable activities), and bipolar disorder (a mental health condition that causes extreme mood swings from emotional highs [mania] to deep lows [depression]) per information in the medical record for one of five residents sampled for unnecessary medications (Resident 26.) The deficient practice of failing to accurately assess active diagnoses and complete MDS Section I increased the risk that Resident 26 may not have received care planning and treatment according to his needs possibly leading to a decline in his overall health and well-being. Findings: A review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure two of six sampled residents (Resident 16 and 10) care plans were revised for Resident 16 who refused to wear hearing aids and for Resident 10 regarding the interventions on when to remove and document the disposal of the smoking patch (skin patches are used to help people to stop smoking cigarettes). This deficient practice had the potential for Resident 16 and 10 to receive insufficient treatment and care. Findings: a. During a review of Resident 16's admission Record, the admission record indicated Resident 16 was admitted to the facility on [DATE]. Resident 16's diagnoses included chronic obstructive pulmonary disease (COPD - a chronic lung disease causing difficulty in breathing), dementia (a progressive state of decline in mental abilities), and heart failure (the heart is unable to pump sufficient blood to the tissues). During a review of Resident 16's Minimum Data Set (MDS, a resident assessment tool), dated 2/10/2025, 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 ensure two of five sampled Residents (Resident 22, and Resident 47) received professional standard of care and services to maintain clean fingernails with trim. This deficient practiced placed Resident 22, and Resident 47 at risk for a potential skin injury and bacteria growth of the fingernails. Findings: a. During a review of Resident 22's admission Record, the admission Record indicated Resident 22 was admitted to the facility on [DATE] with a diagnosis that included Dementia (a progressive state of decline in mental abilities), hypothyroidism (deficiency of thyroid hormones), and hypertension ((HTN-high blood pressure) During a review of Residents 22's Minimum Data Set (MDS - a resident assessment tool), dated 12/25/2024, the MDS indicated Resident 22 rarely/ never make self-understood and rarely/never understand others. The MDS indicated Resident 22 required dependent assistance with Activities of daily living (ADLs- activities such…

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 facility staff assisted one of six sampled residents (Resident 16) with hearing aids (a device worn in or behind the ear designed to amplify sound for individuals who have difficulty hearing) place the hearing aid in the resident's ears daily. This deficient practice of not providing hearing aids to Resident 16 had the potential for the resident to not hear clearly and communicate needs to staff. Findings: During a review of Resident 16's admission Record, the admission record indicated Resident 16 was admitted to the facility on [DATE]. Resident 16's diagnoses included chronic obstructive pulmonary disease (COPD - a chronic lung disease causing difficulty in breathing), dementia (a progressive state of decline in mental abilities), and heart failure (the heart is unable to pump sufficient blood to the tissues). During a review of Resident 16's Minimum Data Set (MDS, a resident assessment tool), dated 2/10/2025, 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 observation, interview, and record review, the facility failed to ensure one of six sampled residents (Resident 341), who was on a low air loss mattress ([LAL]- a medical device that helps prevent and treat pressure ulcers by distributing body weight and improving air circulation) had the correct setting to prevent skin breakdown (damage to the skin caused by prolonged pressure on bony areas of the body). This deficient practice had the potential to worsen skin breakdown. Findings: During a review of Resident 341's admission Record, the admission record indicated Resident 341 was admitted to the facility on [DATE]. Resident 341's diagnoses included malignant neoplasm (a cancerous tumor that can spread to other parts of the body), diabetes mellitus([DM]- a disorder characterized by difficulty in blood sugar control and poor wound healing), and parkinsonism (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements). During a review of Resident 341's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record reviews, the facility staff failed to ensure resident received appropriate treatment and services to prevent urinary tract infections urinary tract infection (UTI- an infection in the bladder/urinary tract) for one of three sampled residents (Resident 46) by failing to ensure report to the resident's physician (MD) the presence of sediment (particles in liquid) in the indwelling urinary (foley) catheter (a hollow tube inserted into the bladder to drain or collect urine). This deficient practice had the potential to delay the healing of Resident 46's urinary tract infection (UTI; an infection in the bladder/urinary tract) or cause the infection to worsen. Findings: During a review of Resident 46's admission Record, the admission record indicated the resident was admitted to the facility on [DATE] with diagnoses that included benign prostatic hyperplasia (BPH; a condition in which the prostate gland [A gland in the male reproductive system] grows larger than normal).…

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 eight sampled residents (Residents 52) received the appropriate treatment and services needed to maintain and prevent gastrostomy tube (GT - a flexible tube surgically inserted through the abdomen into the stomach for feeding, fluid, and medication administration) complications. Resident 52's GT was not securely connected to prevent leakage. This deficient practice caused feeding to leak from the GT soaking the resident's skin and bed linen, placing the resident at risk for malnutrition and skin break down. Findings: During a review of Resident 52's admission Record, the admission Record indicated Resident 52 was originally admitted to the facility on [DATE], with diagnoses including major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), single episode, unspecified ( first time episode of depression ),…

