York Healthcare & Wellness Centre

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure two of two sampled residents (Resident 34 and 4) received appropriate treatment and services for urinary care in accordance with the professional standard of practice and facility's policy and procedures titled Indwelling Catheter, Guideline for Prevention of Catheter-Associated Urinary Tract Infection (2009) (CAUTI, a catheter associated UTI (an infection of the urinary tract that includes urethra, ureters, bladder and kidneys resulting when microorganism gets into the urine and travels to the urinary tract) and Suprapubic Catheter Re-insertion and Management. The facility failing to: 1. For Resident 4, the foley catheter (a thin hollow tube that is inserted through the opening of the urinary tract into a person's bladder and is used to drain the bladder into an external collection bag) was not monitored for use and no date when the catheter was inserted following a change in condition when the resident's urine was observed…

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 insure one out of eight sampled residents (Resident 2) offered and received the sufficient fluid intake to maintain proper hydration as recommended by the Registered Dietitian (RD) baseline daily fluid intake (calculated fluid a resident should consume each day) to ensure proper hydration. This deficient practice had the potential to result in Resident 2's continued dehydration (fluid deficit), impaired oral health, kidney damage, urinary tract infections, hospitalizations, and could result in a decline in the resident's overall condition. Findings: During a review of Resident 2' s admission Record ( AR), the AR indicated Resident 2 was admitted on [DATE], with a diagnoses that included dysphagia (difficulty swallowing) quadriplegia (unable to move all four limbs and is completely dependent on others for mobility and activities of daily living) , and atherosclerotic heart disease (a form of heart disease caused by the buildup of plaque and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that two out of three medication rooms (MR), did not contain medications that were past the discard by date in accordance with the policy MR 2 contained two bags of Ertapenem (an antibiotic, medication that is used to treat infections) that were past the discard date. MR 3 contained one syringe of Enbrel (a medication used to reduce inflammation and swelling) that was past the discard date. This deficient practice had the potential for residents to be administered expired medications, which could lack the intended efficacy to treat the residents' diseases. Findings: a. During a review of Resident 69's admission Record (AR), the AR indicated that the resident was originally admitted on [DATE], and readmitted on [DATE], with diagnoses that included hypotension (low blood pressure), muscle weakness, and diabetes mellitus (condition characterized by high blood sugar levels). During a review of Resident 69's History and Physical (H&P),…

