Maywood Skilled Nursing & Wellness Centre

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interview and record review, the facility failed to ensure one of three sampled residents (Resident 94) who was visually impaired was orientated to his meal tray during lunch time. This failure had the potential to put the resident at risk for serious physical harm (choking, aspiration, malnutrition, and/or burns) and negatively impacts their psychological well being, dignity, and independence Findings: During a review of Resident 94's admission Record (AR) dated 3/25/2026, the AR indicated Resident 94 was a [AGE] year-old male, admitted on [DATE], with the diagnosis that included but not limit to: legal blindness (when a person's eyesight is very poor), chronic obstructive pulmonary disease (a long lasting lung disease that makes it hard to breathe), muscle weakness and hypertension (high blood pressure.) During a review of Resident 94's Minimum Data Set (MDS, a resident assessment tool) dated 2/4/2026, MDS indicated Resident 94 had severely impaired vision and needs supervision or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure their error rate was less than five percent (%) during the medication administration observation for two of five randomly selected residents (Residents 106 and 91).The outcome was four medication errors out of 27 opportunities for errors, which resulted in a medication administration error rate of 14.81%, based on the following:1. Resident 106 was given a multivitamin (dietary supplement containing a combination of essential vitamins) instead of multivitamin-minerals (multivitamin with minerals).2. Resident 106's cholecalciferol (also known as Vitamin D3, a vitamin essential for building and maintaining strong bones and immune function) was unnecessarily omitted and incorrectly documented.3. Resident 106's Colace (stool softener) refusal was inaccurately documented on the Medication Administration Record (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident).4.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 cleaning and sanitization of resident-use dining equipment, and properly label and store one of one resident's (Resident 54) food item brought in from the outside. These deficient practices had the potential to result in the use of improperly cleaned dishware and placed residents at risk for exposure to bacteria and contaminants, increasing the risk of foodborne illness, infection, and compromised health and safety.Findings: 1. During a concurrent observation and interview on 3/23/2026 at 8:40 a.m. with [NAME] 1, in the kitchen, observed the storage rack designated for clean water pitchers. Six water pitchers labeled as clean were observed with a sticky residue with previously dated labels (dated 3/21/2026 and 3/22/2026) on the lids. [NAME] 1 stated the residue of the old labels indicated the pitchers had not been thoroughly cleaned prior to being placed in the clean storage area. [NAME] 1 stated that all labels should be…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the Fall Risk Assessment was updated and accurately reflected the health status for two of 16 sampled residents (Resident 105 and Resident 82), and ensure the List of Residents with Special Needs and Resident Belongings List was updated to reflect upper and lower dentures were received for one of six sampled residents (Resident 28). These deficient practices had the potential to place Residents 105 and 82 at an increased risk for a fall, and resulted in the loss of Resident 28's dentures placing Resident 28 at risk for compromised nutritional intake due to impaired chewing ability, impaired communication, and increasing the potential for unmet needs and a decline in overall health and well-being. Findings: a. During a review of Resident 105's admission Record, the admission Record indicated Resident 105 was admitted to the facility on [DATE] and readmitted on [DATE]. Resident 105's diagnoses included chronic obstructive pulmonary…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interview and record review, the facility failed to ensure one of three sampled residents' (Resident 55) nasal cannula oxygen tubing and humidifier bottle were labeled with a date.This failure had the potential to increase the risk of infection of Resident 55.Findings:During a review of Resident 55's admission Record (AR) dated 3/25/2026, the AR indicated Resident 55 was a [AGE] year-old female, admitted on [DATE], with the diagnosis that included but not limit to: chronic obstructive pulmonary disease (a long lasting lung disease that makes it hard to breathe), respiratory failure (a condition when the lungs cannot get enough oxygen into the body), diabetes (a condition where the body has trouble controlling the amount of sugar in the blood), and heart failure (a condition the heart is not pumping blood as well as it should.)During a review of Resident 55's Minimum Date Set (MDS, a resident assessment tool) dated 2/27/2026, MDS indicated Resident 55 is on oxygen therapy.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.

