Madera Rehabilitation & Nursing Center

Based on observation, interview and record review, the facility failed to ensure all prescribed medications were available and administered to residents as scheduled for three of seven sampled residents (Resident 53, 82 and 144) when the facility did not have the medications available for administration. This failure placed Residents 53, 82 and 144 at risk for not receiving the physician ordered medical treatment, placing residents at risk for ineffective management of their medical conditions.Findings:1. During an observation of the medication administration task on 8/6/25 at 8:50 a.m. with Licensed Vocational Nurse (LVN) 6, LVN 6 stated she did not administer Resident 53's [Polyethylene glycol] (medication that helps people have bowel movements), because it was not available in her medication cart.During a review of Resident 53's admission Record (AR-a document that provides resident contact details, a brief medical history, level of functioning, preferences and wishes), dated 8/7/25, the AR indicated Resident 53 has a history of constipation (when a person had a hard time going…

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 assistive devices during meals for three of 12 residents (Resident 44, 68, and 67) when: 1.Resident 44 was not provided with a right-hand built-up spoon (an adaptive dining aid [a device used to assist with feeding] designed for people who have limited grasp or face difficulties in supination) during his lunch on 8/5/25. This failure resulted in for Resident 44 not being able to feed himself and had the potential risk of losing his independence when eating. 2. Resident 68 was not provided a scoop plate (an assistive plate which helps people scoop up food onto a utensil) during his lunch on 8/5/25 This failure had had the potential to result in Resident 68 to not be able to eat his meal 3. Resident 67's food was not served in bowls on her meal tray during lunch on 8/5/25. This failure had the potential to limit Resident 67's ability to feed herself independently and safely.1.During a concurrent observation and interview on 8/5/25 at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a completed physician informed consent (the process in which residents are given important information of the possible risk and benefits of psychoactive medications) for the use of psychotropic medication (medication used to treat mental and behavioral disorders) was obtained for two of nine sampled residents (Resident 95 and Resident 108) when:Resident 95 had an active order for sertraline (psychotropic medication used to treat conditions such as depression) oral tablet, ordered on 7/5/25, with no electronic provider signature prior to administration.Resident 108 had an active order for aripiprazole (psychotropic medication used to treat conditions such as schizophrenia), ordered on 3/19/25, with no name of the licensed nursing staff that prepared and verified the consent form.These failures resulted in the violation of Resident 95's and Resident 108's right to be informed of, in advance, of their anti-psychotic medication treatment risks and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the Minimum Data Set assessment (MDS -assessment of physical and psychological functions and needs) accurately reflected resident's health and functional status for one of six sampled residents (Resident 13) when Resident 13's antidepressant medication (used to treat depression and mental health conditions), and anticoagulant medication (used to prevent blood clots from forming) use were inaccurately coded on the MDS assessment. These failures had the potential to result in Resident 13's care needs not met. During a review of Resident 13's admission Record, dated 8/8/25, the admission record indicated Resident 13 was admitted to the facility on [DATE] with diagnoses which included hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (one sided weakness or partial paralysis), depression (feeling of persistently sad and hopeless, impacting ability to enjoy life and carry out daily activities),…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure nail care was provided for one of nine sampled residents (Resident 49) when Resident 49's fingernails were long, jagged (sharp, uneven edges) and dirty with brownish to blackish dirt built up underneath the nails.This failure had potential for Resident 49 in obtaining avoidable skin related injuries and infection (the invasion and growth of germs in the body).During a concurrent observation and interview on 8/5/25 at 11:02 a.m. with Resident 49, in Resident 49's room, Resident 49 was lying in bed. Resident 49 was awake with slurred (indistinct and difficult to hear or understand) speech and was able to respond during conversation by nodding his head using yes and no questions. Resident 49 was unable to move his right upper extremity and right lower extremity. Resident 49 moved his left hand towards the left side of the bed. Resident 49's right hand was elevated with pillow; right hand was closed in a fist (a hand with a finger 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, interview, and record review the facility failed to act upon reported drug regimen review irregularities when one of nine sampled residents (Resident 108) had suggested drug regimen updates and there was no action taken to address it or documentation as to why no change in medication was taken. This failure had the potential to lead to unresolved medication related issues and negative health outcomes of Resident 108. Findings: During a review of Resident 108's admission Record (AR - a summary of information regarding a patient which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), dated 8/12/25, the AR indicated Resident 108 was admitted to the facility on [DATE] with diagnoses of heart failure (heart does not pump blood properly), atrial fibrillation (irregular heart rhythm), hypertension (high blood pressure), repeated falls, and schizophrenia (mental illness which affects 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 nine sampled residents (Resident 95) drug regimen was free from unnecessary drugs when Resident 95 received tramadol (opioid pain medication- a controlled substance used to treat moderate to severe pain) prescribed for pain management, despite reporting no pain. This failure resulted in over-medication and inadequate pain management practices of Resident 95 which had the potential to result in adverse consequences and complications which could lead to serious medical conditions.Findings: During a review of Resident 95's admission Record (AR - a summary of information regarding a patient which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), dated 8/12/25, the AR indicated Resident 95 was admitted to the facility on [DATE] with diagnoses of cerebral infarction (condition in which brain tissue dies due to lack of blood flow),…

