Monrovia Gardens Healthcare Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of one sampled resident (Resident 31), was treated with dignity when on 12/16/2025, Licensed Vocational Nurse 3 (LVN 3) failed to knock on Resident 31's door prior to entering Resident 31's room.This deficient practice resulted in Resident 31 feeling bothered and had the potential to result in Resident 31 feeling invaded to Resident 31's privacy and feeling humiliated, embarrassed, and ashamed.Findings:During a review of Resident 31's admission Record (AR), the AR indicated, Resident 31 was admitted to the facility on [DATE] with multiple diagnoses including paraplegia (loss of movement and/or sensation, to some degree, of the legs), unspecified, major depressive disorder (a mental health condition characterized by persistent feelings of sadness, loss of interest, and other symptoms that significantly interfere with daily life), single episode, unspecified, and colostomy (a surgery to create an opening for the large intestine…

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 do a background check for one of three sampled certified nursing assistant (CNA 2).This failure had the potential to risk the residents' personal safety, mistreatment and misappropriation of personal funds.Findings:During a review of Certified Nursing Assistant (CNA) 2's employee file, it indicated CNA 2 was hired on 2/18/2025. CNA 2's employee file did indicate a background check was completed.During an interview on 12/19/2025 at 9:19 am with Director of Staff Development (DSD), DSD stated there was no background check done on CNA 2. DSD stated background checks should always be done to make sure the patients are safe and that they are qualified to work for the facility.During an interview on 12/19/2025 at 11:30 am with the DSD, DSD stated she was unable to find paperwork for CNA 2's background check that included criminal conviction investigation and sex offender checks. DSD stated CNA 2 was hired when there was no Director of Staff Development in the facility.During a review of the facility's policy and procedure (P&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.

Based on interview and record review the facility failed to develop a comprehensive care plan (CP), for one of one sampled residents (Resident 4), that addressed diabetes mellitus (a chronic [persistent or long-lasting] disease characterized by high blood sugar levels due to insufficient insulin [a hormone which regulates the amount of sugar in the blood] production) and anticoagulant (a medication that helps prevent blood clots) use.This failure had the potential to result in unmet individualized medical needs for Resident 4 and the potential to affect the resident's physical and psychosocial well-being.Findings:During a review of Resident 4's admission Record (AR), the AR indicated the facility originally admitted Resident 4 on 9/3/2025 with diagnoses including hemiplegia and hemiparesis (paralysis or weakness on one side of the body) following cerebral infarction (a medical condition where blood flow to the brain is disrupted, causing brain tissue damage) affecting the left non-dominant side (the side of the body that is used less) and type 2 diabetes mellitus with hyperglycemia…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to revise one of one sampled resident's (Resident 8's) fall risk care plan after Resident 8 had a fall on 11/26/2025. This failure placed Resident 8 at risk for future and recurrent falls.Findings: During a review of Resident 8's admission Record (AR), the AR indicated Resident 8 was admitted on [DATE] with diagnoses that included end-stage renal disease (ESRD-irreversible kidney failure), diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), and blindness in the left eye. During a review of Resident 8's History & Physical (H&P), dated 7/27/2025, the H&P indicated the resident did not have the capacity to understand and make decisions. During a review of Resident 8's Minimum Data Set (MDS - a resident assessment tool), dated 10/2/2025, the MDS indicated Resident 8 had moderately impaired cognition (ability to think) and was dependent (helper does all the effort and the resident does none of the effort…

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 one of one sampled resident (Resident 60) with their chosen individual activity when their television was not working.This failure had the potential to affect the resident's psychosocial well-being, mental health and self-satisfaction.Findings:During a review of Resident 60's admission Record, it indicated Resident 60 was admitted on [DATE] with diagnoses that included but not limited to: fracture (crack or break) of right femur, major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), generalized anxiety disorder (a mental health condition marked by persistent, excessive, and hard to control worry about everyday things), and abnormalities of gait and mobility.During a review of Resident 60's Minimum Data Set (MDS - a comprehensive assessment and screening tool) dated 11/16/2025, the MDS indicated Resident 60 has normal thinking and memory. Resident 60 requires a helper for less…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure pressure ulcer/injury (localized damage to the skin and/or underlying tissue usually over a bony prominence) measures for one of two sampled residents (Resident 9) were provided as ordered by the physician when Resident 9's low air loss mattress (LALM - a specialty bed that alternates pressure to help heal and prevent pressure injuries) was set to static (not moving, changing, or active) and Resident 9's heel protectors were not on. These failures had the potential to worsen and prevent the healing for Resident 9's pressure ulcer/injury and had the potential for Resident 9 to develop further skin injury.Findings: During a review of Resident 9's admission Record (AR), the admission Record indicated Resident 9 was admitted to the facility on [DATE] with diagnoses that included encounter for a gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a post-fall review (assessment done by the facility to identify underlying medical conditions, environmental factors, and other fall risk factors to create/revise interventions to prevent falls) for one of one sampled resident (Resident 8) was completed after Resident 8 fell on [DATE]. This failure had the potential to place Resident 8 at an increased risk of further falls.Findings: During a review of Resident 8's admission Record (AR), the AR indicated Resident 8 was admitted on [DATE] with diagnoses that included end-stage renal disease (ESRD-irreversible kidney failure), diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), and blindness in the left eye. During a review of Resident 8's History & Physical (H&P), dated 7/27/2025, the H&P indicated the resident did not have the capacity to understand and make decisions. During a review of Resident 8's Minimum Data Set (MDS - a resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of one sampled resident (Resident 7) who received enteral feeding (liquid form of nutrients given to people who cannot eat or drink by mouth safely) through a gastrostomy tube (G-tube, a tube inserted through the wall of the abdomen directly into the stomach, can be used to give nutrition and/or drugs) had a properly labeled enteral feeding bag. This failure had the potential to result in Resident 7 receiving an expired or inappropriate amount of enteral feeding/nutrition and experiencing nausea, vomiting, abdominal bloating, or other complications.Findings: During a review of Resident 7's admission Record (AR), the AR indicated Resident 7 was admitted to the facility on [DATE] with diagnoses that included diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) dysphagia (difficulty swallowing), and gastrostomy (a surgical opening fitted with a device to allow feedings to 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.

Based on observation, interview, and record review, the facility failed to ensure one of one sampled resident (Resident 23), received proper respiratory (relating to breathing) care when, on 12/16/2025 and 12/18/2025, Resident 23 did not receive 4 liters per minute (L/min, unit of measurement) of oxygen (02, a colorless, odorless, tasteless gas essential for living) therapy as indicated in the physician's order dated 11/30/2025.This deficient practice had the potential to result in desaturation (a drop in the oxygen level in the blood), respiratory distress, and a physical decline to Resident 23.Findings:During a review of Resident 23's admission Record (AR), the AR indicated Resident 23 was originally admitted to the facility 3/29/2024 and readmitted the resident on 11/4/2025 with multiple diagnoses including chronic (long standing) obstructive pulmonary disease (COPD - a lung disease causing difficulty in breathing), unspecified, acute (sudden) respiratory failure (when the lungs can't release enough oxygen into your blood) with hypoxia (low levels of 02 in the body tissues), and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow infection (the invasion and growth of germs in the body) prevention and control practices for 1 of 5 sampled residents (Residents 10) by failing to ensure Resident 10's restroom which was in full view of Resident 10 remained clean and orderly.This failure could potentially result in health hazards such as cross contamination (bacteria or microorganisms are unintentionally transferred from one surface/object to another and can result in a harmful effect) and compromise Resident 10's physical well-being.Findings:During a review of Resident 10's admission Record (AR), the AR indicated, Resident 10 was originally admitted to the facility on [DATE] and readmitted the resident on 11/4/2025 with multiple diagnoses including acute (sudden) respiratory failure (when the lungs can't release enough oxygen into your blood), extended spectrum beta lactamase (ESBL - enzymes produced by some bacteria that may make them resistant to some…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement the antibiotic stewardship program (promotes the appropriate use of antibiotics [ABX, a medicine that inhibits growth of infection]) for one of three sampled residents (Resident 31). Resident 31s' physician (Medical Doctor [MD] 1) was not informed Resident 31 did not meet Loebs (a tool used to help prescribers decide if to start the use of ABX aiming to reduce unnecessary use of ABX) or the McGreer's criteria (infection surveillance checklist used to determine the appropriate ABX) for ABX use. This deficient practice had the potential to result in unnecessary ABX treatment and lead to ABX resistance (germs, mostly bacteria, that have become strong enough to resist many common ABX, making infections harder to cure) to Resident 31.Findings:During a review of Resident 31's admission Record (AR), the AR indicated Resident 31 was admitted to the facility on [DATE] with diagnosis that included arthritis (joint pain and swelling) due to 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 ensure an allegation of abuse was reported to the California Department of Public Health (CDPH) within two hours of being notified, for 1 of 1 sampled resident (Resident 1), when Resident 1 had right eye discoloration on 10/10/25.Findings:During a review of Resident 1's admission Record (AR), the AR indicated Resident 1 was admitted to the facility 10/4/2023 with diagnoses including conversion disorder (thought to be caused by the mind converting psychological stress or trauma into physical symptoms, often after a stressful event) and major depressive disorder (a mental health condition that causes a persistently low or depressed mood and a loss of interest in activities that once brought joy).During a review of Resident 1's History and Physical (H&P), dated 9/4/25, the H&P indicated Resident 1 had the capacity to understand and make decisions.During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 10/6/25, the MDS…