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 signs and symptoms of bleeding and bruising related to the use of aspirin (a medication used to prevent blood clots and Eliquis (a medication used to prevent blood clots) in one of five residents sampled for unnecessary medications (Resident 78). The deficient practice of failing to monitor for signs and symptoms of bleeding during aspirin and Eliquis therapy increased the risk that Resident 78 could have experienced adverse effects (unwanted and dangerous side effects of medication) such as bleeding and bruising leading to medical complications requiring hospitalization. Findings: A review of Resident 78 ' s admission Record dated 3/2/25, indicated he was admitted to the facility on [DATE] with diagnoses including unspecified sequelae of cerebral infarction (medical complications following a blood clot in the brain) and personal history of other venous thrombosis and embolism (a history of blood clots causing medical complications). A review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to: -Ensure the antipsychotic medication (a class of medications used to treat mental illness), pimavanserin (an antipsychotic medication used to treat mental illness) was used for a clear indication or diagnosed condition as documented in the clinical record for one of five residents sampled for unnecessary medications (Resident 26). -Ensure the lowest possible dose of the antipsychotic medication, aripiprazole (an antipsychotic medication used to treat mental illness), was used for behavioral management in one of five residents sampled for unnecessary medications (Resident 43). The deficient practices of failing to use antipsychotics for a clear indication and at the lowest practicable dose increased the risk that Residents 26 and 43 could have experienced adverse effects related to antipsychotic medication therapy, such as drowsiness, dizziness, constipation, or increased risk of fall, possibly leading to impairment or decline in their mental or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that its medication error rate was less than five percent (%). Two medication errors out of 26 total opportunities contributed to an overall medication error rate of 7.69 % affecting two of three residents observed for medication administration (Residents 19 and 48.) The medication errors noted were as follows: -Attempted to administer carbamazepine (a medication used to treat nerve pain) suspension (a liquid medication dosage form in which a solid is suspended, but not dissolved, in a liquid vehicle) without first shaking the bottle to Resident 48. -Administered the wrong formulation of multivitamins (a vitamin supplement) to Resident 19. The deficient practice of failing to administer medications in accordance with professional standards and the physician ' s orders increased the risk that Residents 19 and 48 may have experienced medical complications possibly resulting in hospitalization. Cross Reference F760 Findings: A review…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure its residents were free from significant medication errors by attempting to administer carbamazepine (a medication used to treat nerve pain) suspension (a liquid medication dosage form in which a solid is suspended, but not dissolved, in a liquid vehicle) without first shaking the bottle to one of three sampled residents observed for medication administration (Resident 48). The facility failed to ensure to follow the parameteres (fixed high and low limits in which the blood pressure must be to safely administer the medication) when administering antihypertensive (used to treat high blood pressure) medication for Resident 18. These deficient practices increased the risk that Resident 48 and Resident 18 may have experienced medical complications such as increased nerve pain or hypotension (low blood pressure) due to the improper administration possibly leading to a decline in quality of life. Cross Reference F759 Findings: a. 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 and interview, the facility failed to ensure the treatment nurse (TN) 1 changed gloves after removing a soiled dressing from Resident 13 and applying a clean dressing. This deficient practice had the potential to result in spread of infection and can lead to a delay in wound healing process. Finding: During a concurrent observation and interview on 3/1/2025 at 9:48 a.m., TN 1 was observed applying gloves and removing a soiled dressing from the right foot of Resident 13. TN 1 proceeded to clean the wound with normal saline (NS- sterile, clear solution containing 0.9% sodium chloride (NaCl) without changing gloves. TN 1 pat dry the wound. TN 1 did not change her gloves and applied Betadine Solutions (topical antiseptic), and cover wound with dry gauze. TN 1 removed gloves, sanitized hands, and applied clean gloves. TN 1 then proceeded to change the dressing from the left heel wound. TN 1 removed soiled dressing, did not change gloves and cleaned the wound with NS. TN 1 applied Calcium Alginate…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide a copy of the records upon written request on 1/20/2025 from a legal representative of one of three sampled residents (Resident 1). This deficient practice had resulted in the violation of the rights of Resident 1's family member to obtain copy of the records. Findings: During a review of Resident 1's admission Record dated 2/12/2025, it indicated, Resident 1 was admitted to the facility on [DATE]. During a review of Resident 1's Order Summary dated 2/12/2025, it indicated, Resident 1 to transfer to General Acute Care Hospital (GACH) secondary to right shoulder pain for further evaluation. During a review of the Facsimile Transmission Cover Sheet, it indicated, Resident 1's legal representative faxed a record request to the facility on 1/20/2025 at 10:55 AM. The fax transmission result indicated OK for a 10 pages fax delivered to the facility on 1/20/2025 at 10:55 AM. During an interview with the facility's Administrator (ADM), on 2/11/2025 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.

Based on interview and record review the facility failed to ensure the medications were given and skin treatment were done for one of three sampled residents (Resident 1). For Resident 1, the facility failed to ensure: 1. Resident 1 ' s skin treatment was done and documented in the Treatment Administration Record (TAR, daily documentation record used by a licensed nurse to document treatments given to a resident) on 12/20/24 and 12/21/24. 2. Resident 1 ' s eyedrops Brimonidine Tartrate 0.2% solution (eye drops used to lower pressure in the eyes of residents who have glaucoma) was administered and documented in the Medication Administration Record (MAR, daily documentation record used by a licensed nurse to document medications given to a resident) on 12/22/24 and 12/23/24. These deficient practices resulted in Resident 1 not given his skin treatment and eye drops that may potentially affect skin healing and increase Resident 1 ' s eye pressure. Findings: During a review of the admission Record indicated the facility admitted Resident 1 on 12/18/24 with diagnoses including left above…