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 accuracy of documentation for two out of four sampled residents (Resident 9 and Resident 94) who were observed during medication administration in accordance with the facility's policy and procedures titled Medication Administration- General Guidelines, by failing to ensure: 1. Licensed Vocational Nurse (LVN) 2 did not document the administration of Resident 94's meclizine (a medication used to treat dizziness) prior to the administration of the medication. 2. LVN 1 did not document the administration of Resident 9's acetaminophen (a medication used to control pain) prior to the administration of the medication. This deficient practice had the potential to cause inaccuracies in the residents' records, which could cause the misadministration of medications. Findings: 1. During a review of Resident 94's admission Record (AR), the AR indicated that the resident was originally admitted on [DATE], and readmitted on [DATE], 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 implement the facility's policy and procedure for infection control by failing to ensure a safe and sanitary environment to prevent transmission of diseases and infections for one of three sampled resident (Resident 8), who was observed on 5/20/2026 with a suction cannister (a medical receptacle used with suction machines to collect bodily fluids-such as mucus, and secretion) dated 5/18/2026 half-filled with cloudy secretions. This deficient practice can result in the suction cannister to harbor bacteria and/or virus (microscopic germs that can invade the body and cause infections) which potentially can get Resident 8 and negatively affect her quality of life. Findings: During a review of Resident 8's admission record indicated the resident was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included asthma (a condition that causes airways become swollen, narrow, and clogged with mucus),…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure call light (consists of a button that, when pressed, sends a signal to the nursing station or a centralized system, alerting healthcare providers that assistance is required in the patient's room) was within reach for Three out of eight sampled residents (Residents 66, 83, and 54). This deficient practice has the potential to delay care and services to the residents and preventing a timely response to care needs. Findings: 1. A review of Resident 66 ' s admission record indicated the resident was originally admitted to the facility on [DATE], with diagnoses that included aphasia ( loss of language) and dysphagia ( difficulty with verbal communication) following cerebral infarction with hemiplegia(paralysis or weakness of one side of body) and hemiparesis ( weakness or inability to move on one side of body) affecting right dominant side. A review of Resident 66 ' s Minimum Data Set (MDS, a resident assessment tool) dated 04/18/2025,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow their infection control policy of two out of two sampled residents (Resident 25 and Resident 29) by failing to: 1. Ensure Resident 25, who had a wound infection and used a peripheral inserted central catheter (PICC a long, thin tube that's inserted through a vein in the arm and passed through the larger veins near the heart) to receive antibiotics (medicines that fight bacterial infections in people) was provided care using enhanced barrier precaution (EBP) (taking extra steps to prevent the spread of serious infections, like using gowns and gloves) by Certified Nurse Assistant (CNA) 4 who failed to wear a gown. 2. Ensure a used glove was disposed of properly after each use and not placed on Resident 29 ' s blanket while Resident 29 laid in bed. This deficient practice had the potential to transmit and spread infection (a process when a microorganism, such as bacteria, fungi, or a virus, enters a person's body and causes harm) and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide a homelike environment for two of two sampled residents (Residents 89 and 32) by failing to ensure: Resident 89 was provided with a wall clock in the room, and Resident 32 ' s bedside table was in functional and working condition. These deficient practices had the potential to create an uncomfortable environment leading to Resident 89 verbalizing feelings of frustration and Resident 32 ' s personal items to be exposed. Findings: 1. A review of Resident 89's admission Record indicated the facility admitted Resident 89 on 12/27/2024 with diagnoses that included hemiplegia (characterized by paralysis on one side of the body) and hemiparesis (partial weakness on one side of the body) affecting left non-dominant side, depression (a persistent feeling of sadness and a loss of interest or pleasure in activities, lasting for at least two weeks, that interferes with daily life) and anxiety disorder (A condition in which a person has…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to develop a person-centered care plan (a treatment plan that focused on the needs and preferences of a resident or individual) for one of three sampled residents (Resident 94) Speech Therapy (ST, helped people who had trouble with speaking, understanding language, or swallowing). This deficient practice had the potential for a lack of individualized care and to affect the quality of services provided to Resident 94. Findings: A review of Resident 94 ' s admission Record (AR), indicated the resident was admitted to the facility on [DATE], with diagnoses that included encephalopathy (a disease, disorder, or damage that affected the brain ' s structure or function), muscle weakness (decrease in muscle strength), and abnormalities of gait and mobility (a change to your walking pattern). A review of Resident 94 ' s History and Physical (H&P) dated 4/1/2025, indicated the resident ' s neurological status alert and oriented times four (A&Ox4, someone who was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the comprehensive care plan were revised for two of two sampled residents (Resident 1 and Resident 94) that included resident-specific interventions. This deficient practice had the potential to delay care and services that were specific to the residents ' needs. Findings: 1. A review of Resident 1 ' s admission Record indicated the resident was initially admitted on [DATE], and readmitted on [DATE], with diagnoses that included dementia (a progressive state of decline in mental abilities), Alzheimer ' s disease (a disease characterized by a progressive decline in mental abilities), fractures, and muscle wasting (weakening, shrinking, and loss of muscle). A review of Resident 1 ' s History and Physical (H&P), dated 7/2/2024, indicated the resident had the capacity to understand and make decisions. A review of Resident 1 ' s Minimum Data Set (MDS - a resident assessment tool), dated 4/2/2025, indicated the resident has severely…

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 insulin order to manage the diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing ) of one of one sampled residents (Resident 79) was followed when Resident 79 ' s blood sugar was tested above 300 mg/dL, in accordance with the physician ' s order to notify the physician of the results. This deficient practice had the potential for facility staff to mismanage the Resident 79 ' s diabetes mellitus. Findings: During a review of Resident 79 ' s admission Record indicated the resident was admitted on [DATE] with diagnoses that included diabetes mellitus, sepsis (a life-threatening blood infection), and kidney failures (a condition in which the kidneys stop working and are not able to remove waste and extra water from the blood or keep body chemicals in balance). During a review of Resident 79 ' s care plan for diabetes mellitus, initiated on 3/4/2025, the care plan indicated the resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of eight sampled residents (Resident 84) who had a Foley catheter (a thin, flexible catheter used especially to drain urine from the bladder), received appropriate care when Resident 84 ' s Foley catheter was nonfunctioning and leaking. This deficient practice had the potential to result in an increased risk for urinary tract infection (UTI- an infection in any part of the urinary system), increased pain and discomfort for Resident 84. Findings: A review of Resident 84 ' s admission Record (AR) indicated Resident 84 was originally admitted to the facility on [DATE] with a diagnosis not limited to Retention of urine( a condition in which you are unable to empty all the urine from your bladder), and urinary tract infection with prostatic hyperplasia (Prostate gland enlargement ). A review of Resident 84 ' s History and Physical (H&P), Dated 04/25/2025 indicated resident 84 was alert and had no apparent neurological disease. A…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure one of six sampled residents (Resident 7) who received dialysis (a life-sustaining treatment for people whose kidneys were not functioning properly, replacing their filtering function) had a post-dialysis weight documented on 5/3/2025 and 5/10/2025. This deficient practice had the potential for unidentified complications after dialysis such as fluid shifts or significant weight loss. Findings: A review of Resident 7 ' s admission Record (AR),indicated the resident was admitted to the facility on [DATE] and re-admitted to the facility on [DATE], with diagnoses that included end stage renal disease (ESRD, the kidneys have failed and could no longer perform their essential functions, requiring dialysis or a kidney transplant to survive), arteriovenous fistula (AV fistula, an abnormal connection between an artery and a vein, bypassing the normal capillary network), and dependence on renal dialysis. A review of Resident 7 ' s Dialysis Care Plan…