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 the dignity of one of three sampled residents (Resident 1) when Certified Nursing Assistant (CNA) 1 left Resident 1 in soiled diapers following an episode of stool incontinence (lack of voluntary control over urination or defecation). This failure resulted in Resident 1 feeling frustrated and helpless and had the potential for Resident 1 to experience a decline in health and wellbeing.Findings: During a review of Resident 1's admission Record, the admission record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including conversion disorder (a mental health condition characterized by unexplained neurological symptoms that are not caused by a physical medical condition) with mixed symptoms presentation, aphonia (loss of ability to speak), and general anxiety disorder (mental health disorder characterized by feelings of worry, or fear that are strong enough to interfere with one's 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 two of four sampled residents (Resident 2 and Resident 4), received activities of daily living care according to the facility's policy and procedure (P&P) titled, Activities of Daily Living (ADL), Supporting, by failing to: 1. Ensure Resident 4 was not left soiled with urine and/or feces on 8/29/2025. 2. Ensure Resident 2's hair was regularly brushed and groomed. As a result of these failures, Residents 2's and Resident 4's needs were unmet. Resident 4 was left soiled in Resident 4's brief (disposable under garment used for those who have a loss of continence [ability to hold the bladder and bowels]) with urine and feces. Resident 2's hair was matted (hair that is closely tangled into a dense mass). Resident 2 experienced pain and itching in Resident 2's head.These failures have the potential for Resident 2 and Resident 4 to experience psychosocial (mental, emotional, social, and spiritual effects) harm. 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.

Based on observation, interview, and record review, the facility to ensure one of four sampled residents (Resident 4) received timely response to Resident 4's requests and needs in accordance with the facility's policy and procedure (P&P) titled, Answering the Call Light, by failing to ensure: On 8/29/2025, Resident 4's call light was fully connected to the wall and was within reach of Resident 4. This failure caused Resident 4 to not be able to get assistance from staff when Resident 4 needed to be changed. Resident 4 was left soiled in Resident 4's briefs (disposable under garment used for those who have a loss of continence [ability to hold the bladder and bowels]) with urine and/or feces. Findings: During a review of Resident 4's admission Record (AR), the AR indicated the facility admitted Resident 4 on 10/4/2023 with diagnoses that included conversion disorder (CD, a mental illness where a person experiences physical symptoms that cannot be explained by a medical or neurological causes) with mixed symptom presentation, aphonia (inability to produce voiced sounds), and…

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

Based on observation, interview, and record review, the facility failed to ensure one of four sampled residents (Resident 3) was given a therapeutic diet (a medically-prescribed meal plan tailored to manage or treat a specific health condition, often by modifying nutrient intake, texture, or food types) according to the facility's policy and procedure (P&P) titled, Therapeutic Diets, by failing to ensure Resident 3, who was prescribed a minced and moist diet (a dietary modification designed for individuals with moderate to severe difficulty swallowing [dysphagia] that adds moisture and small pieces of food aid in swallowing), did not receive toasted bread on Resident 3's lunch tray on 9/2/2025.This failure resulted in Resident 3 being served food that was not minced and moist. This failure had the potential for Resident 3 to be unable to swallow the bread and lead to choking. Findings: During a review of Resident 3's admission Record (AR), the AR indicated the facility admitted Resident 3 on 8/8/2025 with diagnoses that included dysphagia (difficulty swallowing). The AR indicated…

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

Based on observation, interview, and record review, the facility failed to ensure swamp coolers (evaporative cooler, a device that cools air by using water evaporation) used in resident's rooms and in the facility were maintained in a safe and operable manner for two of three sampled residents (Resident 1 and Resident 2).This deficient practice had the potential to result in electrical resident care equipment not in safe operating conditions and affecting residents' wellbeing.Findings:During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 4/2/2019 and readmitted Resident 1 on 2/15/2025 with diagnoses which included bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs) and hypertension (high blood pressure).During a review of resident 1's History and Physical (H&P), dated 2/16/2025, the H&P indicated Resident 1 had capacity to understand and make decisions.During a review of Resident 1's Minimum Data Set (MDS- a resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility to ensure one of five sampled residents (Resident 1) was provided timely responses to requests and needs according to the facility's policy and procedure (P&P) titled, Answering the Call Light, by failing to ensure:On [DATE], [DATE] and [DATE], Resident 1's call light was fully connected to the wall and was within reach of Resident 1.This failure caused Resident 5 to not be able to get assistance from staff when Resident 1 needed to be changed. Resident 1 was left soiled in Resident 1's briefs (disposable under garment used for those who have a loss of continence [ability to hold the bladder and bowels]) with urine, feces, and/or blood.During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident 1 on [DATE] with diagnoses that included conversion disorder (CD- a mental health condition where a person experiences neurological symptoms, like paralysis [the loss of muscle function in part of the body,…

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

Based on observation, interview, and record review, the facility failed to ensure one of five sampled residents (Resident 1) received activities of daily living care according to the facility's policy and procedure (P&P) titled, Activities of Daily Living (ADL), Supporting, by failing to: Ensure Resident 1 was not left soiled of urine, feces, and/or menstruation fluid on 7/12/2025, 8/1/2025, and 8/5/2025. As a result of these failures, Resident 1 was left soiled in Resident 1's brief (disposable under garment used for those who have a loss of continence [ability to hold the bladder and bowels]) with urine, feces, and/or blood. Cross Reference: F558Findings: During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident 1 on 10/4/2023 with diagnoses that included conversion disorder (CD- a mental health condition where a person experiences neurological symptoms, like paralysis [the loss of muscle function in part of the body, resulting from problems with how messages travel between the brain and muscles] or blindness [partial or full 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement its past plan of correction regarding providing means of communication for one of five sampled residents (Resident 1).This deficient practice had the potential for facility staff to inappropriately communicate with residents that could lead to a delay in care, needs being unmet, or neglect. During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident 1 on [DATE] with diagnoses that included conversion disorder (CD- a mental health condition where a person experiences neurological symptoms, like paralysis [the loss of muscle function in part of the body, resulting from problems with how messages travel between the brain and muscles] or blindness [partial or full loss of vision], that cannot be explained by a medical or neurological condition due to the brain converting psychological distress into physical symptoms) with mixed symptom presentation, aphonia, and generalized anxiety 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.

Based on observation, interview and record review, the facility staff failed to ensure one of three sampled residents (Resident 3) who was unable to speak would have a communication board to assist her to communicate with the facility staff as indicated in the care plan. This deficient practice had the potential for the resident's inability to express her needsFindings: During a review of Resident 3's nursing care plan dated 10/14/2024, the care plan indicated Resident 3 had communication problem. The care plan goal was for Resident 3 to maintain current level of communication by (how, with what assistance i.e. making sounds, using appropriate gestures, responding to yes/no questions, using communication board, writing messages). The care plan interventions were to ensure availability and functioning of adaptive communication equipment message board, telephone. Use alternative communication tools as needed, such as communication book/board, writing pad, gestures, signs, and pictures. During an observation on 7/9/2025 at 12:55 PM, in the presence of Certified Nurse Assistant 3 (CNA…

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 the facility's Use of Restraints policy and procedure (P&P) to ensure one of two sampled residents (Resident 1) freedom from physical restraint (any manual method, physical or mechanical device, equipment, or material that meets all of the following criteria: Is attached or adjacent to the resident's body; Cannot be removed easily by the resident; and Restricts the resident's freedom of movement or normal access to his/her body) not required to treat the resident's medical symptoms (an indication or characteristic of a physical or psychological condition) by using a gown to confine Resident 1 on Resident 1's wheelchair to prevent resident's falling on 6/26/205.This deficient practice violated Resident 1's right and had the potential to result in impairing Resident 1's physical and psychosocial wellbeing.Findings:During an interview on 7/9/2025 at 2:12 p.m. with Licensed Vocational Nurse (LVN)/Treatment Nurse (TN) 1, LVN/TN 1 stated on 6/26/2025…