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 drugs and biologicals used in the facility were labeled and stored in accordance with the facility policy and procedures when:1. A box of Nicotine Transdermal Patches (a patch that released nicotine [a chemical found in tobacco] through the skin to help people stop smoking) were found in the Station 5 Medication Cart without a resident identifier on the box.This failure had the potential to cause a medication error and place residents at risk for receiving the wrong medication.2. An opened foil envelope packet of Budesonide inhalation suspension (a medicine that helped reduce swelling and irritation in the lungs) was found in the Station 5 Medication Cart without the date of opening written on the packet.This failure had the potential to compromise the integrity, potency and safety of the medication and placed residents at risk for receiving ineffective or unsafe treatment.3. An open bottle of iodine (a chemical used to clean 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 to provide food in a form to meet individual needs for two of 15 sampled residents (Resident 68 and 143) when:1. Resident 68 received hard toast for lunch on 8/5/25 while he was on a mechanical soft diet.2. Resident 143 was served hard toasted bread during lunch on 8/5/25. Resident 143 attempted to eat the hard toasted bread. Resident 143's prescribed diet was mechanical soft texture diet.These failures had the potential to place Resident 68 and 143 at increased risk of choking (is a blockage of the upper airway by food or other objects, which prevents a person from breathing effectively).1.During a review of Resident 68's admission Record (AR- a document that provides resident contact details, a brief medical history, level of functioning, preferences, and wishes), dated 6/25/25, the AR indicated, Resident 68 was admitted to the facility on [DATE] with the following diagnoses: unspecified sequel of cerebral infarction (the long-term effects 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 Number of residents sampled:nineNumber of residents cited:oneBased on observation, interview and record review, the facility failed to follow the policy and procedure (P&P) for Foods Brought by Family/Visitors for one of nine sample residents (Resident 49) when perishable food (food that spoil, decay, and unsafe to eat if not stored properly) was stored in Resident 49's bedside table. This failure had the potential for Resident 49 at an increased risk of acquiring food-borne illnesses (referred to as food poisoning, are caused by eating or drinking something that is contaminated with germs/spoiled). During a concurrent observation and interview on 8/5/25 at 11:02 a.m. with Resident 49, in Resident 49's room, Resident 49 was lying in bed. Resident 49 was awake with slurred (indistinct and difficult to hear or understand) speech and was able to respond during conversation by nodding his head using yes and no questions. Resident 49 was unable to move his right upper extremity and right lower extremity. Resident 49…

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 establish and maintain an infection prevention and control program to provide a safe and sanitary environment to prevent infections for one of four sampled residents (Resident 13) when Resident 13's handheld nebulizer tubing (device that delivers medication into fine mist directly into the lungs) had a date of 7/17/25. This failure had the potential to put Resident 12 at risk for possible respiratory infection.During an observation on 8/5/25 at 10:01 a.m. during initial tour in Resident 13's room, Resident 13 was not in his room. Observed a handheld nebulizer at bedside inside a plastic bag a handheld nebulizer tubing dated 7/17/25. During a review of Resident 13's admission Record, dated 8/8/25, the admission record indicated Resident 13 was admitted to the facility on [DATE] with diagnoses which included hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (one sided weakness or partial…

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 maintain a safe and comfortable environment for two of 13 sampled residents (Resident 1 and Resident 8) when Resident 1 and Resident 8 ' s wheelchairs were covered with black and brown unknown substances and were visible to passersby. This failure violated Residents 1 and Resident 8 ' s rights to a comfortable and homelike environment that would respect the residents' dignity and well-being. Findings: During a review of Resident 1's admission Record (AR- a document that provides resident contact details, a brief medical history, level of functioning, preferences, and wishes), dated 6/11/25, the AR indicated, Resident 1 was admitted from an acute care hospital on [DATE] to the facility, with diagnoses that included Encephalopathy (a disorder caused by a buildup of toxins in the brain that can happen with advanced liver disease), Protein-Calorie Malnutrition (not consuming enough protein and calories, resulting to weight loss), Anxiety (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 maintain an effective infection control program when two of ten sampled residents (Resident 1 and Resident 8) when Resident 1 and Resident 8 ' s wheelchairs were covered with black and brown unknown substances. This failure placed Resident 1 and Resident 8 at an increased risk to develop healthcare-associated infections. Findings: During a review of Resident 1's admission Record (AR- a document that provides resident contact details, a brief medical history, level of functioning, preferences, and wishes), dated 6/11/25, the AR indicated, Resident 1 was admitted from an acute care hospital on [DATE] to the facility, with diagnoses that included Encephalopathy (a disorder caused by a buildup of toxins in the brain that can happen with advanced liver disease), Protein-Calorie Malnutrition (not consuming enough protein and calories, resulting to weight loss), Anxiety (a mental health disorder characterized by feelings of worry, anxiety, or…

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

Based on interview and record review, the facility failed to ensure the Infection Preventionist (IP) have the specific competencies, and skill sets to ensure facility staff were properly trained and educated to properly managed and care for residents with infections and to prevent the risk for infections to other residents, staff and visitors when the IP did not provide on-going in-service training and education to facility staff when facility had an outbreak of Noro virus (highly contagious virus [easily spread] that causes vomiting and diarrhea) and Influenza virus (contagious respiratory illness). These failures placed residents, staff and visitors at increased risk for exposure to infections. Findings: During a concurrent interview and record review on 4/15/25 at 1:58 p.m. with Dietary Supervisor (DS), Inservice Meeting Minutes, dated 1/2/25 was reviewed. The DS stated the topic was on Infection Control in the dietary area only because of a Noro Virus and Influenza virus outbreak in the facility. The DS stated she discussed with her staff about wearing of surgical masks, hand…