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 (Resident 52), who was receiving Apixaban (anticoagulant medication used for the treatment of blood clots) was adequately monitored for signs and symptoms of bleeding. This deficient practice had the potential for Resident 52 to not be adequately monitored leading to the worsening of Resident 52 ' s health condition.Findings: A review of Resident 52 ' s admission Record indicated Resident 52 was admitted to the facility on [DATE], with a diagnosis that included Obstructive Pulmonary Embolism (a blood clot in the lung artery) and Atrial Fibrillation (an abnormal heartbeat). A review of Resident 52 ' s Minimum Data Set ( MDS, a resident assessment tool), dated 04/22/2025, indicated Resident 52 was cognitively intact ( mentally alert, oriented, and capable of thinking clearly and making decisions) but required moderate assistance ( helper lifts, holds, or supports limbs) with tasks that include eating and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1), having a history of dementia ( a Condition of brain that makes it hard for a person to make decisions , and think clearly), requiring 1:1 supervision (one staff member is assigned to stay with and closely monitor one specific person at all times) for safety was not left unsupervised by Licensed Vocational Nurse (LVN) 2. This deficient practice resulted in Resident 1 sustaining a fall on 3/13/2025, requiring transfer to the acute hospital for evaluation and had the potential for serious physical injury. Findings: During a review of Resident 1 ' s admission Record, (AR), the AR indicated Resident 1 was originally admitted on [DATE] with diagnoses including dementia (a Condition of brain that makes it hard for a person to make decisions , and think clearly), disorders of bone density and structure (fragile bones, more likely to break) and history of falling. During a review of Resident 1 '…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1), to be readmitted back to the facility on the first available bed, in accordance with the facility ' s policy and procedure titled Bed-Holds and Return, and the California Standard admission Agreement for Skilled Nursing Facilities and Intermediate Care Facilities. Resident 1, was transferred from the Skilled Nursing Facility (SNF 1) to GACH 1 on 2/04/2025 for further evaluation of Candida Auris (CRS) and was medically stable to be discharged back to the SNF 1 on 2/05/2025 but SNF 1 refused to readmit Resident 1 back to the facility. Resident 1 had to stay in the GACH for additional seven (7) days (from 2/05/2025 to 2/11/2025) and was discharged home on 2/12/2025 with home health. This deficient practice resulted to Resident 1 incurring extra seven days of unnecessary acute hospital stay at GACH 1, from 2/5/2025 to 2/12/2025. Findings, During a review of Resident 1 ' s admission Record…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to prevent one of four sampled residents (Resident 2) from developing pressure injuries (localized damage to the skin and/or underlying tissue usually over a bony prominence) by not providing the necessary treatment and services to prevent the formation of and promote healing of pressure injury in accordance with the facility's policy and procedure and physician's order. This failure resulted in Resident 2 developing Deep Tissue Injuries (damage to the soft tissue and skin caused by pressure or shear forces) to the left and right heels and had the potential for complications that included pain, infection, tissue necrosis, delayed wound healing, and reduced mobility. Findings: During a review of Resident 2 ' s admission Record, the facility admitted Resident 2 on 5/27/2024 and readmitted Resident 2 on 11/23/2024 with diagnoses that included fracture of unspecified part of neck of left femur(broken upper leg), Type 2 Diabetes Mellitus (DM, a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the residents had the right to participate in self-care as indicated in the resident's care plan titled ADL (activities of daily living) self – care promoting independence and autonomy for one of three sampled residents (Resident 1). This deficient practice violated the residents ' rights to participate in his or her own care and had the potential to create emotional distress leading to loss of autonomy. Findings: A review of the admission record indicated Resident 1 was initially admitted on [DATE], with a primary diagnosis of Metabolic encephalopathy (a change in consciousness that can cause confusion, memory loss, and loss of consciousness). A review of the History and Physical report completed on July 20, 2024, indicated Resident 1 had the capacity to understand and make decisions. A review of Resident 1 ' s Minimum Set Data (MDS – a federally mandated resident assessment tool) dated October 17, 2024, indicated resident had a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of seven sampled residents (Resident 2), who was assessed by the facility as a high risk for developing pressure ulcer (PU, a localized injury to the skin and/or underlying tissue usually over a bony prominence due to unrelieved prolong pressure in combination with shear) and was admitted without pressure ulcers received the necessary care and services to prevent PU as indicated in the facility's policy and procedure. Resident 2 was observed with Stage 2 PU (a partial-thickness skin loss that appears as an open sore or blister) in the sacrococcyx (tailbone) that was not previously assessed and identified by the facility. This deficient practice placed the resident and other potentially high risk residents for PU to be at risk of developing pressure ulcer that could result in delayed treatment, infection, discomfort, poor healing, and deterioration of PU. Findings: During a review of Resident 2's admission Record, 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 the resident received treatment and services in accordance with professional standards of practice and the facility's policy and procedures on Fall Management Program, revised 3/13/2021 and Completion & Correction, revised 1/1/2012 for one of two sampled residents (Resident 1) by failing to: 1. Ensure Resident 1 had appropriate footwear as indicated in the resident's care plan and on oxygen while ambulating as indicated in the physician's order, during the time of fall incident on 1/13/2024. 2. Perform neurological check monitoring immediately after the fall incident on 1/13/2024 as indicated in the facility's fall management protocol, to perform neurological checks at the ordered frequency every 15 minutes for one hour, then every 30 minutes for one hour, then every hour for 4 hours. 3. Ensure thorough assessment of Resident 1's Fall Risk Evaluation (FRV) on 11/26/2023, completion of post fall FRV and revision of care plan during…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to revise care plans for two of five sampled residents (Resident 1 and Resident 2) ensuring care plan was revised following Covid 19 infection. This deficient practice had the potential to affect the provision of care for these affected residents. Finding: A review of the facility ' s policy and procedure titled COVID-19 infection, dated with the revision date of January 28th, 2022, indicated resident vital sign monitoring - Residents in the red area will have vital signs, blood pressure, pulse, respiration rate, temperature and oxygen saturation documented every four hours. A review of Resident 1 ' s admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses including hemiplegia (inability to move affected body part) and hemiparesis (one sided weakness) following a cerebral infarction (stroke). A review of Resident 1 ' s History and Physical dated 06/23/2023, indicated Resident 1 had the capacity to understand and 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.