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

Based on interview and record review, the facility failed to ensure a physician-ordered diagnostic test (MRI) was scheduled and completed for one of three residents (Resident 3 ) reviewed for follow-up medical care. This failure resulted in a delay in diagnostic testing for Resident 3 and had the potential to result in delayed diagnosis and treatment for the resident. Findings: During a review of Resident 3's admission Record (Face Sheet), the facility admitted Resident 3 on 10/4/2023 with diagnoses including Aphonia (Loss of Voice), Dysarthria and anarthria (refer to a condition that interferes with the muscles that control speech). During a review of Resident 3's History and Physical (H&P), dated 10/4/2024 indicated, Resident 3 had the mental capacity to make medical decisions. During a review of the After Visit Summary (AVS) from the resident's neurology appointment, dated 11/12/2024, the neurologist assessment and plan for Resident 3 was an MRI of the thoracic and lumbar spine (without contrast). During a review of Resident 3's Minimum Data Set (MDS-a federally mandated resident…

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

Based on observation, interview, and record review, the facility failed to ensure the call light was plugged in and functioning for one of two sampled residents (Resident 1). This deficient practice had the potential to result in unmet needs for Resident 1. Findings: During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident 1 on 10/4/2023, with diagnoses that included conversion disorder (a psychiatric disorder characterized by symptoms affecting sensory or motor function which are inconsistent with patterns of known neurologic diseases or other medical conditions) and aphonia (voice disorder, loss of voice). During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 4/8/2025, the MDS indicated Resident 1 had intact cognition (ability to understand and process information). The MDS indicated Resident 1 was dependent on staff with toileting hygiene and required maximal assistance (helper lifts or holds trunk or limbs and provides more than half the effort). During an observation on 5/12/25 at 1:55 PM, 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 interview and record review the facility failed to ensure the facility's Policy and Procedure (P&P) titled, Abuse, Neglect, Exploitation, and Misappropriation Prevention Program included screening of potential employees, previous employers, and/or current employers. The facility failed to maintain documentation indicating screening of 3 of 6 sampled employees (Certified Nursing Assistant [CNA] 1, CNA 2 and CNA 3). This deficient practice had the potential to result in hiring of employees that were involved in resident abuse incidents and the potential to jeopardize the safety of the residents. Findings: During a record review of Employee Files and a concurrent interview with the Director of Staff Development (DSD) on 5/9/2025 at 1:52 PM. Six employee files were reviewed. The employee files indicated 3 out of 6 employees did not have reference checks. a. (CNA) 1 had no reference check and the Pre-Employment Reference Checklist (PRC) was left blank. b. CNA 2 had no reference check and there was no PRC in CNA 2's employee file. c. CNA 3 had no reference check and there was no…

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 Certified Nursing Assistant (CNA) 7 and CNA 8 provided incontinent (loss of bladder control, varying from a slight loss of urine after sneezing, coughing, or laughing to complete inability to control urination) care to one of two sampled residents (Resident 1). This deficient practice had the potential to result in a rash or skin irritation to Resident 1. Findings: During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident 1 on 10/4/23, with diagnoses that included conversion disorder (a psychiatric disorder characterized by symptoms affecting sensory or motor function which are inconsistent with patterns of known neurologic diseases or other medical conditions) and aphonia (voice disorder, loss of voice). During a review of Resident 1's care plan (CP), initiated 10/14/23, the CP indicated Resident 1 was incontinent with both bowel and bladder secondary to impaired mobility and inability to alert staff. The CP's interventions indicated CNAs to check 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 observations, interview, and record review, the facility failed to follow its infection control measure for three of three sampled residents (Residents 6, 7, and 8) by failing to ensure: 1. Certified Nurse Assistant (CNA) 2 used proper hand hygiene after handling Resident 8 ' s dirty food tray. 2. CNA 2 used proper hand hygiene before handling Resident 6 and 7 ' s food tray to CNA 1. 3. CNA 1 used proper personal protective equipment (PPE, clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments) in a SARS-CoV-2 (COVID-19) exposed room 4. CNA 1 used proper hand hygiene before tray-set up and in-between Resident 6 and 7. These failures had the potential to contribute to poor infection control and had the potential to result on the continued widespread infection (a process when a microorganism, such as a bacteria, fungi, or a virus, enters a person ' s body and causes harm) of COVID-19 affecting residents, staff members, and visitors 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.

Based on observation, interview, and record review, the facility failed to develop a person-centered comprehensive care plan (a plan that outlines resident-specific interventions used to guide a resident ' s care for a given area of concern), with measurable objections for one of three sampled residents (Resident 6) to ensure Resident 6 was monitored and interventions were identified for her non-compliance to wear Resident 6's facemask during a SARS-Co2-V (COVID-19) outbreak in the facility. This failure had the potential to result in Resident 6 not receiving the necessary care and interventions for non-compliance that could lead to a decline in the resident ' s physical and psychosocial well-being. Findings: During a review of Resident 6 ' s admission Records, the facility admitted Resident 6 on 8/24/2024 with diagnoses that included Alzheimer ' s disease (a disease characterized by a progressive decline in mental abilities), generalized muscle weakness, and displaced fracture of second cervical vertebra (spinal fracture). During a review of Resident 6 ' s History and Physical…

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 sufficient nurse staffing for one of two night shifts (11 pm to 7 am shift) staffing reviewed to provide incontinent (unable to control excretion of urine or the contents of the bowels) care to one of 15 sampled residents (Resident 3) on 3/26/2025, in accordance with the facility's Policy and Procedure (P&P) titled, Staffing, Sufficient and Competent Nursing, and the facility's Facility Assessment (a guide used by the facility to evaluate what resources are necessary to care for the facility's residents). This failure had the potential to delay the provision of care and services for Resident 3 and other residents in the facility. Findings: During a review of Resident 3's admission Record (AR), the AR indicated the facility admitted Resident 3 on 3/18/2025 with diagnoses that included Type 2 diabetes mellitus (a condition where the body has trouble controlling blood sugar ) with foot ulcer (open sore), other abnormalities of gait (pattern of walking) and mobility (ability to move freely), and benign…

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 protect resident's rights to privacy and confidentiality of protected health information (PHI, any information in the medical record that can be used to identify an individual and that was created, used, or disclosed in the course of providing a health care service such as diagnosis or treatment) for one of 15 sampled residents (Resident 8) when the Social Services Director (SSD) emailed Resident 8 ' s Face Sheet (admission Record) and podiatry (medical care and treatment of the feet) care needs to an unauthorized recipient. This deficient practice had the potential to compromise Resident 8's privacy and confidentiality. Findings: During a review of Resident 8 ' s admission Record (AR), the AR indicated the facility admitted Resident 8 on 11/17/2022, with diagnoses including anemia (a condition in which the blood does not have enough healthy red blood cells to carry oxygen throughout the body), chronic pain, and gout (a form of arthritis [a disease…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of four sampled residents (Resident 1) who required assistance with activities of daily living (ADLs- tasks of everyday life such as bathing, dressing, and toileting) was provided care when staff did not change Resident 1 ' s incontinence (involuntary loss of urine or feces) brief (diaper) promptly. This failure resulted in Resident 1 to not receive assistance with ADL as needed and had the potential to result in skin breakdown and affect Resident 1 ' s well-being. Findings: During a review of Resident 1's admission Record (AR), the AR indicated Resident 1 was admitted to the facility on [DATE], with diagnoses which included conversion disorder (condition where a mental health issue causes physical symptoms), anarthria (loss of speech due to inability to control the muscles used for speaking), and aphonia (loss of voice). During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 1/9/25, the MDS…

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 manage pain for one of seven sampled residents (Resident 2) as indicated in Resident 2's care plan and the facility's policy and procedure (P&P) titled, Pain Assessment and Management, by failing to: 1. Ensure licensed nurses (LNs) assessed and documented Resident 2's pain level before and after administration of oxycodone (medication used to treat moderate to severe pain) for pain management. 2. Ensure LNs assessed and documented Resident 2's abdominal pain level and characteristic and administered pain medication as needed and ordered by the physician on 1/13/2025 and 1/14/2025. These deficient practices had the potential for Resident 2 to experience unrelieved/uncontrolled pain that could result in physical, mental, and emotional distress. Findings: During a review of Resident 2's admission Record (AR), the AR indicated the facility admitted Resident 2 on 12/13/2024, with diagnoses that included fracture (break in a bone) of the right femur (thigh bone), subsequent encounter for closed fracture (broken bone without…

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 honor 1 of 15 sampled residents' (Resident 1's) food preferences when the dietary services department did not provide Resident 1's requested meal for dinner on 3/26/25. This failure resulted in Resident 1's food choices not being honored and had the potential for unmet nutritional needs to Resident 1. Findings: During a review of Resident 1's admission Record (AR), the AR indicated Resident 1 was admitted to the facility on [DATE], with diagnoses which included conversion disorder (condition where a mental health issue causes physical symptoms), anarthria (loss of speech due to inability to control the muscles used for speaking), and aphonia (loss of voice). During a review of Resident 1's care plan (CP) titled, Care Plan Report, revised on 9/24/24, the CP indicated Resident (Resident 1) has special foods request for dietary; dietary will provide foods per resident preference however resident 1 will decline the food tray . The CP's interventions…

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 1 of 15 sampled residents (Resident 1) was provided with water according to Resident 1's need and preference when Resident 1's water pitcher was not filled during the morning of 3/27/25. This deficient practice had the potential for Resident 1 to not receive proper hydration. Findings: During a review of Resident 1's admission Record (AR), the AR indicated Resident 1 was admitted to the facility on [DATE], with diagnoses which included conversion disorder (condition where a mental health issue causes physical symptoms), anarthria (loss of speech due to inability to control the muscles used for speaking), and aphonia (loss of voice). During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 1/9/25, the MDS indicated Resident 1 had no speech but was able to express ideas and wants and had moderate impaired cognition (ability to think, learn, and remember). The MDS indicated Resident 1 was dependent 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.