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 report abuse allegations to the California Department of Public Health (CDPH) within the required timeframe for two of four sampled residents (Resident 10 and Resident 7) when: 1. CNA 5 alleged CNA 6 pushed Resident 10 roughly onto her bed while providing care on 4/5/25 and did not report the allegation of abuse to the facility until 4/6/25. 2. Family Member (FM) 1 contacted the local police department (PD) alleging Resident 7 was abused by facility staff on 3/5/25 and 3/27/25, the PD went to the facility for welfare checks and the facility staff was made aware of the abuse allegations. The facility staff did not report the abuse allegations to CDPH on 3/5/25 and 3/27/25 according to federal regulations and the facility's policy and procedure (P&P). This failure resulted in the abuse allegations not being investigated timely and had the potential to result in Residents 10 and 7's safety needs not being met. Findings: 1. During 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 Administrator (ADM) failed to provide consistent administrative oversight and resources to ensure residents received adequate supervision and care planning when the ADM was aware of 63 resident falls between 1/1/25 and 3/4/25 and did not establish an effective fall prevention program. This failure resulted in three of six sampled residents (Residents 1, 2 and 6) having unwitnessed falls with injury requiring transportation to the acute care hospital (ACH) for treatment and placed other residents at risk for falls with injury. (cross reference F689) Findings: During a review of the facility ' s document titled Incidents By Incident Type, dated 1/1/25 to 3/4/25, the document indicated, . Total ' Fall ' Incidents: 64 . One fall was crossed out in error. During a review of Resident 1 ' s ACH document titled Case Management Discharge Summary/Orders Report, dated 2/7/25, the note indicated, . admission date: 1/31/2025 . discharge date : [DATE] . Slip and fall coming out 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 a comprehensive, person-centered care plan was developed and implemented to meet the identified needs for two of six sampled residents (Residents 1 and 2) when: 1. Resident 1 was admitted to the facility with a history of falls, assessed as being a fall risk and a known behavior of not calling staff for assistance and the facility did not develop and implement effective care plan interventions including assistance and supervision to prevent falls. This failure resulted in Resident 1 ' s unwitnessed fall on 1/30/25, sustaining an intertrochanteric fracture (a type of hip fracture [broken bone] where the femur [upper thigh bone] meets the pelvis), pain, decreased mobility and required transportation to the emergency room and admission to the acute care hospital (ACH) for seven days. (cross reference F689) 2. Resident 2 was admitted to the facility with left sided paralysis, a history of falls and assessed as a fall risk with 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 provide sufficient staff with the appropriate competencies and skill sets to provide nursing services to ensure residents receive services to maintain their highest practicable physical, mental, and psychosocial well-being when seven of seven sampled nursing staff (Registered Nurse [RN] 1, RN 2, Licensed Vocational Nurse [LVN] 1, LVN 2, Certified Nursing Assistant [CNA] 1, CNA 2, CNA 3) did not have their fall prevention competency (ability to do something successfully) skills checked within the last year and there were 42 falls between 1/1/25 and 2/12/25. This failure resulted in one of three sampled residents (Resident 1 ' s) unwitnessed fall on 1/30/25, sustaining an intertrochanteric fracture (a type of hip fracture [broken bone] where the femur [upper thigh bone] meets the pelvis), pain, decreased mobility and required transportation to the emergency room and admission to the acute care hospital (ACH) for seven days and placed other…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow its hospice (care that focuses on the quality of life for people who are experiencing an advanced, life-limiting illness) policy and procedures (P&P) for two of 12 sampled residents (Resident 8 and Resident 14) when Resident 8 and Resident 14 were receiving hospice services with unsigned hospice agreement. This failure had the potential to place Resident 8 and Resident 14 at risk of not receiving appropriate medical, physical, psychosocial, and spiritual support to manage symptoms associated with terminal illness. Findings: During a concurrent interview and record review on 3/5/25, at 2:15 p.m., with the Administrator (ADM), the facility's Hospice Agreement with [Name of Hospice Agency], dated 6/16/16 was reviewed. The hospice agreement indicated, . IN WITNESS WHEREOF, each intending to be legally bound, have duly executed this Addendum as of the day, month and year first above written . Hospice Services include: (1) nursing care and services 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.

Based on interview and record review, the facility failed to identify, develop and implement an effective Quality Assurance and Performance Improvement (QAPI- a systematic, comprehensive, and data-driven approach to maintaining and improving safety and quality in nursing homes while involving all nursing home caregivers in practical and creative problem solving) program when the facility did not establish an effective fall prevention program and there were 63 resident falls between 1/1/25 and 3/4/25. This failure resulted in three resident falls (Residents 1, 2 and 6) with significant injury requiring transportation to the acute care hospital for treatment and placed other residents at risk for falls with significant injury and had the potential to affect the quality of care, quality of life, services and safety of the facility's residents. (Cross reference F835, F689) Findings: During a review of the facility ' s document titled Incidents By Incident Type, dated 1/1/25 to 3/4/25, the document indicated, . Total ' Fall ' Incidents: 64 . One fall was crossed out in error. During an…

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 notify the Responsible Party (RP) for one of six sampled resident ' s (Resident 2) when Resident 2 ' s room was changed on 2/23/25 and he fell on 2/26/25. This failure violated Resident 2 ' s rights when his RP was not informed of a change in care. Findings: During a concurrent observation and interview on 3/6/25 at 10:50 a.m. with Resident 2, Resident 2 sat up in his wheelchair, Certified Nursing Assistant (CNA) 1 was at bedside. CNA 1 stated she was assigned to provide Resident 2 with one-on-one supervision while the assigned CNA was at lunch. Family Member (FM) 3 walked into Resident 2 ' s room and asked Resident 2 why there was a CNA sitting with him. Resident 2 informed FM 3 he had multiple falls since his admission to the facility. FM 3 was upset and asked, why are they letting him fall? FM 3 stated he had not been notified Resident 2 had fallen, but FM 2 was his RP, and they may have notified her. Resident 2 stated FM 2 was his RP, and he 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.