Based on observation, interview, and record review, the facility failed to ensure one of two outdoor refuse containers (a waste container that a person controls that includes dumpsters, trash cans, garbage pails, and plastic trash bags) was placed in covered garbage cans. This failure had the potential to attract insects and harbor rodents and pests in the refuse area that can cause a wide spread of diseases and affect the residents, staff, and visitors. Findings: During a concurrent observation and interview on 5/6/24 at 9:05 AM, with Dietary Aide (DA) 2 at the facility's parking lot, the outdoor refuse container was observed with no secured lid covered. The open refuse container was one-third full, filled with several closed plastic bags of garbage and a foam plate with food items lying on top of the garbage bags. DA 2 stated the lid of the refuse container should be closed at all times. DA 2 stated she would report to the Maintenance Supervisor (MS). During an interview on 5/6/24 at 9:31 AM with the MS, the MS stated he was notified by the dietary staff that the lid of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to promote the resident's rights of four (4) of eight (8) alert and oriented resident (23, 26, 31, and 58) who attended the Resident Council meeting (meeting held in the facility attended by the residents) reported they were not informed of the State Long Term Ombudsman program (a program consist of resident advocacy group that promotes resident's rights) and/or provided with the telephone numbers and/or email on how to contact the Ombudsman's office. This deficient practice had violated the resident's rights, and a potential not to receive residents' assistance from resident advocacy group should unresolved issues arise in the facility. Findings, On 5/8/24 at 11:43 AM, during the Resident Council meeting and resident group interview with eight alert and oriented residents that attended the meeting, four Residents (Residents 23, 26, 31, and 58) from the group stated they were not aware of what a State Long Term Ombudsman program does and how to contact…