Based on observation, interview and record review, the facility failed to provide restorative nursing services (RNS- specialized nursing interventions provided by a restorative nursing assistant [RNA] focused on helping to maintain or regain functional abilities to achieve the highest level of well-being, often after rehabilitation or to prevent decline) for one of three sampled residents (Resident 2), according to the facility's policy and procedure (P&P) titled, Restorative Nursing Services, by failing to: 1. Ensure Restorative Nurse Assistant (RNA) 5 completely followed Resident 2's physician orders (PO) for range of motion (ROM- exercises and/or movements designed to improve the flexibility and mobility of joints) when RNA 5 provided RNS to Resident 5 on 2/25/2025, 2/26/2025 and other unspecified days in 2/2025. 2. Ensure RNA 1 and RNA 2 did not initial Resident 2's Restorative Nursing Flow Sheet (RNFS) to indicate RNS was provided to Resident 2 on 1/16/2025, 1/24/2025, 1/27/2025, 1/28/2025, 1/29/2025, 1/30/2025, and 1/31/2025 when RNA 1 and RNA 2 were not clocked in to work 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.

Based on observation, interview, and record review, the facility failed to ensure accurate documentation of restorative nursing services (RNS- specialized nursing interventions provided by a restorative nursing assistant [RNA] focused on helping to maintain or regain functional abilities to achieve the highest level of well-being, often after rehabilitation or to prevent decline) provided to one of three sampled residents (Resident 2), according to the facility's policy and procedure (P&P) titled, Charting and Documentation, by failing to: 1. Ensure RNA 5 did not initial Resident 2's Restorative Nursing Flow Sheet (RNFS) when RNA 5 did not provide Resident 2 with range of motion (ROM- exercises and/or movements designed to improve the flexibility and mobility of joints) as ordered by the physician on 2/25/2025, 2/26/2025 and other unspecified days in 2/2025. 2. Ensure RNA 1 and RNA 2 did not initial Resident 2's RNFS to indicate RNS was provided to Resident 2 on 1/16/2025, 1/24/2025, 1/27/2025, 1/28/2025, 1/29/2025, 1/30/2025, and 1/31/2025 when RNA 1 and RNA 2 were not clocked 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 protect one of three sampled residents' (Resident 2's) property from loss, according to the facility's policy and procedure (P&P) titled, Personal Property, when facility staff did not inventory Resident 2's durable medical equipment (DME- reusable medical devices, equipment, or supplies prescribed by a healthcare provider to assist with the treatment, monitoring, or management of a medical condition or disability) of a right hand resting splint (RHRS) in Resident 2's Resident Clothing and Possession (RCP) form on 1/21/2025, and the RHRS was not lost in the facility. These failures had the potential for Resident 2 to develop further loss of function and contracture (a condition of shortening and hardening of muscles, tendons, or other tissues, often leading to deformity and rigidity of joints) of the right hand. Findings: During a review of Resident 2's admission Record (AR), the AR indicated the facility admitted Resident 2 on 10/4/2023 with diagnoses that included conversion disorder with mixed symptom…

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 care plan (CP - document created that outlines the type of care a patient needs) for one of seven sampled residents (Resident 4) for a rash discovered on admission. This failure had the potential to result in unmet individualized needs for Resident 4 and to lead to a break in continuity of care for an existing condition. Findings: During a review of Resident 4's admission Record, (AR), the AR indicated Resident 4 was admitted on [DATE] with multiple diagnoses including toxic encephalopathy (brain disorder or disease that affects how the brain functions) and chronic kidney disease (when the kidneys become damaged and cannot filter blood properly). During a review of Resident 4's Admission/readmission Data Tool (ARDT) dated 1/13/2025, the ARDT indicated Resident 4 had a generalized body rash on the arms, back, chest, and abdomen. The ARDT described the rash as spotted dark brownish red on the entire body with itching. 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 ensure 4 of 18 sampled residents (Residents 3, 8, 17, and 18) who required assistance with activities of daily living (ADLs- activities such as bathing, dressing and toileting, a person performs daily) were provided assistance with ADLs when: 1. Resident 3's, Resident 8's, and Resident 18's wet and/or dirty incontinence briefs (diapers) were not changed promptly. 2. Resident 17's hair was not washed and combed as scheduled. These failures resulted in Resident 3, Resident 8, Resident 17, and Resident 18 to not receive assistance with ADLs as needed and had the potential to affect Resident 3's, Resident 8's, Resident 17's, and Resident 18's well-being. Findings: 1. During a review of Resident 3's admission Record (AR), the AR indicated Resident 3 was admitted to the facility on [DATE], with diagnoses which included spina bifida (a birth defect that occurs when the spine and spinal cord don't form properly) and diabetes mellitus (DM-a 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 ensure sufficient Certified Nursing Assistants (CNAs) provided care and services to four of 18 sampled residents (Residents 3, 8, 17, and 18) in accordance with the facility's policy and procedure (P&P) titled, Staffing, Sufficient and Competent Nursing, and the facility's Facility Assessment Tool (a guide used by the facility to evaluate what resources are necessary to care for the facility's residents), on 12/16/2024, 12/22/2024, 12/23/2024, 12/26/2024, 12/28/2024, 1/4/2025, and 1/7/2025. This failure resulted in residents having to wait for up to an hour for call lights (device used by a resident to signal their need for assistance from staff) to be answered and for residents to be changed and cleaned promptly. This failure also had the potential to result in a decline in the residents' physical and psychosocial well-being due to poor quality of care. Findings: 1. During a review of Resident 3's admission Record (AR), the AR indicated Resident 3 was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a communication device was provided to 1 of 18 sampled residents (Resident 17) when Resident 17, who was not able to speak, went out to a medical appointment on 1/21/2025. This failure had the potential for Resident 17 to not be able to communicate during a medical appointment. Findings: During a review of Resident 17's admission Record (AR), the AR indicated Resident 17 was admitted to the facility on [DATE], with diagnoses which included conversion disorder (condition where a mental health issue causes physical symptoms), anarthria (loss of speech due to inability to control the muscles used for speaking), and aphonia (loss of voice). During a review of Resident 17's Minimum Data Set (MDS - a resident assessment tool), dated 1/9/2025, the MDS indicated Resident 17 had no speech but was able to express ideas and wants. The MDS indicated Resident 17 was dependent (helper does all the effort) on staff for toileting hygiene, lower…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement the care plan for 2 of 18 sampled residents (Residents 12 and 17) by failing to: 1. Ensure Certified Nursing Assistant (CNA) 4, Licensed Vocational Nurse (LVN) 6, and all nurses (any CNAs, LVNs, and Registered Nurses [RNs]) in the nursing station provided frequent visual checks and kept Resident 12 at the nursing station for monitoring. 2. Ensure LVN 9 administered medications to Resident 17 accompanied by another staff. These failures had the potential for Resident 12 and Resident 17 to not receive the care and services needed to address Resident 12's fall risk and Resident 17's psychosocial well-being. Cross Reference F689 Findings: 1. During a review of Resident 12's admission Record (AR), the AR indicated the facility admitted Resident 12 to the facility on 9/16/2022, with diagnoses that included congested heart failure (CHF - a heart condition that develops when the heart does not pump enough blood for the body's needs),…