Based on observation, interview, and record review, the facility failed to maintain a safe and comfortable environment for one of 13 sampled residents (Resident 9) when Resident 9 ' s hospital bed ' s footboard was loose and detached from the bedframe, and visible to passersby. This failure violated Residents 9 ' s rights to a comfortable and homelike environment that would respect the residents' dignity and well-being. Findings: During a review of Resident 9's admission Record (AR- a document that provides resident contact details, a brief medical history, level of functioning, preferences, and wishes), dated 3/7/25, the AR indicated, Resident 9 was admitted from an acute care hospital on 5/19/16 to the facility, with diagnoses that included Cerebrovascular Disease (stroke- bleeding inside the brain) affecting right side of the body, Congestive Heart Failure (CHF- weakness in the heart where fluid accumulates in the lungs), Generalized Muscle Weakness, and Hypertension (high blood pressure). During a review of Resident 9's Minimum Data Set (MDS-comprehensive, standardized…

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 unwitnessed fall with injury to the California Department of Public Health (CDPH- State survey agency) within the required time frame for one of ten sampled residents (Resident 2) when Resident 2 fell twice from his bed on 2/20/25, unwitnessed on both occasions. Resident 2 hit his head during a fall on 2/20/25 at 6:15 a.m. causing a skin tear to his left eyebrow and fell again on 2/20/25 at 10:35 p.m. hitting his head in the same area causing further trauma to the left eyebrow resulting in a laceration (cut or tear in the skin caused by blunt force). Resident 2 required transportation to the emergency room for sutures (threads used to close wounds) to repair the wound. This failure resulted in Resident 2's fall not investigated timely within the required time frame and had the potential to result in Resident 2's safety needs not met. Findings: During a review of Resident 2's admission Record (AR - a summary of information regarding a patient…

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 services provided met professional standards of quality for one of 12 sampled residents (Resident 3) when Resident 3 ' s low air loss (LAL – a special mattress used to prevent skin injuries, often occurring in individuals who are bedbound) mattress setting was not used according to the manufacturer ' s recommendation. This failure had the potential to result in Resident 3 to develop pressure ulcer (injury to the skin and underlying tissues by prolonged pressure on the skin) and placed Resident 3 at an increased risk for falls and discomfort. Findings: 1. During a review of Resident 3's admission Record (AR- a document that provides resident contact details, a brief medical history, level of functioning, preferences, and wishes), dated 3/3/25, the AR indicated, Resident 3 was admitted from an acute care hospital on [DATE] to the facility, with diagnoses that included Dementia (a decline in memory or other thinking skills severe enough to reduce a…

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

Based on observation, interview, and record review, the facility failed to maintain an effective infection control program when one of 12 sampled residents' (Resident 8) oxygen concentrator filter was found covered with dust and lint. This failure placed Resident 8 at an increased risk to develop respiratory and healthcare-associated infections. Findings: During a review of Resident 8's admission Record (AR, a document that provides resident contact details, a brief medical history, level of functioning, preferences, and wishes), dated 3/7/25, the AR indicated, Resident 8 was admitted from an acute care hospital on 1/9/25 to the facility, with diagnoses that included Congestive Heart Failure (CHF- define), Type 2 Diabetes Mellitus (abnormal levels of blood sugar), Hypertension (high blood pressure), and Pleural Effusion (an abnormal accumulation of fluid in the lungs and the chest wall). During a review of Resident 8's Minimum Data Set (MDS, an assessment tool which indicates physical, medical, and cognitive abilities), dated 1/15/25, the MDS indicated Resident 8's Brief 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to maintain an effective infection control program when: 1. One of 11 sampled Certified Nursing Assistants (CNA 1) assisted Resident 1, who was on contact precautions for symptoms of norovirus (a highly contagious virus [infectious agent] that causes nausea, vomiting and diarrhea), from the bathroom to his bed and failed to wear personal protective equipment (PPE-includes protective gowns, gloves, face shields or goggles and face masks to protect the wearer from injury or the spread of infection or illness) according to the facility ' s policy and procedure (P&P) for norovirus prevention and control. This failure had the potential for CNA 1 to spread norovirus to other residents and staff. 2. Eleven of 22 (rooms 1, 2, 6, 16, 21, 24, 35, 38, 42, 47 and 48) with isolation precautions did not have biohazard receptacles in the room for staff and visitors to dispose of contaminated PPE prior to exiting the room. This failure had the potential for…

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 person-centered care plan to prevent falls for two of four sampled residents (Residents 2 and 8) when: 1. Nursing staff were aware of Resident 2 ' s decline in functional status, poor safety awareness and need to be supervised while ambulating and did not develop and implement effective care plan interventions to prevent falls. This failure resulted in Resident 2 ' s fall on 1/2/25 sustaining a laceration (cut in the skin caused by an injury) above the left eyebrow requiring transportation to the emergency department (ED) for sutures (a row of stitches holding together edges of a wound). 2. Nursing staff were aware of Resident 8 ' s severe cognitive impairment, poor safety awareness and failed to develop and implement effective person-specific care plan interventions to prevent falls. This failure resulted in Resident 8 suffering avoidable falls on the following dates: 10/13/24, 12/20/24, 12/29/24,…