Based on observation, interview, and record review, the facility failed to prepare food by methods that conserved temperatures when the lunch tray line food temperatures were as follows: 1. Quesadillas temperature measurement indicated 120 degrees Fahrenheit (°F, a degree of temperature). 2. Lasagna temperature measurement indicated 126°F . This deficient practice had the potential to place 112 of 115 facility residents who received food from the kitchen at risk of unplanned weight loss, a consequence of poor food intake from food in the kitchen. Cross reference to F812. Findings: During an observation on 12/17/2024 at 11:50 a.m., the dietary staff were observed starting the tray line service for lunch. During a concurrent observation and interview on 12/17/2024 at 12:05 p.m., in the kitchen, with [NAME] 1, a tray of quesadillas and lasagna was observed placed on the shelf away from the stove and steam table (a large metal table or container with openings that held smaller metal pans of food over hot water or steam). [NAME] 1 was observed taking the temperature of the food items…

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

Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen when food temperatures were out of range as follows: 1. Quesadillas measurement indicated 120 degrees Fahrenheit (°F, a degree of temperature). 2. Lasagna measurement indicated 126°F. This deficient practice had the potential to result in harmful bacteria growth and cross contamination (transfer of harmful bacteria from one place to another) that could lead to foodborne illness (transfer of bacteria from one object to another) in 112 of 115 medically compromised residents who received food from the kitchen. Cross reference to F804. Findings: During an observation on 12/17/2024 at 11:50 a.m., the dietary staff were observed starting the tray line service for lunch. During a concurrent observation and interview on 12/17/2024 at 12:05 p.m., in the kitchen, with [NAME] 1, a tray of quesadillas and lasagna was observed placed on the shelf away from the stove and steam table (a large metal table or container with openings that held…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 garbage storage area was maintained in a sanitary manner to prevent the harborage and feeding of pests when the outside trash dumpster lids were not closed. This deficient practice had the potential to result in creating harborage and feeding of pests which could lead to diseases and increase the morbidity (the amount of disease in a population) and mortality (the state of being subject to death) among facility residents. Findings: During a concurrent observation and interview on 12/17/2024 at 9:58 a.m., of the outdoor garbage storage area, with the Dietary Supervisor (DS), two trash dumpster lids were observed not closed completely. The DS stated the trash dumpster lids should be closed completely to keep flies away. The DS stated flies transported bacteria and residents might catch bacteria and get sick. During an interview on 12/17/2024 at 1:40 p.m. with the Infection Preventionist Nurse (IPN), the IPN stated the outside trash dumpster lids should be closed completely for infection control…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 abuse allegations to the State Agency (Department of Public Health), ombudsman (an advocate for residents of nursing homes, board and care centers, and assisted living facilities), and the police department for two of 24 sampled residents (Residents 88 and 259) when: 1. Responsible Party (RP) 1 informed Registered Nurse (RN) 1 that Certified Nursing Assistant (CNA) 2 said hurtful things to Resident 88. 2. Resident 259 informed Licensed Vocational Nurse (LVN) 3 that CNA 2 had made him feel uncomfortable during a bed bath. These deficient practices resulted in a delay of an onsite inspection by the State Agency and had the potential for potential ongoing abuse. Cross Reference F610. Findings: a. During a review of Resident 88's admission Record (Face Sheet), the Face Sheet indicated Resident 88 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 88's diagnoses included urinary tract infection (UTI, an infection 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to thoroughly investigate abuse allegations and implement interventions to prevent further potential abuse for two of 24 sampled residents (Residents 88 and 259) when: 1. Responsible Party (RP) 1 informed Registered Nurse (RN) 1 that Certified Nursing Assistant (CNA) 2 had said hurtful things to Resident 88. 2. Resident 259 informed Licensed Vocational Nurse (LVN) 3 that CNA 2 made him feel uncomfortable during a bed bath. These deficient practices had the potential to result in unidentified abuse in the facility and failure to protect residents from further potential abuse. Cross Reference F609. Findings: a. During a review of Resident 88's admission Record (Face Sheet), the Face Sheet indicated Resident 88 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 88's diagnoses included urinary tract infection (UTI, an infection in the bladder/urinary tract), type two diabetes mellitus (a disorder characterized by difficulty 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to respect the rights and provide dignity to two of six sampled residents (Resident 95 and Resident 75) by failing to: 1. Obtain a public guardian (a legally appointed person who manages the care and finances of individuals who are unable to do so for themselves) or conduct an interdisciplinary team (IDT, group of different disciplines working together towards a common goal for a resident) meeting to facilitate the care and medical treatments provided for Resident 75. 