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 coordinate with an outside care provider to provide necessary care and services for 1 of 18 sampled residents (Resident 17) when the facility did not obtain an after visit care record or after visit summary (AVS- document which details everything that happened during an appointment, the treatment plan, and any new medications, tests, and instructions from the care provider) from Resident 17's neurologist's (a medical doctor who diagnoses, treats and manages disorders of the nervous system [brain, spinal cord and nerves]) office after Resident 17's appointment on 11/12/2024. This failure had the potential for Resident 17 to not receive the necessary care and services. Findings: During a review of Resident 17's admission Record (AR), the AR indicated Resident 17 was admitted to the facility on [DATE], with diagnoses which included conversion disorder (condition where a mental health issue causes physical symptoms), anarthria (loss of speech due 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 interview and record review, the facility failed to ensure certified nursing assistants (CNAs) turned and cared for 2 of 18 sampled residents (Resident 7 and Resident 8) according to the CNAs training when: 1. CNAs (unable to identify) did not use a draw sheet (lift sheet- small sheet used to reposition patients in bed) to turn Resident 7 and Resident 8 in bed. 2. CNAs (unable to identify) roughly and hurriedly turned Resident 8 to Resident 8's side while changing Resident 8 in bed. These failures resulted in Resident 7 and Resident 8 to have pain during care provision and had the potential to affect Resident 7's and Resident 8's well-being. Findings: 1. During a review of the admission Record (AR) for Resident 7, the AR indicated Resident 7 was admitted to the facility on [DATE], with diagnoses which included dislocation of internal right hip prosthesis (an artificial device or implant used to replace or enhance a missing or damaged body part or function). During a review of Resident 7'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 interview and record review, the facility failed to ensure sufficient nursing staff was available to answer call lights timely and provide care and nursing related services to 2 of 3 sampled residents. This deficient practice resulted in the failure to answer Resident 1's and Resident 2's call lights timely, and Resident 3 to feel nursing service provided was too rushed. Findings: 1. During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident 1 on 4/9/24, with diagnoses that included Stage 4 pressure ulcer (full-thickness skin and tissue loss that exposes bone, tendon, or muscle) of the sacral region (the triangular-shaped bone at the base of the back) and malnutrition (lack of sufficient nutrients in the body). During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool) dated 10/11/24, the MDS indicated Resident 1 had intact cognition (ability to think, learn, and remember) and was dependent on staff for toileting hygiene,…

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

Based on interview and record review, the facility failed to protect one of three sampled residents' (Resident 1) right to be treated with dignity and respect when Registered Nurse (RN) 1 instructed Resident 1, in the presence of Resident 1's visitor, that Resident 1 needed to provide a urine sample (a collection of urine that can be used for a variety of tests). This failure resulted in Resident 1 feeling embarrassed and disrespected. Findings: During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident 1 on 7/12/2019, with diagnoses including congestive heart failure (condition in which the heart cannot pump enough blood to all parts of the body), acquired absence of right and left leg below knee (amputation, a surgical procedure to remove a limb), and anxiety disorder (mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities). During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 10/16/2024, 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.

Based on interview and record review, the facility failed to monitor blood sugar levels for one of three sampled residents (Resident 4) who was diabetic (diabetes, also known as diabetes mellitus, is a chronic condition that affects how the body uses glucose [sugar] for energy). This failure had the potential for Resident 4's blood sugar levels to be too high or too low which could lead to illness and/or death. Findings: During a review of Resident 4's admission Record (AR), the AR indicated the facility admitted Resident 4 on 12/21/2024. During a review of Resident 4's LTC Skilled admission History & Physical (H&P), dated 12/22/2024, the H&P indicated Resident 4 had diagnoses including type 1 diabetes (a type of diabetes also called juvenile diabetes), major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). The H&P indicated Resident 4 had a history of using an insulin pump (a small, portable device that delivers insulin [hormone that regulates blood sugar…

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 immediately remove Certified Nurse Assistant 1 (CNA 1) from performing resident care duties in accordance with the facility's policy and procedure for one of three sampled residents (Resident 1), who alleged CNA 1 was rough while changing Resident 1 while the facility's investigation was in progress. This deficient practice had the potential to result in the potential for Resident 1 to be subjected to further abuse. Findings: During a review of Resident 1's admission Record (AR), the AR indicated the facility originally admitted Resident 1 on 10/12/23 and readmitted Resident 1 on 7/8/24 with diagnoses that included acute osteomyelitis to the right hand (inflammation of bone or bone marrow, usually due to infection), other lack of coordination (a condition that causes uncoordinated or unsteady movements), bilateral primary osteoarthritis of the knee (a degenerative joint condition where the cartilage in both knees breaks down, causing pain, stiffness, and limited mobility), and a pressure ulcer of the sacral region, Stage 3…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to accommodate to the needs of two of two sampled residents (Resident 36 and Resident 26) when: a. The facility failed to ensure a toilet paper dispenser was installed in the restroom for Resident 36. b. The facility failed to ensure Resident 26 had footrests when transported via the wheelchair. This deficient practice led to pain in Resident 36's shoulder when reaching for toilet paper and resulted in Resident 26 feeling uncomfortable during transport. Findings: a. During a review of Resident 36's admission Record, (AR) dated 10/17/2024, the AR indicated Resident 36 was admitted on [DATE] with diagnoses encephalopathy (disorder of the brain often causing confusion, memory loss, and coma in severe cases) and lack of coordination (not able to move different parts of the body well or easily.) During a review of Resident 36's Minimum Data Set (MDS -a federally mandated resident assessment tool) dated 10/17/2024, indicated Resident 36 had intact…

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 two sampled residents (Resident 14 and 40) and/ or their representatives were informed of their right to formulate an advanced directive as indicated in the facility's policy and procedure (P&P) titled, Advanced Directives. This deficient practice infringed on the resident's and/or the representatives' right to be fully informed of the option to formulate an advance directive and had the potential to cause conflict with the residents' wishes regarding health care decision making. Findings: During a review of Resident 14's admission Record, (AR), the AR indicated Resident 14 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included end stage renal disease (condition in which a person's kidney's stop functioning on a permanent basis) and type 2 diabetes (long standing disease that affects the way one's body processes sugar). During a review of Resident 14's Minimum Data Set (MDS - a federally mandated…

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 three of three sampled residents (Residents 34, 48 and Resident 79) received appropriate care, treatment, and services to meet each resident's physical, mental, and psychosocial needs when the facility failed to: a. Initiate 72-hour monitoring when Resident 79 experienced a change of condition (COC, a sudden clinically important deviation from a resident's baseline in physical, cognitive, behavioral, or functional domains) and when Resident 79 was found with bruising and a scab on Resident 79's left eye and left eyebrow. b. Follow physician's order for Resident 34's doxazosin (medication used to treat high blood pressure and used to treat an enlarged prostate). These deficient practices could have resulted in Resident 34's blood pressure to drop and for Resident 79 not to receive treatment and services needed for Resident 79's left eye. Findings: a. During a review of Resident 79's admission Record(AR), the AR indicated the facility…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure facility provided care and services to prevent pressure ulcers for two of four sampled residents (Resident 47 and Resident 79.) As a result, Resident 47 developed a recurrent Associated Skin Damage (MASD, an erosion or inflammation of the skin caused by long-term exposure to moisture and irritants such as urine or stool) and Resident 79 developed a skin rash on the scrotum and buttocks. Cross Reference F690 Findings: a. During a review of Resident 47's admission Record, the admission Record indicated the facility admitted the resident on 5/25/2021, with diagnoses that included hemiplegia and hemiparesis following cerebral infarction (paralysis/weakness of one side of the body following a stroke,) type 2 diabetes mellitus (a disease in which the body's ability to produce or respond to the hormone insulin is impaired, resulting in elevated levels of glucose/sugar in the blood and urine.) During a review of Resident 47's Minimum Data…

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 incontinent (having no or no voluntary control over urination or defecation [discharge of feces from the body]) care was provided for two of two sampled residents (Resident 47 and Resident 79). This deficient practice resulted in Resident 47 and Resident 79 to develop Moisture Associated Skin Damage (MASD, an erosion or inflammation of the skin caused by long-term exposure to moisture and irritants such as urine or stool), this failure had the potential to result in physical declines to Residents 47 and 79. Cross Reference F686 Findings: a. During a review of Resident 47's admission Record (AR), the AR indicated the facility admitted the resident on 5/25/2021, with diagnoses that included hemiplegia and hemiparesis following cerebral infarction (paralysis/weakness of one side of the body following a stroke,) type 2 diabetes mellitus (a disease in which the body's ability to produce or respond to the hormone insulin is impaired,…

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 there was sufficient nursing aides to provide care and respond to each resident's basic needs for two of two sampled residents (Residents 29 and 51). This failure resulted in Residents 29, 51 felt frustrated and the residents not receiving the care or receiving delayed care and treatments. Findings: During an interview on 10/29/24 at 9:52 a.m. with the Restorative Nurse Assistant (RNA) 1, RNA 1 stated, staff felt short-staffed especially when some staff called in sick or came to work late and facility's administrative staff did not have time to call for coverage. RNA 1 stated, facility's administrative staff would take an RNA to work as a CNA (Certified Nursing Assistant) on the floor when the facility was short-staffed. RNA 1 stated, only certain licensed nurses helped. During an interview on 10/29/24 at 10:37 a.m. with the residents (present) conducted during the Resident Council Meeting (RCM), Resident 51 stated, staff on the night shift would ignore the call light or would turn the call light off and say I will…