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 Dietary Aide (DA) 1 washed her hands properly before touching the clean dishes after sorting the dirty dishes in a dish rack and pushing the dish rack into the dish washer. This deficient practice had the potential to cause food-borne illnesses (diseases are caused by eating food contaminated with bacteria, viruses, parasites or chemical substances) to the residents. Findings: During an observation on 5/6/24 at 9 AM, DA 1 was wearing a pair of vinyl exam gloves while sorting the dirty dishes on the counter on the left side of the dishwasher. After DA 1 put the dirty dishes on the dish rack and push the dish rack into the dishwasher, DA 1 dipped her hands with the vinyl exam gloves on into a red bucket with clean solution in it. Then, DA 1 took her hands with the gloves on out of the red bucket and touched the clean dishes on a dish rack. DA 1 moved the clean dishes on the dish rack to the drying cart. During a concurrent observation and interview on 5/6/24 at 9:01 AM with DA 1, DA 1 stated she washed…

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 three of three sampled Residents (Residents 89, 77, and 193) were informed and verbalized understanding of the concept of the proposed arbitration (solving disputes with a neutral third party instead of the court) and the Binding Arbitration Agreement (BAA, a binding agreement by the parties to submit to arbitration all or certain disputes between them in respect of a defined legal relationship, whether contractual or not) before having Residents 89,77, and 193 signed and entered into a binding arbitration agreement. The deficient practice resulted in Residents 89, 77, and 193 unknowingly giving up their right to resolve any disputes with the facility through a court of law before a jury. Findings: During an interview on 5/9/2024 at 11:02 AM with admission Director (AD), AD stated she was responsible for explaining and obtaining the BAA to the residents upon admission. The AD stated if the BAA was signed by the resident, the BAA was effective…

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 accommodate the needs for one of one sampled resident (Resident 288) in accordance with the facility's policy and procedure by failing to ensure the call light (a device used by residents to signal his or her needs for assistance) was within reach. This deficient practice had the potential for Resident 288 not able to call the facility staff to ask for help or assistance specially during emergency. Findings: During a review of Resident 288's admission Record indicated the facility originally admitted Resident 288 on 11/6/21 and readmitted on [DATE] with diagnoses that included encephalopathy (a disorder of brain function that often impairs consciousness) and history of fall. During a review of Resident 288's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 3/28/24, indicated Resident 288 had severely impaired memory and cognition (ability to think and reason). The MDS indicated Resident 288 required setup or…

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

Based on interview and record review, the facility failed to maintain a current copy of the resident's Advanced Healthcare Directive (AHCD, a legal document that provide instructions for medical care and only go into effect if you cannot communicate your own wishes) in the resident's medical record for one (1) of one (1) sampled residents (Resident 69). This deficient practice had the potential for Resident 69 to not have her wishes met regarding life-sustaining treatment (any treatment that serves to prolong life without reversing the underlying medical condition). Findings: A review of Resident 69's admission Record indicated the facility admitted the resident on 5/14/23 with diagnoses that included end stage renal disease (ESRD-occurs when a gradual loss of kidney function reaches an advanced state in which kidneys no longer work as they should to meet the body's needs), type 2 diabetes mellitus (a disease that occurs when the body's blood sugar is too high), weakness, and depression (a constant feeling of sadness and loss of interest, which stops a person doing 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 2. During a review of Resident 66's Record of admission indicated the resident originally admitted to the facility on [DATE], and readmitted on [DATE] with diagnoses that included dementia (a group of related symptoms associated with an ongoing decline of the brain and its abilities), pulmonary fibrosis (lung tissue becomes damaged and scarred), and disorder of kidney and ureter (organs that collects and drains out urine from the body). During a review of Resident 66's Minimum Data Set (MDS, a standardized assessment and care-screening tool) dated 2/3/2024 indicated cognitive skills (ability to make daily decisions) was intact. Resident 66 required partial/moderate assistance (helper does less than half the effort) with sit to stand and walk 10 feet, supervision or touching assistance (helper provides verbal cues and/or touching/steadying and or contact guard assistance as resident completes activity) with persona hygiene and toileting hygiene. A review of Resident 66's History and Physical dated 5/2/2024…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to develop a person-centered comprehensive care plan to address the resident's medical and physical needs for one of one sampled resident (Resident 28), had a physician order to receive Amoxicillin-Pot Clavulanate (a medication used to treat bacterial infections) tablet and Tylenol (medication used for aches and pains) tablet for tooth infection and tooth pain on 5/6/2024. This deficient practice had the potential to affect Resident 28's quality of care and quality of life by not receiving the appropiate interventions for the dental care. Findings: A review of Resident 28's admission Record indicated the resident was admitted to the facility on [DATE], with diagnoses that included cerebral infarction (damage to tissues in the brain due to a loss of oxygen to the area) with hemiplegia (paralysis that affects one side of your body) and hemiparesis (weakness or the inability to move on one side of the body) affecting the right side, dysphagia…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement a post fall intervention for one of two sampled residents (Resident 13) who was at high risk for fall, by not having a bed alarm (alarms to alert staff to respond quickly and intervene to assist the patient, thus preventing a fall) and bilateral floor mats (placed adjacent to the bed may prevent injury for those prone to rolling out of bed) placed as indicated in the resident's plan of care. This deficient practice had the potential for Resident 13 to have a recurrent fall that could cause serious injury and compromise the resident's well being. Findings: A review of Resident 13's admission record indicated the resident was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included generalized muscle weakness, cervical disc disorder with radiculopathy (nerve compression in the neck, leading to pain, numbness, and weakness in specific areas), and anxiety disorder (feeling of unease, 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 the resident was free from significant medication error by not omitting Carvedilol (medication used to treat high blood pressure) during medication pass observation for one of five (Resident 67) sampled residents. This deficient practice had the potential to cause complications of hypertension hypertension (high blood pressure) and lead to heart attack ( lack of blood flow to the heart), heart failure(failure of the heart to meet the body's demand) and stroke-poor blood flow to the brain results in cell death). Findings: On 5/8/24 at 9:01 AM, during a Medication Pass (Med Pass) observation, conducted with Licensed Vocational Nurse 4 (LVN 4) at Nursing Station 3, LVN 4 prepared and administered the following medications to Resident 67 orally (by mouth): 1. Colace 100 MG (milligrams - unit of measure) one capsule (for bowel management). 2. Lisinopril 40 MG one tablet (for hypertension). 3. Nifedipine ER Osmotic Release 30 MG one tablet…