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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure services provided met professional stands of practice for six of nine sampled residents (Residents 1, 2, 3, 6, 7 and 8) when: 1. Nursing staff were aware that four of four sampled residents (Residents 2, 3, 7 and 8) with severe cognitive impairment, poor safety awareness and a history of falls did not perform fall risk assessments (medical evaluation that determines likelihood of falling by examining factors such a medical history, physical abilities, balance, gait, and medications) after falls and quarterly. This failure resulted in Resident 2 ' s falls on 12/13/24 and 1/2/25 sustaining a laceration above the left eyebrow, Resident 3 ' s fall on 12/18/24, Resident 7 ' s falls on 10/22/24, 10/25/24, 11/13/24, 11/19/24 and 12/23/24 and Resident 8 ' s falls on 10/13/24, 12/20/24, 12/29/24, 1/1/25 and 1/8/25 and had the potential for severe injuries. (cross reference F689) 2. Licensed Nurses did not follow the manufacturer guidelines to check two 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 the quarterly Minimum Data Set Assessment (MDS-a resident assessment tool used to identify resident cognitive and physical function) accurately reflected the residents healthcare and functional status for one of nine sampled residents (Resident 2) when Resident 2 ' s plan of care addressed an unsteady gait (manner of walking) and declining health status on 11/2/24 and Minimum Data Set Coordinator (MDSC) 2 assessed his ambulation (ability to walk) status as independent in the MDS Assessment Section GG-Functional Abilities on 11/23/24. This failure resulted in an inaccurate assessment of Resident 2 ' s functional status as not needing supervision to ambulate, and the resident was left on an outside patio unsupervised and fell on 1/2/25 sustaining a laceration above his left eye. (Cross reference F689) Findings: During an observation on 1/6/25 at 11:33 a.m. in the activities room, Resident 2 in a sat chair. Resident 2 had a sutured…

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 protect and promote resident rights to be free from abuse for one of three sampled residents (Resident 1) when Licensed Vocational Nurse (LVN) 1 and other facility staff left Resident 1 in her room during a verbal altercation between four facility visitors, in a manner that made Resident 1 felt threatened and fearful. This deficient practice resulted in the violation of Resident 1's right to be treated with respect and dignity, and free from emotional distress. Findings: During a review of Resident 1's admission Record (AR- a document that provides resident contact details, a brief medical history, level of functioning, preferences, and wishes), dated 11/22/24, the AR indicated, Resident 1 was re-admitted from acute hospital on 7/29/24 to the facility, with diagnoses that included Chronic Obstructive Pulmonary Disease (COPD – define), Congestive Heart Failure (CHF - weakness in the heart where fluid accumulates in the lungs), Major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of…

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

Based on observation, interview, facility policy review, the facility failed to implement their water management plan and failed to conduct an assessment to identify where bacterium Legionella and other waterborne pathogens could grow. This had the potential to affect all residents in the facility who consumed water. Findings include: Review of the facility's policy titled Legionella Water Management Program, dated 09/2022, revealed, Our facility is committed to the prevention, detection and control of water-borne contaminants, including Legionella 3. The purposes of the water management program are to identify areas in the water system where Legionella bacteria can grow and spread, and to reduce the risk of Legionnaire's disease .d. The identification of situations that can lead to Legionella growth, such as: (1) construction; (2) water main breaks; (3) changes in municipal water quality; (a) the presence of biofilm, scale, or sediment; (5) water temperature fluctuations; (6) water pressure changes; (7) water stagnation; and (8) inadequate disinfection . e. Specific measures used…

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 record review, policy review, and interview, the facility failed to ensure that six (Residents (R) 5, R9, R21, R33, R70, R148) of 12 residents reviewed out of a total sample of 36 residents for Advance Directives and/or their representatives were informed and provided written information to formulate an advanced directive upon admission to the facility. Failure to provide residents and/or their representatives with this information upon admission has the potential to result in residents' needs or wishes not being met. Findings include: 1. Review of the admission Record in R5's electronic medical record (EMR) under the Profile tab indicated he was admitted to the facility on [DATE]. Review of the Social Service Review, in R5's EMR under the Miscellaneous tab, dated 09/24/20, indicated there was no evidence the facility offered R5, or his family any information related to the formulation of an advance directive or offer to help formulate one. 2. Review of the admission Record in R9's EMR under the Profile…

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 the resident and/or representative; and the Ombudsman with written notification of a facility-initiated transfers for five of six sampled residents (Resident (R) 2, R32, R96, R130, R148) reviewed for hospitalization out of 36 total sampled residents. This failure had the potential to affect the residents and/or their representative about the reason for the transfer and the resident's appeal rights. Findings include: Review of the facility's policy titled, Transfer or Discharge, Facility-Initiated dated 10/2023 stated, . Facility-initiated transfers and discharges, when necessary, must meet specific criteria and require resident/representative notification and orientation, and documentation as specified in this policy . Notice of Transfer is provided to the resident and representative as soon as practicable before the transfer and to the long-term care (LTC) ombudsman when practicable (e.g., [example] in a monthly list of residents that includes…