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 food were stored, prepared, and distributed under sanitary conditions for all the residents in the facility by failing to: C. Ensure food past it's use-by date was not stored in one of two freezers observed in the kitchen. D. Check the quaternary sanitizing solution (ammonium solution used for sanitizing surfaces) with the quaternary test strip according to the manufacturer's instructions for one of two Kitchen Aides observed. These deficient practices placed the residents at risk for an outbreak of foodborne illnesses (refers to illness caused by the ingestion of contaminated food or beverages). Findings: During an observation on 10/28/2024 at 08:30 AM, in the kitchen, Freezer 1 had ice cream cups stored in a clear plastic bag that were past the used by date and to use by 10/25/2024. During an interview on 10/28/2024 at 08:32 AM, with the [NAME] (CK), the CK stated food past the use-by date should not be stored in the freezer, and should be discarded, as it could potentially cause a foodborne illness…

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 c. During a review of Resident 71's AR, the AR indicated the facility admitted Resident 71 on 3/26/2024, and re-admitted on [DATE], with diagnoses that included pneumonia (an infection of the lungs that may be caused by bacteria, viruses, or fungi), quadriplegia (a condition that causes partial or total paralysis [the loss of the ability to move some or all of the body] of all four limbs and the torso), neuralgia (a sharp, burning, or stabbing pain that occurs in a nerve pathway and is caused by nerve damage or irritation), and neuritis (inflammation of a nerve or nerves). During a review of Resident 71's MDS, dated [DATE], indicated Resident 71 was dependent (helper does all of the effort) with activities of daily living (ADL, term used in healthcare that refers to self-care activities) and dependent with mobility. During a review of Resident 71's H&P, dated 10/27/2024, indicated Resident 71 had the capacity to understand and make decisions. During an observation on 10/28/2024 at 09:51 AM, Resident 71's 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 ensure one of two sampled residents (Resident 34) was treated with dignity by failing to provide privacy while accessing Resident 34's G-tube (gastrostomy tube, a tube inserted through the belly to bring nutrition and/or medications directly to the stomach) during medication administration. This deficient practice resulted in exposure of Resident 34's portion of the abdomen (belly) and had the potential to result in Resident 34's value as human being not respected. Findings: During a review of Resident 34's admission Record (AR), the AR indicated, Resident 34 was originally admitted to the facility on [DATE] and readmitted on [DATE] with multiple diagnoses including sepsis (a serious condition in which the body responds improperly to an [infection, refers to an invasion of the body by harmful microorganisms]), unspecified organism, gastrostomy status (the presence of a G-tube) and essential (primary) hypertension (high blood pressure).…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility staff failed to promptly notify the physician that a resident had broken bottom dentures which caused difficulty with eating for one of one sampled resident (Resident 73). This deficient practice resulted in a delay in the provision of necessary care and services. Findings: During a review of Resident 73's admission Record (AR), the AR indicated Resident 73 was admitted to the facility on [DATE], and re-admitted on [DATE], with diagnosis that included acute respiratory failure (ARF, a condition that occurs when the body's respiratory system can't supply enough oxygen to the blood and organs, or remove enough carbon dioxide [a colorless, odorless gas that's naturally present in the air, essentially a waste product that we breathe out when we exhale] from the body), type 2 diabetes mellitus (T2DM, a disease that occurs when your blood glucose [blood sugar], is too high), and congestive heart failure (CHF, a serious condition that occurs when the heart can't pump…

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 bed hold (holding or reserving a resident's bed during periods of absence) notification was provided to one of one sampled resident (Resident 83) or the resident's representative when Resident 83 was transferred to the General Acute Care Hospital (GACH) on 9/7/2024. This deficient practice had the potential to result in Resident 83 or the resident's representative to not be aware of the option to return to the facility following hospitalization. Findings: During a review of Resident 83's admission Record (AR), the AR indicated the facility admitted the Resident 83 on 8/31/2024, with diagnoses that included encephalopathy (disease that affects the function or structure of the brain), acute lymphoblastic leukemia (cancer of the blood that affects the bone marrow and blood cells). During a review of Resident 83's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 9/3/2024, the MDS indicated Resident 83 was able to understand, be understood (able to express ideas and wants) by others and had…

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 an accurate assessment was conducted for one of one sampled resident (Resident 40). Resident 40 did not have physical restraints as indicated on Resident 40's Minimum Data Set (MDS - a federally mandated resident assessment tool). This deficient practice led to an inaccurate assessment of Resident 40's status during the observation period captured on the MDS and had the potential to result in incorrect care and services provided to Resident 40. Findings: During a review of Resident 40's admission Record, (AR), the AR, indicated Resident 40 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease (a brain disorder that slowly destroys memory and thinking to an extent that it interferes with a person's daily life and activities) and hypertension (condition where one's blood is pumping with more force than normal through the arteries). During a review of Resident 40's, Minimum Data Set (MDS - a federally…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement the intervention to monitor and document peripheral edema (swelling caused by fluid trapped in the body such as the hands, legs and feet) for one of one sampled resident (Resident 14) as indicated in Resident 14's care plan (CP - document developed that describes the supports, services and interventions for a person's care) titled, At risk for fluid/ electrolyte (type of mineral found in fluids and body) imbalance, at risk for peripheral edema. This deficient practice had the potential to lead to Resident 14 developing shortness of breath and fluid overload (when the body has too much fluid). Findings: During a review of Resident 14's admission Record, (AR), the AR indicated Resident 14 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included end stage renal disease (condition in which a person's kidney's stop functioning on a permanent basis) and dependence on renal dialysis (a procedure to remove waste…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of one sampled residents (Resident 27) was provided with appropriate treatment and services in accordance with the physician's orders and as outlined in the resident's plan of care (CP [provides direction on the type of nursing care an individual needs that include goals of treatment, specific nursing interventions [actions, treatments, procedures, or activities designed to meet an objective] and an evaluation plan]) to maintain, restore or improve the functional ability for Resident 27. This deficient practice had the potential for Resident 27's contracture (shortening of muscles, tendons, skin, and nearby soft tissues that causes the joints to shorten and become very stiff, preventing normal movement) of the left hand to get worsened and cause considerable pain, strength loss and muscle atrophy (partial or complete wasting away). Findings: During a review of Resident 27's admission Record (AR), the AR indicated, Resident 27…

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 honor the food preferences of one of one sampled resident (Resident 69) and ensure Boost (nutritional supplement shake) was given to Resident 69 on 10/29/2024. This deficient practice led to Resident 69's decreased appetite and potentially contributed to significant weight loss. Findings: During a review of Resident 69's admission Record, (AR), the AR indicated Resident 69 was admitted to the facility on [DATE] with diagnoses that included conversion disorder (a psychiatric disorder characterized by symptoms affecting sensory or motor function) and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). During a review of Resident 69's Care Plan (CP - document developed that describes the supports, services and interventions for a person's care) titled, The resident has a potential nutritional problem, dated 4/17/2024, and revised 7/12/2024, the CP indicated interventions to provide,…

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 promptly provide dental services for one out of one sampled resident (Resident 73). This deficient practice had the potential to result in the inability to effectively chew foods, weight loss, lack of energy and loss of muscle mass for Resident 73. Findings: During a review of Resident 73's admission Record (AR), the AR indicated Resident 73 was admitted to the facility on [DATE], and re-admitted on [DATE], with diagnosis that included acute respiratory failure (ARF, a condition that occurs when the body's respiratory system can't supply enough oxygen to the blood and organs, or remove enough carbon dioxide [a colorless, odorless gas that's naturally present in the air, essentially a waste product that we breathe out when we exhale] from the body), type 2 diabetes mellitus (T2DM, a disease that occurs when your blood glucose [blood sugar], is too high), and congestive heart failure (CHF, a serious condition that occurs when the heart can't…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of one sampled resident (Resident 68), was honored, and served her food preferences during tray-line observation of the kitchen. This deficient practice had the potential to negatively impact Resident 68's nutritional status. Findings: During a review of the admission record indicated Resident 68 was admitted to the facility on [DATE], and re-admitted on [DATE], with diagnosis including but not limited to, congestive heart failure (CHF, a serious condition that occurs when the heart can't pump enough blood to meet the body's needs), end stage renal disease (ESRD, is a medical condition in which a person's kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis), and type 2 diabetes mellitus (T2DM, a disease that occurs when your blood glucose [blood sugar], is too high. During a review of Resident 68's Minimum Data Set (MDS, a federally mandated resident assessment tool),…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of one sampled resident's (Resident 27) call light (a device used by a resident to signal the need for assistance) system was within reach in accordance with Resident 27's care plan (CP, provides direction on the type of nursing care an individual needs that include goals of treatment, specific nursing interventions [actions, treatments, procedures, or activities designed to meet an objective] and an evaluation plan]) and the facility's policy and procedure (P&P) titled, Call Lights. This failure had the potential to result in Resident 27 to not have Resident 27's needs met in a timely manner and/or Resident 27 to experience harm if Resident 27 was unable to alert staff during an emergency. Findings: During a review of Resident 27's admission Record (AR), the AR indicated Resident 27 was originally admitted to the facility on [DATE] and last readmitted on [DATE] with multiple diagnoses including hemiplegia (paralysis of 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 interview and record review, the facility failed to protect one of one resident (Resident 1) from physical abuse (willful infliction of injury, deliberate aggressive or violent behavior with the intention to cause harm), when Resident 2 hit Resident 1 in the face with a closed fist on 6/5/2024. This failure had the potential to result in serious mental and physical injury and a physical and psychosocial decline to Resident 1. FINDINGS: During a review of Resident 1's admission Record, (AR), the AR indicated Resident 1 was admitted to the facility on [DATE] with multiple diagnoses including diabetes mellitus type 2 (disease that occurs when a person's blood sugar is too high), and epileptic syndrome with complex partial seizures (a type of seizure [sudden, uncontrolled burst of electrical activity in the brain] that results in a sudden absence of awareness regarding surroundings). During a review of Resident 1's History and Physical, (H&P) dated 12/9/2023, the H&P indicated Resident 1 was able to make…