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 resident ' s wishes for medical care and treatment were clarified with the resident and/or the representative for one of three sampled residents (Resident 1). For Resident 1 who had a do not resuscitate status (DNR, allow natural death) order at general acute hospital (GACH 1), the facility failed to clarify with the family and the physician the code status (designation that communicates the type of emergent healthcare a resident would want or would not want to receive if the heart or breathing stops), when Resident 1 was admitted to the facility on [DATE] and subsequent days. This deficient practice had the potential for the facility to deny and honor Resident 1 and Resident 1 ' s next of kin (NOK) of their right regarding Resident 1 ' s treatment preferences during emergency. Findings: During a review of the admission Record indicated the facility admitted Resident 1 on 7/12/24 and readmitted on [DATE] with diagnoses including metabolic…

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 permit one of four residents (Resident 1) and implement their Bed-hold policy and procedures (P&P) after Resident 1 was transferred General Acute Care Hospital 1 (GACH 1) and was ready to be transferred back to the facility on [DATE]. The facility did not permit Resident 1 back to the facility. This deficient practice resulted in the Resident 1 remaining at GACH 1 and the potential to cause psychosocial harm. Findings: A review of Resident 1's admission Record indicated resident was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD - a group of lung diseases that block airflow and make it difficult to breathe), encephalopathy (a disease in which the functioning of the brain is affected by some agent or condition-such as viral infection or toxins in the blood) and respiratory failure (condition in which your blood does not get enough oxygen or has too much carbon dioxide). A review of the Minimum…

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 the two sampled residents (Resident 1) who was on oxygen via nasal cannula (NC-a thin, flexible tube with two prongs at one end that are inserted into the patient's nostrils and provides oxygen through the nose) the tubing was changed weekly and off the ground per the facility's policy and procedures (P&P) titled Changing of Nasal Cannula/Oxygen Tubing, This deficiency practice had the potential to result in Resident 1 contracting pneumonia (an infection that inflames the air sacs in one or both lungs. The air sacs may fill with fluid or pus, causing cough with phlegm or pus, fever, chills, and difficulty breathing. A variety of organisms, including bacteria, viruses, and fungi, can cause pneumonia). Findings: A review of resident 1 ' s admission Record (FS) indicated Resident 1 was admitted to the facility on [DATE] sepsis (a life-threatening medical emergency that occurs when the body's immune system has an extreme response…

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 follow infection prevention and control practices needed to prevent/control the spread of infections, by failing to: a. Ensure Certified Nurse Assistant (CNA 1) wore gloves when entering a novel respiratory isolation precaution (isolation room that requires staff and visitors to wear a gown, gloves, face shield and a N-95 mask [disposable respirator mask]) room for one of three sampled residents (Resident 1). b. Ensure CNA 1 doffed (removed) her face shield and N-95 mask after leaving a novel respiratory isolation precaution room (Resident 1 ' s room). These deficient practices had the potential to result in an increased spread of infection to facility residents and staff. Findings: a. A review of Resident 1 ' s admission Record indicated the facility admitted the resident on12/18/2018 with diagnoses including hemiplegia (one-sided muscle paralysis or weakness) and hemiparesis (one-sided muscle weakness) following cerebral infraction (interrupted blood flow to the brain) affecting the right dominant side,…

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

Based on observation, interview,and record review the facility failed to ensurea Registered Nurse (RN) was available to work (excluding the DON) as federally required for at least 8 consecutive hours a day from 7/1/2024 to 7/18/2024. This deficient practice placed all 85 residents in the facility at risk for delayed care and services, missed treatments and/or medications, and a potential delay in emergency care. Findings: A review of the Facility Assessment Tool (a tool to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies of the facility) indicated, the facility had a bed capacity of 98 with average daily census (a complete count of the residents in the facility) of 87. A review of the facility ' s Licensed Nurses Schedule from 7/1/2024 – 7/18/2024 indicated there was one staff RN in the facility which was also the Director of Nursing (DON). During an interview with Licensed Vocational Nurse 3 (LVN 3) on 7/17/2024 at 3:46 p.m., LVN 3 stated, she assisted with scheduling the licensed nurses staffing. LVN 3…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to develop and implement and individualized and comprehensive care plan (CP) to meet individual needs for two of six sampled residents (Resident 1 and Resident 2) by failing to: a. Ensure a CP was developed timely for Resident 1 ' s indwelling urinary (foley) catheter (a flexible plastic tube inserted into the bladder that remains there to provide continuous urinary drainage). b. Ensure that a comprehensive CP was developed and implemented for Resident 2 ' s self-administration of medication. This deficient practice had the potential to result negative impact on residents ' health and safety, as well as the quality of care and services received. Cross Reference: F690, F755 Findings: 1. A review of Resident 1 ' s admission Record indicated the facility admitted the resident on 6/19/2024 with diagnoses including spinal stenosis (narrowing of the spaces within the spine, which can put pressure on the nerves that travel through the spine), fusion…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that one of six sampled residents, (Resident 1) received treatment and care accordance with professional standards of practice to meet the resident's physical, mental, and psychosocial needs by failing to ensure a physician ' s order dated 6/21/2024 indicating Resident was to be seen by a Neurologist (a medical doctor who diagnoses, treats and manages disorders of the brain and nervous system) on 6/24/2024. Resident 1 was not seen by the Neurologist. This deficient practice resulted to failure in the delivery of necessary care and services for Resident 1. Findings: A review of Resident 1 ' s admission Record indicated resident was admitted to the facility on [DATE] with diagnoses including spinal stenosis (narrowing of the spaces within the spine, which can put pressure on the nerves that travel through the spine), fusion of spine (refers to various spinal surgery techniques that connect two or more vertebrae in the lumbar spine [lower back]),…