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 record reviews, interviews, and facility policy review, the facility failed to ensure residents and/or their responsible party was given a written bed hold policy/notice at the time of their hospital transfer for four of six residents reviewed for hospitalizations (Resident (R) 2, R96, R130, and R148) out of a total sample of 36 residents. This failure had the potential for the residents to be denied return to their original room or denial of the resident returning to the facility. Findings include: Review of the facility policy titled Bed Holds and Returns, dated October 2023 indicated All residents/representatives are provided written information regarding the facility and state bed-hold policies, which address holding or reserving a resident's bed during periods of absence (hospitalization or therapeutic leave). Residents, regardless of payer source, are provided written notice about these policies at least twice: well in advance of any transfer (e.g., in the admission packet); and at the time 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, record review, and facility policy review, the facility failed to develop comprehensive care plans that reflected the residents' current status for 10 residents (Resident (R) 5, R9, R21, R33, R70, R93, R96, R148, R161, and R420) of 38 sampled residents. The residents' care plans were developed; however, the care plan did not reflect the residents' right to refuse treatment (Do Not Resuscitate (DNR)) and did not reflect residents' sex offender registry status. These failures had the potential for staff not to be informed of residents' care needs or offender history of residents. Findings include: Review of the facility's policy titled Care Plans, Comprehensive Person Centered, dated [DATE] indicated A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychological, and functional needs is developed and implemented for each resident. The policy indicated The comprehensive, person-centered 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 document review, the facility failed to provide and maintain a minimum of at least 80 square feet per resident in 32 of 73 rooms (Rooms 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49 and 50). This failure had the potential for residents to not have reasonable privacy or adequate space. Findings include: Review of a letter signed by the facility's Administrator dated [DATE], provided by the facility, revealed To Whom it may concern, The following rooms at [NAME] Rehabilitation and Nursing Center are less than the required square footage: 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50. (While this letter revealed room [ROOM NUMBER] did not have the required SF, the room measured 166.75 and had two beds, which meets the required SF.) Review of undated Maintenance Records provided by the facility, revealed the following…

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, record review, and policy review, the facility failed to ensure there was a dialysis contract for two of six residents (Resident (R) 44 and R87) reviewed for dialysis of 36 sample residents. This has the potential to affect the residents overall care between the facility and dialysis center. Findings include: Review of facility policy titled ''End-Stage Renal Disease, Care of a Resident with,'' revised 09/23, revealed, ''Residents with end-stage renal disease (ESRD) will be cared for according to currently recognized standards of care. Policy Interpretation and Implementation . 4. Agreements between this facility and the contracted ESRD facility include all aspects of how the resident's care will be managed.'' 1. Review of R44's admission Record located in the resident electronic medical records (EMR) under the ''Profile'' tab, revealed the resident was re-admitted on [DATE] with diagnoses that included ESRD. Review of R44's ''Physician Orders'' for June 2024. Located in the resident's EMR…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a baseline resident-centered care plan was developed and implemented for two of three sampled residents (Resident 3, and 4) when: 1.Resident 3 did not have a care plan for chronic obstructive pulmonary disease (COPD- lung disease making it difficult to breathe) until after being discharged from the facility and Resident 4 did not have a care plan until onsite investigation. 2. Resident 3 did not have a care plan for end stage renal disease (ESRD-inability to remove waste products from blood and produce urine) on dialysis [is a process by which dissolved substances are removed from a patient's body by diffusion (movement or spread) from one fluid compartment (space) to another across a semipermeable membrane (a layer that only certain molecules (smallest particle of a substance) can pass through] until after being discharged from the facility. This failure placed Resident 3 and 4 at risk for complications from not having care needs planned 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 interview and record review, the facility failed to provide services which met professional standards of quality for two of four sampled residents (Resident 3, and 4) when Licensed Nurses 's (LN)'s did not administer oxygen per physician's order for residents (Resident 3 and 4) when physician ordered parameters for oxygen administration were not followed. This failure had the potential for Resident 3 and 4 to receive inadequate amount of oxygen. Findings: During a review of Resident 3's admission Record undated, the admission record indicated Resident 3 was admitted to the facility on [DATE]. Resident 3's diagnosis included chronic obstructive pulmonary disease (COPD- lung disease making it difficult to breathe). During a concurrent interview and record review on 3/5/24 at 11:16 a.m., with Licensed Vocational Nurse (LVN) 2, Resident 3's Order Summary(OS), dated 1/3/24 was reviewed. The OS indicated, Oxygen at 4 LPM(liters per minute) VIA NASAL CANNULA (NC- (thin plastic tube that delivers oxygen…

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 revise and implement a person centered comprehensive care plan for one of 10 sampled residents (Resident 1) when Resident 1's care plan did not accurately reflect Resident 1's refusal for staff to consistently use a mechanical lift during Activities of Daily Living )ADL) transfer. This failure resulted in Resident 1 to experience a fall on (indicate the date) . Resident 1 complained of pain, sustained a fracture of the right femur and placed Resident 1 at risk to experience re-occurring falls. Findings: During a review of Resident 1 ' s admission Record (AR) (a document containing demographic information), the AR indicated Resident 1 was admitted to the facility on [DATE]. During a review of Resident 1 ' s Diagnosis Report (a document listing resident ' s diagnoses) dated 03/07/24, indicated Resident 1 ' was admitted to the skilled nursing facility with diagnoses which included, .Osteoarthritis (protective tissues at the ends 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 follow the facility verbal abuse policy and procedure for one of four sampled residents (Resident 1) when Certified Nursing Assistant (CNA) 3 reacted aggressively and told Resident 1, If I had my way, I would have straightened you out right now. This failure resulted in the violation of Resident 1's right to be free from verbal abuse and placed Resident 1 at risk to experience psychosocial trauma related to the incident. Findings: During a review of Resident 1 ' s admission Record (AR- a document that provides resident contact details, a brief medical history, level of functioning, preferences, and wishes), dated 10/11/23, the AR indicated, Resident 1 was admitted to the facility on [DATE] with diagnoses which included schizophrenia (a disease which involves a range of problems with thinking, behavior and emotions), depression (a mental disorder with loss of pleasure or interest in activities for long periods of time), and anxiety (a…