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

Based on interview and record review, the facility failed to notify the physician of a change in condition (COC- a change in the resident's health or functioning that requires further assessment and intervention) for one of four sampled residents (Resident 1) as indicated in the facility's policy and procedure (P&P) titled, Change in a Resident's Condition or Status, by failing to: Ensure Resident 1's assigned Licensed Vocational Nurses notified Resident 1's Primary Physician (PP/Medical Doctor [MD] 1) promptly (punctually [with little or no delay]) when Resident 1 was assessed not taking in foods or liquids from 5/11/2024 at 5 pm to 5/13/2024 at 7:30 am. This failure resulted in a delay in providing the necessary care and treatment for Resident 1. Findings: During a review of Resident 1's admission Record (AR), the AR indicated, the facility originally admitted Resident 1on 7/7/2021, and readmitted Resident 1 on 5/27/2024, with diagnoses that included dysphagia (difficulty or discomfort in swallowing), failure to thrive (FTT- a decline in older adults that manifests as a downward…

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 they had a certified Infection Preventionist (IP- a nurse who helped prevent and identify the spread of infectious disease in the healthcare environment) on staff from 4/24/2024 to 5/7/2024. This failure had the potential for lack of oversight of the facility's infection control practices during a COVID-19 (minor to severe respiratory illness caused by a virus and spread from person to person) outbreak at the facility. Findings: During an interview on 5/9/24 at 2:06 pm with the Infection Preventionist Nurse (IPN), the IPN stated IPN was on vacation for two weeks and the Director of Nursing (DON) covered the IP duties at the facility during that time. During an interview on 5/9/24 at 3 pm with the IPN, the IPN stated another staff member, Licensed Vocational Nurse (LVN) 1 was a certified IP and usually covered the IP duties if IPN was not available. The IPN stated the facility needed to always have a certified IP on staff because it could potentially lead to a lapse in oversight of infection control practices. During…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of two sampled residents (Resident 1) received restorative nursing services ([RNS], person-centered nursing care provided by a restorative nursing assistant [RNA] designed to improve or maintain the functional ability of residents to achieve their highest level of well-being possible) as ordered by the physician. This deficient practice had the potential for Resident 1 to experience decreased functional mobility and decline in Activities of Daily Living ([ADL] fundamental skills required to independently care for oneself, such as eating, bathing, and mobility). Findings: During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident 1 to the facility on [DATE], with diagnoses that included conversion disorder (a condition in which a person experienced physical and sensory problems, such as paralysis, numbness, blindness, deafness or seizures, with no underlying neurologic pathology) with mixed symptom…

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 and control the spread of COVID-19 (minor to severe respiratory illness caused by a virus and spread from person to person) in accordance with the facility's policy and procedure by failing to: 1. Ensure Certified Nursing Assistant (CNA) 1 wore proper personal protective equipment ([PPE] protective clothing, helmets, goggles, or other garments or equipment designed to protect the wearer's body from injury or infection) while in a suspected COVID-19 room. 2. Ensure CNA 1 removed used gloves after leaving a resident's room (Resident 1). These deficient practices had the potential to cause the spread of COVID-19 infection to other residents and staff members in the facility. Findings: During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident 1 to the facility on [DATE], with diagnoses that included conversion disorder (a condition in which a person experienced…

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 provision of pharmaceutical services for two of five sampled residents (Resident 282 and Resident 16) by failing to: a. Ensure Resident 282's discontinued medication was removed from one of two medication carts observed (Medication Cart 1). b. Ensure physician ordered medication Calcium 500 milligram (mg, unit of measurement- supplement used to prevent or treat low blood calcium) was not expired for Resident 16. This failure had the potential to lead to medication administration errors and/or drug diversion (transfer of a resident's prescribed medication to another individual). Findings: a. During a review of Resident 282's admission Record (AR), the AR indicated the facility initially admitted Resident 282 on 3/30/2023 with multiple diagnoses including dementia (group of mental conditions affecting memory, judgment, and behavior severe enough to affect daily activities), chronic kidney disease, and chronic respiratory failure. The AR indicated Resident 282 was discharged on 10/8/2023. During a…

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

Based on observation, interview, and record review, the facility failed to ensure safe and sanitary conditions were maintained in one of one kitchen (Kitchen 1). On 10/16/23, a bag of frozen chicken was unlabeled and undated. This failure had the potential to result in foodborne illnesses to all residents residing at the facility. Findings: During an initial tour of Kitchen 1 on 10/16/23 at 9:00 a.m., with the dietary cook (DC), a bag of frozen white meat was inside the meat freezer. The DC stated the bag looked like it was frozen chicken. The DC stated the bag of food did not have a label to indicate the content or an expiration date. The DC stated food should be labeled and dated to determine the type of food and how long the food was good for. During an interview with the Dietary Supervisor (DS) on 10/16/23 at 9:01 a.m., the DS stated food should be labeled and dated to know the kind of food and how long we (the facility) could use it. A review of the facility's Policy and Procedure (P&P) titled, Labeling and Dating of Food, revised 1/3/2018, indicated all food will be 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 maintain infection control practices when: a. The water temperature for two of two laundry room washing machines were 71 degrees Fahrenheit (F, unit of measurement). b. Personal Protective Equipment (PPE, protective clothing or equipment, designed to protect the wearer from injury or the spread of infection or illness) was not use while providing care for two of two sampled residents (Resident 29 and Resident 31). These failures had the potential to result in the spread of infections throughout the facility. Findings: a. During a concurrent observation and interview on 10/19/23 at 9:10 a.m. with the Housekeeping Manager (HM) in the soiled laundry room, two of two washers were operating. The HM stated that the temperature gauge for the washing machine water was located over a sink in the corner of the room. The temperature gauge indicated the water temperature for both washing machines was 71 degrees F. The HM turned on the water faucet…

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 protect one of one sampled resident's (Resident 235) right of self-determination (make choices and manage one's own life) and treat Resident 235 with respect and dignity. Certified Nursing Assistant (CNA) 1 cut Resident 235's hair without Resident 235's consent. This failure resulted in Resident 235 to feel angry and sad. Findings: During a review of Resident 235's History and Physical (H&P), dated 10/12/23, the H&P indicated, Resident 235 had multiple diagnosis including metabolic encephalopathy (brain disease that alters brain function or structure), hypertension (high blood pressure), and hypothyroidism (a condition in which the body doesn't produce enough thyroid hormone). The H&P indicated Resident 235 had the capacity to understand and make decisions. During a review of Resident 235's Change in Condition Evaluation (CIC), dated 10/17/23, the CIC indicated, Resident 235 was admitted to the facility on [DATE]. The CIC indicated…

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

Based on interview and record review, the facility failed to submit a new Level I Screening (identifies if an individual has a suspected mental illness or an intellectual/developmental disability) for one of four sampled residents (Resident 29) for Preadmission Screening and Resident Review (PASRR). This failure had the potential to result in Resident 29 to not receive special services for treatment of mental illnesses. Findings: During a review of Resident 29's admission Record (AR), the AR indicated Resident 29 was admitted to facility on 12/24/19 with multiple diagnoses including schizoaffective disorder (a mental health condition including schizophrenia and mood disorder symptoms), bipolar disorder (a mental illness that causes unusual shifts in a person's mood), and type 2 diabetes mellitus (a chronic [long standing] condition that affects the way the body processes blood sugar). During a review of Resident 29's MDS, dated 9/21/23, the MDS indicated Resident 29 was moderately impaired in cognitive skills (the ability to make daily decisions). The MDS indicated Resident 29…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to develop and implement an individualized care plan (CP) for one of one sampled resident (Resident 30) by failing to: A. Implement Resident 30's CP related to rehab services to reflect the current individualized plan of care for physical therapy (PT) services. B. Develop and/or implement Resident 30's CP related to the monitoring of Resident 30's hemoglobin (red protein in red blood cells that transport oxygen to the body's tissues) and occult bleeding (refers to the positive lab test from a stool sample to determine blood loss not visible to the resident or physician). C. Develop and/or implement Resident 30's CP related to Resident 30's eye specialist consultations to reflect all interventions, including the follow-up appointments and ophthalmologist's recommendations. These failures had the potential to negatively affected Resident 30's physical and psychosocial well-being due to the inaccurate or inconsistent provision of the necessary treatment 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 revise a Care Plan (CP), for one of one sampled resident (Resident 68), to reflect the Registered Dietitian's (RD) recommendation to increase daily Boost (high calorie nutritional support for weight loss or maintenance) consumption as indicated in the facility's Policy and Procedure (P&P), titled, Care Plans, Comprehensive Person-Centered, This failure had the potential to result in a physical decline and additional weight loss to Resident 68. Findings: During a review of Resident 68's admission Record (AR), the AR indicated Resident 68 was admitted to the facility on [DATE] with diagnoses that included unspecified dementia without behavioral disturbance (a group of thinking and social symptoms that interfere with daily function), bilateral primary osteoarthritis (breakdown of cartilage in the joint with no known cause), and unspecified psychosis (loss of touch with reality). During a record review of Resident 68's CP, initiated 2/8/23, the CP…