2. Follow its policy and procedure (P&P) titled Catheter - Care of, to provide a dignity bag (a bag used to cover and hold the catheter drainage/collection bag, so it is not visible) for Resident 95 who had both a left and right nephrostomy (a tube that lets urine drain from the kidney through an opening in the skin on the back) bag. This failure resulted in Resident 75 receiving medical treatment and antipsychotics (medications that affect the mind, emotions, and behavior) that had not been…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to obtain updated informed consents (a voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered) prior to the administration of psychotropic (medications that affect the mind, emotions, and behavior) medications for one out of six sampled residents (Resident 75). This failure had the potential to place Resident 75 at risk for avoidable harm from unwanted adverse effects (a harmful and undesired effect resulting from a medication or intervention) related to psychotropic medication use during the two months he was deemed to unable to make medical decisions. Cross Reference F550. Findings: During a review of Resident 75's admission Record, the admission Record indicated Resident 75 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including schizophrenia (a mental illness that can affect thoughts, mood, and behavior), depressive disorder…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 physician of one of 24 sampled residents' (Resident 259) abuse allegation when Resident 259 felt uncomfortable by Certified Nursing Assistant (CNA) 2 during a bed bath. This deficient practice resulted in Resident 259's physician being unaware of the abuse allegation and delayed any necessary care to be provided to Resident 259. Findings: During a review of Resident 259's admission Record (Face Sheet), the Face Sheet indicated Resident 259 was initially admitted to the facility on [DATE] and on 12/11/2024 with diagnoses the included urinary tract infection (UTI, an infection in the bladder/urinary tract), sepsis (a life-threatening blood infection), and ), type two diabetes mellitus (a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 259's Minimum Data Set ([MDS], a resident assessment tool), dated 9/26/2024, the MDS indicated Resident 259's cognition (process of thinking) was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop a person-centered care plan (document that helps nurses and other team care members organize aspects of resident care) with interventions (actions a nurse takes to implement a care plan, intend to improve the resident's comfort and health) for two of 24 sampled residents (Residents 88 and 259) by failing to: 1. Develop a care plan for Resident 88 after Responsible Party (RP) 1 informed Registered Nurse (RN) 1 that Certified Nursing Assistant (CNA) 2 said hurtful things to Resident 88. 2. Develop a care plan for Resident 259 after Resident 259 informed Licensed Vocational Nurse (LVN) 3 that CNA 2 had made him feel uncomfortable during a bed bath. These deficient practices had the potential to negatively affect Residents 88 and 259's physical, mental, and psychosocial well-being and had the potential to delay the delivery of necessary care and services. Findings: a. During a review of Resident 88's admission Record (Face Sheet), the Face Sheet…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 communication device at the bedside for one of six residents (Resident 17) who had aphasia (a disorder that makes it difficult to speak). This deficient practice prevented Resident 17 from communicating effectively and had the potential to delay appropriate care and treatment the resident needed. Findings: During a review of Resident 17's admission Record, dated 12/18/2024, the admission record indicated Resident 17 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 17's diagnoses included end stage renal disease (ESDR - irreversible kidney failure), chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), schizophrenia (a mental illness that is characterized by disturbances in thought), paraplegia (loss of movement and/or sensation, to some degree, of the legs), dysphasia (difficulty swallowing) and aphasia. During a review of Resident 17's History and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement interventions to prevent the formation and/ or worsening of pressure ulcers/ injuries (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence) for three of three residents (Resident 15, 36, and 94) when the follow occurred: 1. Resident 15's low air loss mattress (LALM, a mattress designed to distribute body weight over a broad surface area to help prevent skin breakdown) did not reflect resident's weight on 12/16/2024. 2. Resident 36's LALM did not reflect resident's weight on 12/16/2024. 