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 staff failed to ensure resident received appropriate treatment and services to prevent urinary tract infections (UTI-an infection in any part of your urinary system your kidneys, ureters, bladder and urethra) for one of one sampled resident (Resident 1) by failing to ensure Resident 1 ' s indwelling urinary (foley) catheter (a flexible plastic tube inserted into the bladder that remains there to provide continuous urinary drainage) was placed below the level of the bladder at all times. This deficient practice had the potential to result or resulted in urinary tract infections for Resident 1. Cross Reference F656 Findings: A review of Resident 1 ' s admission Record indicated resident was admitted to the facility on [DATE] with diagnoses including spinal stenosis (narrowing of the spaces within the spine, which can put pressure on the nerves that travel through the spine), fusion of spine (refers to various spinal surgery techniques that connect two…

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 pharmaceutical services for one of six sampled residents (Resident 2) by failing to: a. Ensure that Resident 2 ' s medications were not left unattended at the bedside. b. Ensure a self-administration assessment was completed when Resident 2 was observed with own medications at bedside: calcium carbonate tablet (Tums – antacid used to relieve heartburn, sour stomach, acid indigestion, and upset stomach) and lactulose oral solution (treats constipation and liver disease). c. Ensure that a comprehensive care plan (CP) was developed and implemented as indicated in the facility ' s policy and procedure (P&P). This deficient practice had the potential to result in Resident 2 in unintended complications related to the management of medications. Cross Reference F656 Findings: A review of Resident 2 ' s admission Record indicated the resident was admitted on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD - 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 interview and record review, the facility failed to report an injury of unknown origin to the State Survey Agency (SSA) within two hours for one of two sampled residents (Resident 1). Resident complained of pain to right upper leg which resulted in a fracture. This deficient practice resulted in a delay of an onsite inspection by the SSA and had potential for ongoing injuries for Resident 1. Findings: A review of Resident 1's admission Record indicated the facility re-admitted the resident on 1/5/2023 with diagnoses that included dementia, schizoaffective disorder (a mental health problem where you experience psychosis [a mental disorder characterized by a disconnection from reality] as well as mood symptoms), generalized anxiety disorder (a feeling of fear, dread, and uneasiness), and cognitive communication deficit (a disorder that affects a person's ability to communicate). A review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care screening tool) dated 4/8/2024, indicated the resident had severely impaired cognition (problems with the ability 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 observation, interview, and record review, the facility failed to ensure one of two sampled residents (Resident 1), who had diagnosis of Dementia (loss of cognitive functioning - thinking, remembering, and reasoning - to such an extent that the loss interferes with a person's activities of daily living), had a history of wandering (a common behavior in those with dementia, walking aimlessly with no real place to go and becoming confused with their location), and was a risk for falls, was provided with the necessary care and services by failing to: -Develop a comprehensive care plan for Resident 1's diagnosis of Dementia, including supervision to prevent injury. -Complete a wandering assessment and fall risk assessment quarterly. As a result, on 6/19/2024, Resident 1 complained of pain to the right femur (thighbone), resulting in an acute subcapital fracture (a sudden broken neck of the right thighbone) of unknown origin. Resident 1 was transferred to the General Acute Care Hospital (GACH) where surgery…

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 meet professional standards of practice by failing to ensure three of four nursing staff (Licensed Vocational Nurse 1-LVN1, Licensed Vocational Nurse 2-LVN2) and Licensed Vocational Nurse 4-LVN4) was using the facility ' s vital signs (VS-clinical measurements, specifically heart rate, temperature, respiration rate and blood pressure that indicate the state of a patient ' s essential body functions) equipment provided to the staff. This deficient practice had the potential to negatively impact the delivery of care service provided to all the residents. Findings: During a concurrent observation and interview with LVN2 on 6/6/2024 at 12:25 p.m., LVN2 was observed using her own blood pressure equipment and thermometer. LVN2 stated that she (LVN2) prefers using her own VS equipment for convenience. During an interview with the Medical Director (MD) on 6/6/2024 at 12:34 p.m., MD stated that nursing staff should not be bringing their own VS equipment since facility should be providing it and calibrating 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 provide services in compliance with accepted professional standards of practice by failing to ensure three of four nursing staff (Licensed Vocational Nurse 1-LVN1, Licensed Vocational Nurse 2-LVN2) and Licensed Vocational Nurse 4-LVN4) was using the facility ' s vital signs (VS-clinical measurements, specifically heart rate, temperature, respiration rate and blood pressure that indicate the state of a patient ' s essential body functions) equipment provided to the staff. This deficient practice had the potential to negatively impact the delivery of care service provided to all the residents. Findings: During a concurrent observation and interview with LVN2 on 6/6/2024 at 12:25 p.m., LVN2 was observed using her own blood pressure equipment and thermometer. LVN2 stated that she (LVN2) prefers using her own VS equipment for convenience. During an interview with the Medical Director (MD) on 6/6/2024 at 12:34 p.m., MD stated that nursing staff should not be bringing their own VS equipment since facility should be…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility staff failed to ensure physician (MD) was notified concerning the change of conditions (COC/CIC) for two of two sampled residents (Residents 3 and 6) when: 1. Resident 3 had multiple episodes of refusing medications. 2. Resident 6 complained of feeling weak. These deficient practices had the potential to result in possible delayed provision of necessary care and services to Resident 3 and 6. Findings: 1. A review of Resident 3's admission Record indicated Resident 3 was admitted to the facility on [DATE], with diagnoses including periprosthetic fracture (broken bone around the implants) around internal prosthetic (artificial device that replaces a missing body part) left hip joint, chronic obstructive pulmonary disease (COPD-group of lung diseases that block airflow and make it difficult to breathe) and diabetes mellitus (DM-a chronic condition that affects the way the body processes blood sugar [glucose]). A review of Resident 3's Minimum Data Set (MDS - 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 prompt attempt was made to resolve grievances for one of two sampled resident (Resident 4). This deficient practice violated Resident 4's right to have grievance addressed. Findings: A review of Resident 4's admission Record indicated Resident 4 was originally admitted to the facility on [DATE], and was re-admitted on [DATE] with diagnoses including neuropathy (weakness, numbness, and pain from nerve damage usually in the hands and feet), asthma (respiratory condition marked by spasms in the bronchi of the lungs, causing difficulty in breathing) and obesity (a disorder involving excessive body fat that increases the risk of health problems). A review of Resident 4's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 3/7/2024, indicated Resident 4's cognitive (relating to mental action or process of acquiring knowledge and understanding) skills for daily decision-making was intact. Resident 4 required supervision…