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 proper storage of medications and/or treatment supplies for one of one sampled residents (Resident 26) who was observed with opened tube of Fluocinonide (medication used to treat many skin disorders), opened tube of hydrocortisone (medication used to help relieve redness, itching, swelling, or other discomfort caused by skin condition), and unopened tube of Ketoconazole (used to treat fungal skin infection) in the wash basin on Resident 26's bedside table. These deficient practices had the potential for other residents to use medications that could cause cross contamination of infection and/ or consume by other residents with cognitive impairment that could be harmful to their wellbeing. Findings, During an initial facility tour with Licensed Vocational Nurse 2 (LVN 2), on 5/7/24 at 10:22 AM, three medications tubes were observed in the wash basin on top of Resident 26's bedside table: Fluocinonide (missing the cap), Hydrocortisone…

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 ensure one of two sampled residents (Resident 55) with history of weight loss was assessed and served food that the resident preferred. This failure had a potential to result in Residnet 55's continued or recurrent weight loss due to that could result in a decline in the resident's well being due to not receiving food items of her choices. Findings: A review of Resident 55's admission Record indicated the facility admitted the resident on 3/27/24 with diagnoses that included type 2 diabetes mellitus (a disease that occurs when the body ' s blood sugar is too high) and protein-calorie malnutrition (a serious condition happens when a person ' s diet does not contain the right amount of nutrients), and muscle weakness. A review of Resident 55's Minimum Data Sheet (MDS, a standard assessment tool that measures health status), dated, indicated Resident 55's cognitive level was cognitively intact (able to process information, remember and reason), needed supervision or touching assistance (helper provides verbal cues…

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 one of two sampled residents (Resident 288) who was receiving hospice care services (hospice care is a type of health care that focuses on the palliation of a terminally ill patient's pain and symptoms and attending to their emotional and spriritual needs at the end of life) collaborated with hospice agency on the resident's plan of care by ensuring the plan of care was in the resident's medical record binder. This deficient practice had he potential to result in a delay or lack of coordination in delivery of hospice care and services to Resident 288. Findings: During a review of Resident 288's admission Record indicated the facility originally admitted Resident 288 on 11/6/21 and readmitted on [DATE] with diagnoses that included encephalopathy (a disorder of brain function that often impairs consciousness) and fall. During a review of Resident 288's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 3/28/24,…