3. Resident 94's LALM did not reflect resident's weight on 12/16/2024. These deficient practices placed Resident 15, 36, and 94 at risk for worsening condition of their exiting pressure injuries, and/ or the development of new pressure injuries. Findings: 1. During an observation on 12/16/2024 at 9:30 a.m., in Resident 15's room, Resident 15 was observed lying on a LALM. The LALM was set 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:1. Provide services to prevent the development of septic shock for one out of six sampled residents (Resident 259), who had long-term usage of an indwelling urinary catheter (a hollow tube inserted into the bladder to drain or collect urine) by failing to ensure the following:1a. Ensure Resident 259's the urinary drainage was monitored for the presence of sediment (a buildup of particles within the catheter tubing, often caused by factors like dehydration, urinary tract infection [UTI- an infection in the bladder/urinary tract], improper catheter care, or the presence of certain bacteria that promote crystal formation), abnormal color, and foul odor, per the facility's P&P and Resident 259's care plan, for a total of six months.1b. Ensure a urine culture (a lab test that checks for bacteria in a urine sample) was performed after Resident 259's urine analysis (a lab test that provides information about the appearance, chemical composition,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 check the gastrostomy tube (GT, a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems) placement and gastric residual volume (GRV - the amount of liquid remaining in the stomach after an enteral feeding [method of feeding that uses the gastrointestinal [GI - stomach and intestines tract to deliver nutrition and calories]) for one of six residents (Resident 12). This deficient practice had the potential to cause aspiration (feeding entering the lungs), stomach irritation, vomiting, and malnutrition for Resident 12 . Findings: During a review of Resident 12's admission Record, dated 12/18/2024, the admission record indicated Resident 12 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 12's diagnoses included type 2 diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement infection control practices for two of two resident (Resident 52 and 310) when the following occurred: 1. Resident 52's nebulizer mask (a plastic cup that fit over the mouth and nose to deliver liquid medication as a mist into the lungs) was unlabeled. 2. Resident 310's nebulizer mask was unlabeled. These deficient practices placed Resident 52 and Resident 310 at risk for infection which could increase the morbidity (the amount of disease in a population) and mortality (the state of being subject to death) among residents. Findings: 1. During an observation on 12/16/2024 at 10:37 a.m., in Resident 52's room, observed an opened, unlabeled nebulizer mask at the bedside. The mask did not indicate the resident's name or date. During an observation on 12/16/2024 at 3:58 p.m., in Resident 52's room, observed an opened, unlabeled nebulizer mask at the bedside. The mask did not indicate the resident's name or date. 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 facility failed to develop a comprehensive plan of care for one of three sampled residents (Resident 1) by failing to: 1. Develop a plan of care for a resident's known behavior of biting. 2. Develop a care plan for a resident at risk for elopement (when a resident leaves or wanders in a healthcare facility against medical advice). These failures resulted in Resident 1 wandering into Resident 2's room, hitting Resident 2 on the face, attempted to bite Resident 2 on the arm, and throwing a pitcher full of water on Resident 2. Findings: A. A review of Resident 1's admission Record, indicated Resident 1 was originally admitted to the facility on [DATE], with diagnoses that included dementia (impaired ability to remember, think, or make decisions), anxiety (a feeling of fear, dread, and uneasiness), and abnormalities of gait (ability to walk) and mobility. A review of Resident 1's Minimum Data Set ([MDS]- a standardized resident assessment and care planning tool), dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to closely monitor a resident with a known history of wandering, aggression, throwing items at staff, and biting for one out of three sampled residents (Resident 1). These failures resulted in Resident 1 wandering into Resident 2's room, hitting Resident 2's face, attempted to bite Resident 2's arm, and throw a pitcher full of water at Resident 2. Findings: A. A review of Resident 1's admission Record, indicated Resident 1 was originally admitted to the facility on [DATE], with diagnoses that included dementia (impaired ability to remember, think, or make decisions), anxiety (a feeling of fear, dread, and uneasiness), and abnormalities of gait (ability to walk) and mobility. A review of Resident 1's Minimum Data Set ([MDS]- a standardized resident assessment and care planning tool), dated 5/21/2024, indicated Resident 1's cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision making was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to readmit one of three sampled residents (Resident 1) from the