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 staff failed to develop and implement a comprehensive care plan that met the care/services based on the resident's individual assessed needs for one of 12 sampled residents (Resident 3) by failing to ensure Resident 3's episodes of refusing medications were care planned. This deficient practice had the potential to result negative impact on Resident 3's health and safety, as well as the quality of care and services Resident 3 received. Findings: A review of Resident 3's admission Record indicated Resident 3 was admitted to the facility on [DATE], with diagnoses including periprosthetic fracture (broken bone around the implants) around internal prosthetic (artificial device that replaces a missing body part) left hip joint, chronic obstructive pulmonary disease (COPD-group of lung diseases that block airflow and make it difficult to breathe) and diabetes mellitus (DM-a chronic condition that affects the way the body processes blood sugar [glucose]). A review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to timely administer medications per facility policy to one of one sampled resident (Resident 11). This deficient practice had the potential to result in medication ineffectiveness and place Resident 11 at risk for unsafe, and improper medication administration use. Findings: A review of Resident 11's admission Record indicated Resident 11 was admitted originally admitted to the facility on [DATE] and was re-admitted on [DATE] with diagnoses including hemiplegia (paralysis on one side of the body), hemiparesis (weakness on one side of the body) and diabetes mellitus (DM-a chronic condition that affects the way the body processes blood sugar [glucose]). A review of Resident 11's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 2/27/2024, indicated Resident 11's cognitive (relating to mental action or process of acquiring knowledge and understanding) skills for daily decision-making was 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 interviews and record review, the facility failed to ensure there was a facility policy developed and implemented to verify whether residents had been provided informed consent or given refusal for the use of psychotropic medications. The facility had inconsistent procedures in documenting informed consent verification for five (5) of 5 sampled residents (Residents 1-5). The facility failed to ensure the interdisciplinary team (IDT, a team of healthcare providers that plan, coordinate and deliver personalized health care to residents) would meet periodically to conduct evaluation of residents on psychotherapeutic medication therapy as per policy and guidance, for 2 of 5 sampled residents (Residents 1 and 2). These deficient practices had the potentials of medication errors and unnecessary medications. Findings: A review of the facility policy and procedures, Psychotropic Medication Use (dated July 2022), indicated . A psychotropic medication is any medication that affects brain activity associated with…

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

Based on interviews and record review, the facility failed to ensure there were descriptive documentations of residents ' behavior episodes and significant specific behavior for one (1) of 5 sampled residents (Resident 1). The facility failed to ensure there were documentations of clinical justifications to decline gradual dose reduction (GDR, a process of tapering) on the dosages of psychotherapeutic medications, for 3 of 5 sampled residents (Residents 1, 4, and 5). The facility failed to ensure there was an order to monitor behaviors being treated with psychotropics for 3 of 5 sampled residents (Residents 3, 4, and 5). These deficient practices had the potentials of unnecessary medications and/or medication error. (Refer to F558) Findings: A review of Resident 1 ' s current medication orders indicated an order dated 2/28/2024 for Seroquel (aka quetiapine, an antipsychotic to treat certain behavioral and/or mental conditions) 175 milligrams (mg, an unit to measure mass) oral tablet to be given by mouth at bedtime for schizoaffective disorder depressive type manifested by…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide means of communication for a non-verbal resident, one (1) of 5 sampled residents (Resident 1). This deficiency had a potential to hinder the communication between the resident and facility staff, which may affect or cause a delay in care. Findings: A review of Resident 1 ' s admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnose including but not limited to: cerebral infarction (also known as stroke, a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it), aphasia (loss of ability to understand or express speech, caused by brain damage), and hemiplegia (paralysis of one side of the body). On 3/7/2024 at 10:18 AM during an interview, the Licensed Vocational Nurse (LVN 1) stated Resident 1 was non-verbal, did not have a conservatorship, and the interdisciplinary team (IDT, a team of healthcare providers that plan, coordinate and deliver personalized…