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

Based on observation, interview, and record review, the facility failed to ensure the results of the annual Recertification and Abbreviated survey results were posted in a readily accessible location for the residents and the public when 7 of 7 sampled residents (Resident 36, Resident 150, Resident 72, Resident 98, Resident 84, Resident 75, Resident 97) did not have access to the survey results. This failure denied Resident 36, Resident 150, Resident 72, Resident 98, Resident 84, Resident 75, Resident 97 and the public access to survey results. Findings: During the resident council meeting an interview with with Residents 72, 36, 84, 98 and 150, on 4/23/19, at 10:40 p.m., Resident 72 stated, I do not know where to find [the facility's] post survey results. Resident 36, Resident 84, Resident 98 and Resident 150 stated they were unaware where to find the binder of the posted survey result for the annual Recertification, Abbreviated surveys. During an interview with Licensed Vocational Nurse (LVN) 1, on 4/23/19, at 10:50 a.m., she stated the post survey binder result was available in…

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

Based on observation, interview and record review, the facility failed to store, prepare and distribute food safely when an undated opened bag of shredded cabbage was stored and ready for use in the walk-in refrigerator and an opened bag of flour was stored and ready for use in the pull out cabinet with no opened date. These failures had the potential to cause foodborne illness to residents, staff and visitors who were served meals from the kitchen. Findings: During an observation on 4/22/19, at 8:15 a.m., in the kitchen, an opened bag of cabbage was stored and ready for use in the walk-in refrigerator without a label of the date when it was opened or when it will expire. The Dietary Supervisor (DS) stated it was opened and not dated. The DS stated the open bag should have been dated. During an observation on 4/22/19, at 8:20 a.m., in the kitchen, an opened bag of flour without a date was stored and ready for use in the pull out cabinet. The DS stated it was open and not dated. The DS stated the bag of flour should have been dated. During an interview with Cook, on 4/22/19, at 11:45…

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 During observation in Resident 62's room, on 4/22/19, at 9:21 a.m., Resident 62 was in bed and her call light was on the floor not within reach. During an interview with CNA 13, on 4/22/19, at 9:25 a.m., she stated Resident 62 was independent and yelled when she needed something. CNA 13 stated, [Resident 62's] call light had to be within resident reach at all time. During an observation on 4/22/19, at 10:17 a.m., in Resident 37's room, Resident 37's call light was on the floor and not within reach. During an interview with CNA 15, on 4/22/19, at 10:21 a.m., she stated, [Resident 37's] call light should be within the resident reach all the time. The facility policy and procedure titled Answering the call light dated 10/2010, indicated The purpose of this procedure is to respond to the resident's request and needs. General Guidelines . 5. When the resident is in the bed or confined to a chair be sure the call light is within easy reach of the resident . The facility policy and procedure titled Quality of Life -…

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 a safe, clean and homelike environment for six of 80 sampled residents (Residents 26, 42, 44, 51, 125 and 133) when their shared restroom remained accessible for use after having smeared feces on the toilet seat, toilet bowl and on the floor. These failures resulted in an unsanitary and unhomelike environment for Residents 26, 42, 44, 51, 125 and 133 Findings: During an observation on 4/22/19, at 9:35 a.m., in Resident 44's restroom, the toilet seat, toilet bowl and floor were smeared with feces. During a concurrent observation and interview with Certified Nursing Assistant (CNA) 7, on 4/22/19, at 9:37 a.m., in Resident 44's restroom, she stated Resident 44 used the toilet at 8:15 a.m. before he left for dialysis. CNA 7 stated the restroom was dirty and she was waiting for the housekeeper to clean it. CNA 7 stated she should have alerted the housekeeper to clean the restroom but did not. During an interview with Housekeeper (HK), on 4/22/19, at 9:42 a.m., she stated, I was just told [about the dirty…

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 policy and procedure titled Medication Storage in the Facility and Labeling of Medication Containers when: 1. Artificial eye drops and ear wax removal drops were stored together with no divider between the medications in the Central Supply room. 2. Two of two tuberculin solution vials (to test for tuberculosis, a bacterial infection affecting the lungs) were stored and ready for use with no open date nor expiration date on the vial. These failures had the potential to place residents at risk of receiving expired tuberculin solution, experience adverse reactions from expired medication and placed residents at risk for potential medication errors from the potential incorrect medication use or route when medications were not stored separately. Findings: 1. During a concurrent observation and interview with the Central Supply Director (CSD), on [DATE], at 12:50 p.m., in the central supply room, artificial eye drops boxes were…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide 80 square feet per resident in multiple resident room for 33 of 74 rooms when there were two to three residents in a room that did not meet the square footage requirement. This practice failed to provide the resident in these rooms with 80 square feet of space and increased the risk for residents not to have enough space for mobility and to accommodate their personal belongings. Findings: During an observation and concurrent interview with Certified Nursing Assistant (CNA) 8, on 4/22/19, at 2:48 p.m., in station 1 hallway, rooms 16, 17 and 18 had two beds positioned on opposite sides of the room which gave space in the middle of the room. There was sufficient space for resident's personal belongings. CNA 8 stated she had no problem with providing care to residents in rooms 16,17 and 18. CNA 8 stated the rooms had enough space for wheelchairs. During an interview with Resident 160, on 4/22/19, at 2:52 p.m., he stated the room space…