general acute care hospital (GACH) after Resident 1 was cleared by the GACH to return to the facility on 1/25/2024. This resulted in the denial of Resident 1 ' s right to return to the facility. Finding: During a review of Resident 1 ' s admission Record (Face Sheet), the Face Sheet indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including diabetes (high blood sugar), muscle weakness (a lack of strength in the muscles), dysphagia (swallowing difficulties), chronic kidney disease ([CKD] a condition in which the kidneys are damaged and cannot filter blood), and heart failure (a condition when heart doesn ' t pump enough blood for body ' s needs). During a review of Resident 1 ' s History and Physical (H&P) dated 11/27/2023. The H& P indicated Resident 1 had the capacity to make medical decisions. During a review of Resident 1 ' s…

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

Based on interview and record review, the facility failed to distribute incoming mail on Saturdays for nine of nine residents (Residents 27, 32, 52, 55, 65, 74, 111, 116, and 119). This failure resulted in residents waiting an extra two days for their mail received by the facility. Findings: During a group interview on 12/12/2023 at 10:50 a.m., with Residents 27, 32, 52, 55, 65, 74, 111, 116, and 119, all nine residents stated the staff in charge of distributing the mail did not work on Saturdays and Sundays, therefore, any mail that arrived on Saturday would be distributed on the following Monday. During an interview on 12/13/2023 at 11:20 a.m., with Activities Aid (AA) 1, AA 1 stated when mail arrived at the facility on Saturdays, the staff member who received it at the entrance would lock it in the cupboard. AA 1 stated once the Business Office Manager (BOM) arrived on Monday, the mail would be given to them. AA 1 stated when a resident would ask about mail on the weekend, she would let the resident know that the BOM was not there and would receive their mail on 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 observation, interview, and record review, the facility failed to provide respect and dignity to three residents out of 32 sampled residents (Resident 53, 84, 107) when: 1. A certified Nurse Attendant (CNA) answered Resident 53's call light from the hallway, screaming out loud to the resident and asking Resident 53 what he wanted. 2. Resident 84 alleged she was treated in a bad manner when the CNAs entered the resident's room to answer the call light. 3. Resident 107 felt disrespected by nursing staff. These deficient practices resulted in Residents 53, 84, and 107 to not be treated in a manner that did not promote and enhance a sense of well-being, self-worth, and dignity. Findings: a. During a review of Resident 53's admission Record (face-sheet), the admission record indicated Resident 53 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included hemiplegia (a condition caused by a brain injury, that results in a varying degree of weakness, stiffness and lack 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 accommodate the needs for one of 32 sampled residents (Resident 46), who had a diagnosis of dysphagia (difficult swallowing) and was at risk for aspiration (when food, drink, or foreign objects are breathed into the lungs), and by not ensuring the call light was within reach for two of 32 sampled residents (Resident 102 and 28) by: 1. Not providing Resident 46 with a proper functioning bed. The head of the resident's bed did not go higher than 25 degrees. 2. Not following the physician's order to raise the head of the bed to 30 to 45 degrees to prevent the resident from being short of breath. 3. Not placing Resident 102's and Resident 28's call light within reach. These failures hindered Resident 46 from eating in bed, the possibility of causing Resident 46 to aspirate his food and prevent the resident from being short of breath and had the potential for Resident 102 and Resident 28 to not make their needs known in a timely manner.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 accurately document behavior monitoring on the Medication Administration Record (MAR) for one out of three residents (Resident 50). As a result, this deficient practice had the potential to affect the evaluation of psychiatric treatment and contribute to unnecessary medications. Findings: During a review of Resident 50's admission Record, the admission record indicated Resident 50 was admitted to the facility on [DATE] with diagnoses including psychosis (a severe mental condition in which thought and emotions are so affected that contact is lost with external reality), dementia (a group of thinking and social symptoms that interferes with daily functioning) with behavioral disturbance (a pattern of disruptive behaviors), and Parkinson's disease (a progressive disorder that affects the nervous system and the parts of the body controlled by the nerves). During a review of Resident 50's History and Physical (H&P), dated 8/15/2023, the 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 licensed nurses followed their own Policy and Procedures (P&P) titled, Blood Pressure, when measuring one of four residents' (Resident 55) blood pressure (BP, the force of blood pushing against the