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 give Carbidopa/Levodopa 25-100 mg (milligrams) po (by mouth) four times a day for Parkinson ' s disease without dyskinesia, with fluctuations (a progressive disease of the nervous system marked by tremors, muscle stiffness, and slow, imprecise movements- without dyskinesia- unwanted movements such as rapid jerking, muscle spasms and rhythmic, dance like movements) on 2/22/2024 and 2/23/2024 for one of three sampled residents, Resident 1. This deficient practice may have placed Resident 1 at risk for falls. Findings: A review of Resident 1 ' s admission Record indicated the facility admitted the resident on 2/2/2024 with diagnoses including Unspecified Dementia (progressive loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), Parkinson ' s disease without dyskinesia, with fluctuations, Open Angle Glaucoma of the left eye (a chronic progressive and irreversible buildup of increased pressure in the eye causing progressive loss of peripheral vision,…

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 alleged abuse of a resident (Resident 1) to the California Department of Public Health (CDPH) immediately or within 2 hours. This deficient practice placed Resident 1 and other residents at risk for potential repeated abuse. Findings: A review of Resident 1's admission Record indicated the facility readmitted the resident on 6/9/2023 with diagnoses including mild cognitive impairment of uncertain or unknown etiology, cognitive communication deficit, and peripheral vascular disease (slow and progressive circulation disorder caused by narrowed or blocked blood vessels). A review of Resident 1's Minimum Data Set (MDS, a comprehensive standardized assessment and care-screening tool), dated 1/23/2024, indicated Resident 1's cognition (ability to think and reason) was moderately impaired. The MDS indicated Resident 1 can be short-tempered, easily annoyed for several days at a time, and rejects care 1 to 3 days a week with worsening behavior since…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the residents' clinical records contained their advance directive (written statements of a person's wishes regarding medical treatment made to ensure those wishes are carried out should the person be unable to communicate them to a doctor) acknowledgement forms for ten of ten sampled residents (Resident 3, 9,15, 28, 34, 39, 40, 55, 58, 59). This deficient practice had the potential to cause conflict with a resident's wishes regarding health care. Findings: a. A review of Resident 9's admission Record indicated the facility admitted Resident 9 on 11/20/2023 and readmitted the resident on 1/15/2024 with diagnoses including diabetes Type II (a long-term medical condition in which the body does not use insulin [a hormone that lowers the level of sugar in the blood] properly), peripheral vascular disease (a systemic disorder that involves the narrowing of peripheral blood vessels [vessels situated away from the heart of the brain]), and essential…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive plan of care with measurable objectives and interventions for six of twenty sampled residents (Residents 9, 15, 39, 51, 58, 17) when the facility failed to: -Develop a plan of care that addressed the administration of insulin (a hormone that lowers the level of glucose[a type of sugar]in the blood) and antibiotics (a medicines that help stop infections caused by bacteria) for Resident 9. -Implement Resident 15's plan of care for pain management and notify the physician. -Develop a plan of care that addressed the administration of insulin (a hormone that lowers the level of glucose[a type of sugar]in the blood) and anticoagulants (a medication that is used to prevent and treat blood clots in blood vessels and the [NAME]) for Resident 51. -Develop a plan of care addressing the change in condition due to a syncope episode (temporary loss of consciousness, but become conscious and alert again after a few…

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

Based on observation, interview, and record review, the facility failed to post daily the Direct Care Service Hours Per Patient Day (DHPPD - refers to the actual hours of work performed per patient day by a direct caregiver) actual hours worked by licensed staff providing direct care to the residents per shift. As a result, residents and visitors did not know the accurate number of hours of staff working. Findings: During an observation on 2/5/2024 at 1:41 PM, the facility's posting of their DHPPD was observed. The facility did not have DHPPD posted to indicate the actual direct care service hours for 2/4/2024. During a concurrent observation and interview on 2/5/2024 at 1:45 PM, with the Director of Staff Development (DSD), the DHPPD posting was observed at nursing station one. The DSD stated she was responsible for calculating the DHPPD hours and she was informed to put the DHPPD projected hours at nursing station one. The DSD stated she did not post any actual DHPPD hours and was not aware the actual DHPPD hours were needed to be posted for residents and visitors to see. The DSD…

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

Based on interview and record review, the facility failed to ensure staff provided showers to one sampled resident (Resident 58) according to his choices. This deficient practice had the potential to affect resident's sense of self-worth and self-esteem. Findings: A review of Resident 58's admission Record indicated the facility admitted the resident on 8/5/2023 with diagnoses including quadriplegia (a form of paralysis that affects all four limbs, plus the torso), diabetes Type II (a long-term medical condition in which the body does not use insulin [a hormone that lowers the level of sugar in the blood] properly), and hyperlipidemia (an elevated level of lipids [fats] in the blood). A review of Resident 58's History and Physical, dated 8/7/2023, indicated the resident had the capacity to understand and make decisions. A review of the Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 11/9/2023, indicated Resident 58 had intact cognition (undamaged mental abilities, including remembering things, making decisions, concentrating, or learning) and was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the Facility Verification Informed Consent (a principle in medical ethics, medical law, and media studies, that a patient must have sufficient information and understanding before making decisions about their medical care) form was fully completed for psychotropic (medications that affect the mind, emotions, and behavior) medications for two sampled residents (Resident 20 and Resident 35). This deficient practice violated the resident's right to be informed regarding the risks and benefits of psychotropic medication therapy, possibly resulting in diminished overall physical, mental, and psychosocial well-being. Findings: a. A review of Resident 35's admission Record indicated the facility admitted the resident on 11/23/2023, with diagnoses including generalized anxiety disorder (GAD - exaggerated worry and tension that is much more severe than most people experience), major depressive disorder (mood disorder that causes a persistent feeling of…