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 facility staffs implemented the facility's policy and procedure titled Resident Isolation - Categories of Transmission-Based Precautions (precautions to prevent spread of infection) to wear isolation gown when taking care of one of two sampled residents (Resident 55). Resident 55 was ordered by the physician to be placed on contact isolation (precautions steps that healthcare facility visitors and staff need to follow before going into a patient's room, used for patients with diseases caused by bacteria and virus that are spread through direct and indirect contact). This failure had a potential to result in the spread of infection to the facility's staffs and residents and could cause a decline in other residents' health. Findings: A review of Resident 55 ' s admission Record indicated the facility admitted the resident on 3/27/24 with diagnoses that included Methicillin Resistant Staphylococcus Aureus Infection [MRSA, a staphylococcus bacteria (a type of germ) that is resistant to certain…

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

Based on observation and interview the facility failed to ensure one of one sampled resident (Resident 34) was provided with safe and comfortable environment by failing to ensure the resident's restroom had a functional toilet's handle. This failure resulted in Resident 34's feeling uncomfortable when manually flushing the toilet and lifting the toilet water tank lid by herself to manually flush the toilet, that could potentially cause accidents and injury to resident. Findings: A review of Resident 34's admission Record indicated the facility admitted the resident on 1/20/24 with diagnoses that included peripheral vascular diseases [a systemic disorder that involves the narrowing of peripheral blood vessels (vessels situated away from the heart or the brain)], type 2 diabetes mellitus (a disease that occurs when the body's blood sugar is too high), protein-calorie malnutrition (a serious condition happens when a person ' s diet does not contain the right amount of nutrients), and muscle weakness. A review of Resident 34's Minimum Data Sheet (MDS, a standard assessment tool that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement comprehensive person-centered care plan for one of three sampled residents (Resident 2) who required one-to-one staff supervision (sitter) and monitoring of the placement of wander guard, to reflect the current interventions and assessment to meet the immediate needs of the resident. This deficient practice in establishing, documenting, and implementing the care and services to be provided to the resident has the potential to negatively affect the physical well-being of Resident 2 and could potentially place the resident at risk for harm or injury. Findings: A review of Resident 2 ' s admission Record indicated the resident was admitted to the facility on [DATE], with diagnoses that included but not limited to dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities) and cognitive communication deficit (cannot recognize everyday social cues, both verbal and non – verbal). 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 interviews and record review, the facility failed to ensure that Licensed Vocational Nurse (LVN) 1 and Registered Nurse (RN) 1 implement the facility ' s policy and procedures titled Receiving Controlled Substances (controlled medications), by failing to: 1. Reconcile controlled drug records with valid orders and administration record to detect irregular controlled medications activities and identify inventory discrepancy that occurred after a resident had been discharged from the facility. The facility accepted a pharmacy delivery of Norco for Resident 1 after Resident 1 had been discharged from the facility. The facility did not have a record of the physician order that matched the aforementioned delivery. As a result, there was a loss of 38 tablets of Norco (hydromorphone-acetaminophen, a narcotic or controlled medications, a potent opioid to treat pain) 10-325 milligrams (mg, an unit to measure mass) for one (1) of 2 sampled residents (Resident 1) These deficient practices may have led to the loss or diversion of Resident 1 ' s controlled drug, Norco. Findings: On…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure consistent treatments and services were implemented to promote the healing and prevention of pressure ulcers (wound caused when an area of skin is placed under pressure) for one of four sampled residents (Resident 1). 1. The facility did not update Resident 1's pressure ulcer treatment order as recommended by Medical Doctor (MD) 2. The facility did not create a care plan for Resident 1 ' s Stage 4 (deep wounds that may impact muscle, tendons, ligaments, and bone) pressure ulcer. 3. The facility did not completely document Residents 1's pressure ulcer treatments provided ,as indicated on the Treatment Administration Record (TAR) from January 2023 to March 2023. These deficient practices had the potential for delayed healing of pressure ulcers and the potential detrorioration of Resident 1's Sacro-coccyx (middle of the buttocks) Stage 2 (affecting the top layer of the skin, with some loss of skin) pressure ulcer to Stage 4 pressure ulcer.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement fall interventions for 1 of 3 sampled residents (Resident 1) who was identified as high risk for falls. 1. The facility did not place Resident 1 (R 1) close to the nurse ' s station after R1 ' s sustained a fall on 2/20/2024 with a nasal fracture. 2. The facility did not follow fall care plan goal for no fall related injury. 