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 a safe and sanitary environment for six of 80 residents (Residents, 51, 42, 125, 133, 26, and 44) when Resident 51, 42, 125, 133, 26, and 44's shared restrooms had feces stain on the toilet seat, sides and restroom floor. This failure resulted in unsafe and unsanitary restrooms for Resident 51, 42, 125, 133, 26, and 44. Findings: During an observation on 4/22/19, at 9:35 a.m., in Resident 51, 42, 125, 133, 26, and 44's shared restroom, the toilet had dark brown, foul odor substance splattered on the seat, sides of the toilet and on the restroom floor. During a concurrent observation and interview with Certified Nursing Assistant (CNA) 7, on 4/22/19, at 9:37 a.m., in shared restroom, she stated Resident 44 used the toilet at 8:15 a.m. before he left for dialysis. CNA 7 stated, I wiped it with bleach wipes . wiped the chunks (feces) . The toilet is still dirty (feces stains) . I am waiting for housekeeper. CNA 7 stated she should not have waited for an hour and a half for the housekeeper to clean 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 80 sampled residents (Residents 16 and 116) were treated with dignity and respect in an environment that promoted and enhanced their self esteem when: 1. Resident 16's shirt was not changed after being soiled and stained from spilled drink and food particles. For Resident 16 this failure placed him at risk for feeling embarrassed from being left with soiled clothes. 2. Resident 116's urinary catheter (a catheter inserted into the bladder through the urethra to allow urine to drain) bag was left uncovered. For Resident 116 this failure placed him at risk for feeling embarrassed from an exposed urinary catheter drain bag. Findings: 1. During a concurrent observation and interview with Certified Nursing Assistant (CNA) 5, on 4/22/19, at 10:04 a.m., in Resident 16's room, Resident 16's shirt had three dark brown drink stains and food crumbs. There was no food tray on her bedside table. CNA 5 stated, [Resident 16's] shirt is…

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 74) was free from physical abuse when Resident 112 tossed her cup of iced tea at Resident 74 five times in a period of 11 months. The interdisciplinary team (IDT) (team composed of a nurse, social worker, activity staff and physician) did not implement effective interventions to address Resident 112's known behavior of impulsivity and did not implement interventions to keep Resident 74 safe. This failure resulted in Resident 112 feeling afraid, emotional distress and the potential to cause serious physical injuries. Findings: During a concurrent observation and interview with Resident 112, on 4/24/19, at 8:39 a.m., Resident 112 sat on a chair in the hallway next to the dining room and next to other residents. Resident 112 held a Styrofoam cup in her hands which contained liquid. Resident 112 stated she had tea in her Styrofoam cup. During a review of the clinical record for Resident 112, the…

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

Based on observation, interview, and record review the facility failed to ensure services provided met professional standards of practice for one of 13 sampled residents (Resident 119 when: Resident 119's nasal cannula (a plastic tubing used for the delivery of oxygen through the nose) tubing did not have a date label (start date) as ordered by the physician and medications were administered crushed without having a physician's order to administer crushed medications. These failures placed had the potential for Resident 119's nasal cannula to be used for more than the ordered number of days and placed Resident 119 at risk to experience stomach upset from the administration of crushed medications. Findings: During a concurrent observation and interview with the Director of Staff Development (DSD) on 4/22/19, at 9:50 a.m., in Resident 119's room, Resident 119 was asleep in bed and was on two liters of oxygen given by nasal cannula. The nasal cannula was no labeled with a date to indicate start of use. The DSD stated, I don't see any date on [Resident 119]'s cannula. The DSD stated 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 to maintain personal hygiene for one of 80 sampled residents (Resident 16) when Resident 16's shirt was visibly soiled from breakfast and was not changed. This failure resulted in Resident 16 not receiving assistance in dressing which resulted in her wearing a visibly soiled shirt. Findings: During a concurrent observation and interview with Certified Nursing Assistant (CNA) 5, on 4/22/19, at 10:04 a.m., Resident 16's shirt soiled with three dark brown drink stains and food crumbs. There was no food tray on her bedside table. CNA 5 stated, [Resident 16's] shirt is dirty . it looks like what she had for breakfast . She likes hot chocolate. During an interview with CNA 6, on 4/25/19 at 1:58 p.m., she stated, She [Resident 16] does not do things for herself . she is total care [dependent on staff for care]. CNA 6 stated Resident 16 needed help and assistance in changing her clothes. CNA 6 stated, [Resident 16's] shirt should have been changed right away . [Resident 16] cannot change her own…

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 follow their Foods Brought by Family/Visitors policy and procedure for residents' personal food storage when four apples and one mango were found in a plastic bag labeled for Resident 38 with no use by date in one of two resident refrigerators. This failure had the potential for Resident 38 to receive spoiled fruits and experience adverse side effects from ingesting spoiled fruits. Findings: During a concurrent observation in medication room on Station 5 and Station 6 and interview with Minimum Data Set Coordinator (MDSC) 2, on 4/23/19, at 12:45 p.m., she obtained a plastic bag labeled with Resident 38's name. MDSC 2 stated there were four apples and one mango in the plastic bag labeled with Resident 38's name and room number. MDSC 2 stated there was no date labeled on the plastic bag to indicate when the food was put into the refrigerator nor a used by date. MDSC 2 stated there should be a date on the plastic bag to indicate when the food was received. MDSC 2 stated after three days the food would be thrown…

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.