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

Based on interview and record review, the facility failed to ensure one of six sampled residents (Resident 3) preadmission screening and annual resident review (PASARR) assessment form was completed to determine the facility's ability to provide the special need of the resident. This deficient practice placed the residents at risk of not receiving necessary care and services needed for a new mental illness diagnosis. Findings: A review of Resident 3's admission Record indicated the facility originally admitted the resident on 8/17/2020 with diagnoses including cerebral infarction due to unspecified occlusion or stenosis of left middle cerebral artery (one of the blood vessels supplying blood to the brain got blocked and brain tissue has been damaged as a result), aphasia following other nontraumatic intracranial hemorrhage (a language disorder that affects a person's ability to communicate, it can occur suddenly after a stroke or head injury), hemiplegia and hemiparesis following cerebral infarction affecting right dominant side (weakness and unable to move one side of body), 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 ensure residents were provided a communication device or communication board with the language that the resident was able to understand for one sampled resident (Resident 40). This deficient practice prevented the resident from communicating with the staff and had a potential to delay receiving care/treatment the resident needed. Findings: A review of Resident 40's admission Record indicated the facility readmitted the resident on 3/1/2023, with diagnoses including aphasia (loss or impairment of the power to use or comprehend words usually resulting from brain damage) following cerebral infraction (lack of blood flow resulting in severe damage to some of the brain tissue), Type II diabetes mellitus (a chronic condition that affects the way the body processes blood sugar [glucose]), and schizoaffective disorder (mental disorder characterized by abnormal thought processes and an unstable mood). A review of Resident 40's Minimum Data Set (MDS- a standardized assessment and care planning tool) dated 12/11/2023,…

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 apply the correct setting for the resident's Low Air Loss Mattress (LALM - a pressure-relieving mattress used to prevent and treat pressure injuries) for two of two sampled residents (Resident 28 and 58). This deficient practice had the potential to place the resident at risk for discomfort and development of pressure ulcers/injuries (localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device). Findings: a. A review of Resident 28's admission record indicated the facility admitted the resident on 9/6/2023 with diagnoses including epilepsy (a broad term used for a brain disorder that causes seizures [may cause loss of consciousness, falls, or massive muscle spasms]), pressure induced deep tissue damage (purple or maroon area of discolored intact skin due to damage of underlying soft tissue) of sacral region (buttocks), and pressure induced deep tissue damage of left…

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 necessary respiratory care services for one of one sampled resident (Resident 27) by failing to ensure Resident 27 had a date on the nasal cannula (device used to deliver supplemental oxygen placed directly on a resident's nostrils) to ensure prompt weekly changing of the nasal cannula. This deficient practice had the potential to cause complications associated with oxygen therapy, including infections or respiratory distress. Findings: A review of Resident 27's admission Record indicated the facility re-admitted the resident on 1/30/2023 with diagnoses including hypertension (HTN - elevated blood pressure), unspecified dementia (decline in mental ability severe enough to interfere with daily functioning/life), and dysphagia (difficulty swallowing). A review of the Minimum Data Set (MDS- a standardized assessment and care screening tool) dated 11/9/2023 indicated Resident 27 was cognitively moderately impaired (decisions poor; cues/supervision required) and was dependent on staff for oral hygiene,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure opened medications were labeled with an open date, affecting Residents 5, 15 and 186 in two of three inspected medication carts (Medication Cart 1 and Medication Cart 3). This deficient practice caused an increased risk that the above listed residents could have received medication that had become ineffective or toxic due to improper labeling. Findings: During an observation on [DATE] at 10:43 AM, of Medication Cart 3, with the Licensed Vocational Nurse 5 (LVN 5), the following medications were not labeled with an open date as required by their respective manufacturer's specifications: - One Striverdi Respimat (a medication used to treat breathing problems) inhaler for Resident 5 was found opened but not labeled with an open date. According to the manufacturer's product labeling, after assembly, the Striverdi Respimat inhaler should be discarded at the latest 3 months after first use or when the locking mechanism is engaged,…

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 meet professional standards of quality for one of four sampled residents (Resident 1) by failing to ensure documentation after wound care treatment was performed. This deficient practice had the potential to result in miscommunication among staff about Resident 1 ' s wound care treatment. Findings: A review of Resident 1 ' s admission Record (Face Sheet) indicated Resident 1, a [AGE] year-old male, was originally admitted to the facility on [DATE] with diagnoses that included types 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar), peripheral neuropathy (weakness, numbness, and pain from nerve damage usually in the hands and feet), and anemia (a condition that develops when the blood produces lower-than-normal amount of healthy red blood cells so the body does not get enough oxygen-rich blood). A review of the Admit / Readmit Assessment, dated 3/29/2023, identified Resident 1 with 1st to 5th digits arterial…