3. The facility did not follow fall care intervention for fall related injury. These deficient practices resulted in R1 falling on 1/25/2024/, 2/16/2024 and sustaining a nasal fracture after falling on 2/20/2024. A review of Resident 1's Face Sheet (admission record) indicated the resident was admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis of cerebral infarction (also know as a stroke which refers to damage to tissue in the brain due to a loss of oxygen to the area) and a history of falls (to drop or descend under the force of gravity, as to a lower place through loss or lack of support). A…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure a resident was free from physical restraints, when Licensed Vocational Nurse (LVN) 1 placed both bed side rails up and dressers on both sides of the bed to prevent one of three sampled residents (Resident 1) from getting out of bed, without a physician ' s order and on-going assessments, in accordance with the facility policy and procedure on Bed Rails and Restraints. This deficient practice had the potential to place Resident 1 for accidents due to the use of bed side rails and dressers on both sides of the bed, without physician orders and ongoing assessment. Findings: A review of Resident 1 ' s admission Record indicated the facility admitted the resident on 11/21/23, with diagnoses that included but not limited to Alzheimer ' s Disease. (A brain disorder that slowly destroys memory and thinking skills, and eventually, the ability to carry out the simplest tasks. A review of Resident 1 ' s History and Physical (H&P) dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility staff failed to implement the facility's policy and procedure, titled Abuse - Reporting and Investigations, by identifying, protecting, reporting, and initiating an investigation immediately from a suspected abuse allegation brought up by a resident's family member (FAM 1) to facility staff on 11/23/2023, 11/24/2023, and 11/25/2023, for one of four sampled residents (Resident 1). The facility failed to: 1. Identify an allegation of abuse against CNA 1 by Resident 1, when FAM 1 reported on 11/23/2023 to a night shift (11 p.m. to 7 a.m.) facility staff (unable to recall clear staff name), on 11/24/2023 to LVN 1 during the dayshift (7 a.m. to 3 p.m.), and again on 11/25/2023 to LVN 1 during the dayshift (7 a.m. to 3 p.m.), and on 11/25/2023 to CNA 2 during the evening shift (3 p.m. to 11 p.m. shift). 2. Protect Resident 1 from a suspected abuse when CNA 1 continued to work throughout the 11 a.m. to 7 a.m. shift, on 11/23/2023, after FAM 1 reported the abuse…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to report an allegation of resident abuse for one of one resident (Resident 1) to the Department, Ombudsman (an official appointed to investigate individuals' complaints against maladministration), and to the local law enforcement, within two hours. This failure had the potential for Resident 1 to be at risk of further abuse. Findings: During a review of Resident 1 ' s admission Record, dated 11/03/2023, the admission Record indicated, Resident 1 was admitted to the facility on [DATE], with multiple diagnoses including depression (feelings of hopelessness, sadness, and a general disinterest in life, which for the most part have no cause and may be the result of a psychiatric illness), hemiplegia (paralysis on one side of the body) and hemiparesis (weakness or inability to move one side of the body) following unspecified cerebrovascular disease (a group of conditions that affect blood flow and the blood vessels in the brain) affecting left 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to revise and implement the resident's care plan with accurate and updated information regarding allergies and allergic reactions for one of three sampled residents (Resident 4) with documented food/drug allergies. This deficient practice had the potential to delay care and service provided to the residents. Findings: A review of Resident 4 ' s Face Sheet (a document that gives a patient ' s information at a quick glance) indicated the resident was readmitted to the facility on [DATE] with diagnoses that included metabolic encephalopathy (brain dysfunctions due to problems with your metabolism), mycosis(Any disease caused by a fungus that invades the tissue can cause a disease that's confined to the skin, spreads into tissue, bones, and organs, or affects the whole body) A review of Resident 4 ' s History and Physical Assessment, dated 1/15/2024 indicated Resident 4 had the capacity to understand and make decisions. A review of Resident 4 ' s Allergy…

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 and sanitary food preparation practice, when two (2) of 2 staff were observed wearing a watch and bracelets in the kitchen. These failures had the potential to result in harmful bacteria growth and cross contamination (transfer of bacteria from one place to another) that could lead to foodborne illness (an illness caused by contaminated food and beverages) to 93 of 96 medically compromised residents who received food from the kitchen. Findings: During an observation of the [NAME] 2 ' s (Cook 2) chopping of vegetables and Dietary Aide 1 (DA 1) portioning of milk on 1/18/2024 at 12:42 PM in the preparation area inside the facility's kitchen, [NAME] 2 was wearing a gold bracelet on her left arm while chopping vegetables and DA 1 was wearing a wristwatch and a metal bracelet while portioning milk in its individual cups. During a concurrent observation of [NAME] 2 and DA 1's food preparation on 1/18/2024 at 12:45 PM, and interview…

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.