walls of blood vessels). This failure placed Resident 55 at risk for incorrect blood pressure monitoring which could lead to adverse reactions, hospitalization, and/or death. Findings: During a review of Resident 55's admission Record, the admission record indicated Resident 55 was originally admitted to the facility on [DATE] and was readmitted on [DATE]. Resident 55's diagnoses included hypertension (HTN - high blood pressure) and heart failure (an ongoing condition in which the heart does not pump blood as well as it should). During a review of Resident 55's Minimum Data Set (MDS, a standardized assessment and care screening tool) dated 9/26/2023, the MDS indicated Resident 55 had coronary artery disease (damage or disease to 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, interviews, and record review, the facility failed to assist a resident who is unable to carry out ADLs (activities of daily living) for one of 32 sampled residents (Resident 53) by: 1. Not providing oral care to Resident 53 in the last 3 consecutive days. 2. Not changing Resident 53's clothes in the last 3 consecutive days. 3. Not offering Resident 53 to get out of bed or to change his position for 3 consecutive days. 4. Not offering Resident 53 a shower on his scheduled shower day. 5. No cutting Resident 53 fingernails after the resident requested help. These deficient practices resulted in a negative impact on Resident 53's quality of life and self-esteem. Findings: a. During a review of Resident 53's admission Record (face-sheet), the admission Record indicated the resident was admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis of hemiplegia (a condition caused by a brain injury, that results in a varying degree of weakness, stiffness and lack of control in one…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one out of two sampled residents (Resident 82) received a hearing aid to effectively communicate with staff. This failure had the potential to affect Resident 82's dignity, communication with staff, and prevent the resident's needs from being met. Findings: During a concurrent observation and interview on 12/11/2023 at 10:05 a.m., in Resident 82's room, Resident 82 stated, I can't hear you! upon initial interview while pointing to his right ear. When Resident 82 was asked if he could hear better with his other ear, the resident responded, I can't hear you! My hearing is bad. You have to speak louder. No hearing aid was observed in either of Resident 82's ears. Resident 82 stated that he was not sure where the hearing aid was. There was no communication board observed in Resident 82's room. During a record review of Resident 82's admission Record, the admission record indicated Resident 82 was initially admitted to the facility on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow the physician's order for the removal of an intravenous catheter (IV; a soft, flexible tube placed inside a vein to administer medications or fluids) that was inserted more than 48 hours for one of one sampled resident (Resident 46). This deficient practice increased the risk for Resident 46 to develop complications and/or infection. Findings: During the review of Resident 46's admission Record (face sheet), the admission record indicated Resident 46 was admitted to the facility on [DATE] with diagnoses that included dysphasia (difficulty or discomfort in swallowing) and dementia (the loss of cognitive functioning, thinking, remembering, and reasoning, to such an extent that it interferes with a person's daily life and activities). During a review of Resident 46's History and Physical (H&P), the H&P indicated Resident 46 was able to make needs known but could not make medical decisions. The H&P indicated Resident 46 had a history…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to accurately document controlled medications (medications that can cause physical and mental dependence) for one out of three sampled residents (Resident 50). This failure had the potential for Resident 50 to not receive the prescribed medication which would affect his wellbeing and increase potential for drug diversion (the illegal distribution or abuse of prescription drugs or their use for purposes not intended by the prescriber). Findings: During a review of Resident 50's admission Record, the admission record indicated the resident was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included anxiety (a feeling of worry, nervousness, or unease). During a review of Resident 50's care plan, the care plan indicated Resident 50 had episodes of being anxious manifested by unprovoked (not caused by anything done or said) crying. The staff's interventions indicated to administer Ativan (brand name for lorazepam, 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 all medications were properly stored and disposed of by: 1. Not following proper storing instructions of Humulin R insulin (a short-acting medication that starts to work 30 minutes after injection to treat high blood sugar also known as diabetes) for one out of three sampled residents (Resident 75). 