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 assist one of four sampled residents (Resident 2) in ensuring she goes to her appointments. This deficient practice resulted to Resident 2 missing two doctor appointments, which had the potential to negatively affect the resident ' s physical wellbeing. Findings: A review of Resident 2 ' s admission Record (Face Sheet) indicated Resident 2 was admitted to the facility on [DATE] with diagnoses that included rheumatoid arthritis (an inflammatory, autoimmune condition that can affect a person ' s joints and organs), hemiplegia and hemiparesis (paralysis or weakness on one side of the body) following cerebral infarction (stroke; occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it. A lack of adequate blood supply to brain cells deprives them of oxygen and vital nutrients which can cause parts of the brain to die off) and muscle weakness. A review of the Minimum Data Set (MDS, a comprehensive…

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 food preferences were met for two of three sampled residents (Residents 2 and 4). This deficient practice had the potential for the residents consuming less food than their body needed, which could lead to weight loss and malnutrition. Findings: A review of Resident 2 ' s admission Record (Face Sheet) indicated Resident 2 was admitted to the facility on [DATE] with diagnoses that included rheumatoid arthritis (an inflammatory, autoimmune condition that can affect a person ' s joints and organs), hemiplegia and hemiparesis (paralysis or weakness on one side of the body) following cerebral infarction (stroke; occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it. A lack of adequate blood supply to brain cells deprives them of oxygen and vital nutrients which can cause parts of the brain to die off) and muscle weakness. A review of the Minimum Data Set (MDS, a comprehensive…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that the call light (a device used by a resident to call for help) is within reach for one of three sampled residents (Resident 4) who had a history of quadriplegia (a symptom of paralysis that affects all a person's limbs [arms and legs] and body from the neck down). This deficient practice had the potential to delay staff from responding to Resident 4 ' s request for help. Findings: A review of Resident 4 ' s admission Record (Face Sheet) indicated Resident 4 was admitted to the facility on [DATE] with diagnoses that included quadriplegia and diabetes mellitus (a chronic condition that affects the way the body processes blood sugar). A review of the Minimum Data Set (MDS, a comprehensive assessment), dated 1/17/2024, indicated Resident 4 had an intact cognition (thought process). The MDS indicated Resident 4 was dependent (helper does all of the effort) on staff for eating, oral hygiene, toileting hygiene, shower, upper body dressing, lower…

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 safe provision of pharmaceutical services to one of four sampled residents (Resident 1) by failing to ensure Resident 1 ' s baclofen (muscle relaxant medication) was ordered by a physician and accurately dispensed and administered per facility policy. This deficient practice had the potential for medication errors which can possibly compromise Resident 1's safety if taken too much. Findings: A review of Resident 1's admission Record indicated resident was admitted to the facility on [DATE], with diagnoses including protein calorie malnutrition (lack of sufficient nutrients in the body), peripheral vascular disease (PVD-condition in which narrowed blood vessels that reduce blood flow to the limb [arms/legs]) and uropathy (condition in which the flow of urine is blocked). A review of the Minimum Data Set (MDS - a comprehensive assessment and care screening tool), dated 11/25/2023, indicated Resident 1's cognitive (mental action or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure safe provision of pharmaceutical services to one of four sampled residents (Resident 1) by failing to ensure Resident 1 ' s self-administered medications were properly stored and secured inside the room. This deficient practice had the potential to compromise securement of Resident 1's medication and possible safety issues to other residents when left unsecured. Findings: A review of Resident 1's admission Record indicated resident was admitted to the facility on [DATE], with diagnoses including protein calorie malnutrition (lack of sufficient nutrients in the body), peripheral vascular disease (PVD-condition in which narrowed blood vessels that reduce blood flow to the limb [arms/legs]) and uropathy (condition in which the flow of urine is blocked). A review of the Minimum Data Set (MDS - a comprehensive assessment and care screening tool), dated 11/25/2023, indicated Resident 1 ' s cognitive (mental action or process of acquiring…

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 a. investigate an allegation of financial abuse. b. submit 5-day investigation summary to the California Department of Public Health (CDPH) for one of three sampled Residents, Resident 1. These deficient practices could have led to continued alleged abuse. Findings A review of Resident 1's admission record indicated the facility originally admitted Resident 1 on 1/10/2020 and readmitted the resident on 4/21/2023 with diagnoses including Guillain-Barre Syndrome (GBS- a condition that presents with weakness in the lower extremities that spreads to the upper body and may cause paralysis), Diabetes Mellitus (a chronic, metabolic disease characterized by elevated levels of blood sugar), muscle wasting, hypothyroidism (abnormally low activity of the thyroid gland) A review of Resident 1 ' s history and physical (H&P- the formal and complete assessment of the patient and the problems produced through the interview and physical exam of the patient) dated 5/5/2023, indicated Resident 1 ' s cognition (the mental ability to make…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure one of three residents (Resident 1) had accurate documentation of scattered hyperpigmentation (patches of darker skin) in the sacral (tailbone) area. This deficient practice resulted in an inaccurate representation of Resident 1 ' s skin condition, which could potentially delay the identification of worsening condition and delay necessary care and treatment. Findings: A review of the admission Record indicated the facility re-admitted Resident 1 on 4/21/23 with diagnoses including Guillain Barre Syndrome (GBS, a condition where the person ' s own immune system [body ' s defense against infections] harms their body ' s nerves [carry electrical impulses between the brain and the rest of the body]), muscle weakness and diabetes mellitus (an impairment in the way the body regulates and uses sugar [glucose] as a fuel). A review of Resident 1 ' s Minimum Data Set (MDS- standardized data collection tool used to assess cognitive (ability 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.