2. Not abiding by its policy when disposing non-controlled medications by 2 licensed nurses. These failures had the potential to cause resident medications to be diverted (the illegal distribution or abuse of prescription drugs or their use for purposes not intended by the prescriber), misused, and can cause harm, hospitalization or even death to Resident 75 due of loss of medication efficacy (the ability for a medication to produce a desired or intended result). Findings: During a record review of Resident 75's admission Record, the admission record indicated Resident 75's diagnoses included Type 2 Diabetes Mellitus (a chronic condition that affects the way the body processes blood sugar). During a 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 label one of 24 sampled residents' (Resident 369) peripheral intravenous line (IV; a soft, flexible tube placed inside a vein to administer medications or fluids) dressing with the date and time of insertion and the signature of the inserting nurse. This failure had the potential to result in Resident 369 developing an infection. Findings: During a review of Resident 369's admission Record (Face Sheet), the admission Record indicated Resident 369 was admitted to the facility on [DATE] with diagnoses included but not limited to cellulitis of the right and lower limb, chronic obstructive pulmonary disease (COPD, a group of diseases that cause airflow blockage and breathing-related problems), and type 2 diabetes mellitus. During a review of Resident 369's Minimum Data Set (MDS), dated [DATE], the MDS indicated Resident 369's cognition (ability to think and reason) was severely impaired. The MDS indicated Resident 369 usually made himself…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 an abuse allegation within 2 hours for one of three residents (Resident 2). This deficient practice had the potential to result in additional harm to Resident 2 as evidenced by a bruise to the resident's left upper cheek (below the eye). Findings: During a record review of Resident 2 ' s admission Record, dated 10/31/2022, the admission Record indicated Resident 2 was admitted to the facility on [DATE]. Resident 2 ' s diagnoses included dementia (a condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change, resulting from organic disease of the brain). During a record review of Resident 2 ' s Minimum Data Set ([MDS] a standardized assessment and care screening tool), dated 7/29/2023, the MDS indicated Resident 2 was severely cognitively impaired (ability to think and reason). The MDS indicated Resident 2…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 their Infection prevention and control policy and procedures (P&P) by failing to: a. Ensure staff doffed (removed) personal protective equipment ([PPE] specialized clothing or equipment such as a gown, respirator and face shield worn to minimize exposure to serious illness) prior to exiting a Coronavirus Disease ([Covid 19] a highly contagious respiratory infection caused by a virus that could easily spread from person to person) isolation room (designated room to separate sick resident with a contagious illness). b. Ensure nurses maintained short and well-trimmed fingernails. c. Report the facility's Covid-19 outbreak (at least one confirmed case of Covid-19 who had resided in the facility for at least 7 days) to the California Department of Public Health (CDPH) District Office. These deficient practices had the potential to result in the spread of covid-19 and infections to residents, staff and visitors. Findings: a. During a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure two of three sampled residents (Resident 1 and Resident 2) were allowed to return to the facility where they both had been living. Residents 1 and 2 were not provided the first available bed after Resident 1 and Resident 2 were cleared to return to the facility following their stay at a General Acute Care Hospital (GACH). This deficient practice resulted in Residents 1 and 2 being transferred to another facility and had the potential to negatively affect the resident ' s psychosocial well-being. Findings: During a review of Resident 1 ' s admission Record (Face Sheet), the Face Sheet indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included chronic obstructive pulmonary disease [(COPD], lung disease that causes blocked airflow from the lungs), Parkinson ' s disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 Outside Food Monitoring log which indicated hot food will be checked by Licensed Nurses for appropriateness of the temperature prior to serving to the resident, for one of three sampled residents (Resident 1). This failure had the potential to cause food borne illnesses, allergic reactions and choking to Resident 1. Findings: During a review of Resident 1's face sheet (admission record), dated 8/8/2023, the face sheet indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses including chronic obstructive pulmonary disease ([COPD], a group of lung diseases that block airflow and make it difficult to breathe), anxiety (mental disorder that causes excessive fear and or worry, feeling nervous and breathing rapidly), dementia (a condition characterized by progressive or persistent loss of intellectual functioning that interferes with daily functioning) and obesity (excessive fat accumulation…

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