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 staff failed to administer eye drops in accordance with the professional standards of practice for one of six residents selected for medication pass observation (Resident 41). This failure had the potential to cause adverse effects to Resident 41 related to the systemic absorption (process of medication movement from the site of medication administration to the body) or lower-than-prescribed dose administered to Resident 41. Findings: During a review of Resident 41's admission Record (AR), the AR indicated the facility initially admitted Resident 41 on 8/14/2023 with multiple diagnoses including dementia (group of mental conditions affecting memory, judgment, and behavior severe enough to affect daily activities) and glaucoma (progressive eye disease due to a damaged optic nerve [transmits electrical impulses from the eyes to the brain] usually caused by increased eye pressure). During a review of Resident 41's Minimum Data Set (MDS, a standardized resident assessment and care-planning tool), dated 8/21/2023, the MDS…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to ensure follow-up appointments with the eye specialist/s were arranged to address the eye problems of one of one sampled resident (Resident 30). This failure had the potential to cause further vision disturbances or loss of vision of Resident 30 due to a delay in proper eye health services. Findings: During a review of Resident 30's admission Record (AR), the AR indicated the facility initially admitted Resident 30 on 9/27/2020 with multiple diagnoses including Type 2 diabetes mellitus (DM, longstanding condition wherein the body does not produce enough or resists insulin [hormone that regulates blood sugar]), glaucoma (group of eye diseases that cause vision loss and blindness by damaging the optic nerve [nerve in the back of your eye]), and end-stage renal disease (ESRD, loss of kidney function) with dependence on renal dialysis (procedure to filter blood of individuals with ESRD to remove toxins). During a review of Resident 30'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.

Based on observation, interview, and record review, the facility failed to assess for removal of an indwelling catheter (urinary catheter, a tube left in the bladder to drain urine) for one of two sampled residents (Resident 11) according to the facilities policy and procedure (P&P) when they failed to: 1. Assess and document Resident 11's ongoing need for a urinary catheter. 2. Use a standardized tool for documenting clinical indications for the need of Resident 11's urinary catheter. This failure had the potential to result in a urinary tract infection (UTI, an infection of any part of the urinary system, kidneys, bladder or urethra) for Resident 11. Findings: During a review of Resident 11's admission Record (AR), the AR indicated Resident 11 was admitted to facility on 6/11/23 with diagnoses including chronic obstructive pulmonary disease (COPD, a group of diseases that cause airflow blockage and breathing-related problems), type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar), and chronic kidney disease (a long standing condition 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 implement Registered Dietitian's recommendations to prevent weight loss for one of three sampled residents (Resident 68) by failing to provide Resident 68 Boost (nutritional drink) with high protein nourishment four times a day. This failure resulted in Resident 68 experiencing weight loss and had the potential to result in significant weight loss. Findings: During a review of Resident 68's admission Record indicated she was admitted to the facility on [DATE] with diagnoses that included unspecified dementia without behavioral disturbance (a group of thinking and social symptoms that interferes with daily function), bilateral primary osteoarthritis (breakdown of cartilage in the joint with no known cause), and unspecified psychosis (loss of touch with reality). During a record review of the Weight Loss Monthly Report, dated, April 2023 to October 2023, the Weight Loss Monthly Report indicated Resident 68's weight on 9/1/23 was 118 lbs. and her weight…

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 pharmacy recommendations, for one of one sampled resident (Resident 31), to evaluate for discontinuation for the use of megestrol acetate (megace, appetite stimulant) as indicated in the facility's Policy and Procedure (P&P), titled Medication Regimen Review (Monthly Report [MRR]). This failure had the potential to result in administration of unnecessary medication to Resident 31. Findings: During a review of Resident 31's admission Record (AR), the AR indicated Resident 31 was admitted to the facility on [DATE] with diagnosis that included dementia (a disorder that affect the brain), anxiety (a feeling of worry, nervousness, or unease) and encephalopathy (damage or disease that affects the brain). During a review of a History and Physical Examination (H&P), dated 9/12/23, the H&P indicated Resident 31 did not have the capacity to understand and make decisions. During a review of Resident 31's Minimum Data Set, MDS, dated 7/19/23, the MDS…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that the medication error rate was less than 5 percents (%) for two of two sampled residents (Residents 16 & 41) during the medication pass observation by failing to: 1. Ensure Licensed Vocational Nurse 4 (LVN 4) verified the medication expiration date prior to the administration of Calcium (dietary supplement and antacid) to Resident 16 in accordance with the facility's policy and procedures (P&P). 2. Ensure LVN 3 administered Resident 41's eye drops in accordance with the professional standards of practice. As a results, the medication error rates during the medication pass observation was at 5.56% due to two medication errors in a total of 36 opportunities observed. These failures had the potential to result in a decreased medication efficacy (ability to produce a desired or intended result) for Resident 16 and Resident 41. Findings: a. During a review of Resident 16's admission Record (AR), the AR indicated Resident 16 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 interviews and record review, the facility failed to ensure the timely collection of a lab sample as ordered by the physician for one of one sampled resident (Resident 30), who was being monitored for occult bleeding (OB, bleeding not visible to the resident or the physician but would test positive on the fecal occult blood test [lab test to check stool samples for hidden or occult blood]). This failure had the potential to cause a decline in Resident 30's physical and/or psychological well-being due to the delay in services provided. Findings: During a review of Resident 30's admission Record (AR), the AR indicated the facility readmitted Resident 30 on 5/27/2023 with multiple diagnoses including end-stage renal disease (ESRD, loss of kidney function) with dependence on renal dialysis (procedure to filter blood of individuals with ESRD to remove toxins), alcoholic cirrhosis of liver (chronic liver damage that may lead to gastrointestinal bleeding), anemia (lack of healthy red blood cells), and long-term use of anticoagulants (group of medications that decrease the blood'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 interviews and record review, the facility failed to ensure nursing staff notify the resident's physician (PHYS 1) regarding critical lab value/results (blood test result) for one of one sampled resident (Resident 24). This failure resulted in Resident 24 receiving a delay in care. Resident 24 was transferred to General Acute Care Hospital 1 (GACH 1) for a higher level of care one day after Licensed Vocational Nurse 2 (LVN 2) received the critical lab results from the Premier Lab Solutions (PLS). Findings: During a review of Resident 24's admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses that included sepsis (a life-threatening complication of an infection), peripheral vascular disease (narrowed blood vessels reduce blood flow to limbs), and chronic kidney disease (disease of the kidneys leading to renal failure). During a review of Resident 24's Minimum Data Set (MDS, a resident assessment and care screening tool) dated 8/21/23, indicated Resident 24 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 interviews and record review, the facility failed to provide physical therapy (PT) as ordered by the physician for one of two sampled residents (Resident 30). This failure had the potential to negatively affect Resident 30's physical well-being due to a decline in mobility and/or psychosocial well-being. Findings: During a review of Resident 30's admission Record (AR), the AR indicated the facility readmitted Resident 30 on 5/27/2023 with multiple diagnoses including periprosthetic fracture around prosthetic right knee joint (cracking or breaking around the stem of the metal component placed in the femur [thigh bone]), history of falling, abnormalities of gait and mobility, and end-stage renal disease (ESRD, loss of kidney function) with dependence on renal dialysis (procedure to filter blood of individuals with ESRD to remove toxins). During a review of Resident 30's History and Physical Examination (H&P), dated 5/28/2023, the H&P indicated Resident 30 had the capacity to understand and make decisions. The H&P indicated Resident 30 had an Open Reduction and Internal…

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's governing body (individuals such as the facility owner, chief executive officer, or other individuals who are legally responsible to establish and implement policies regarding the management and operations of the facility) failed to ensure, for one of one sampled resident (Resident 71), policies regarding wheelchair alarms ( fall prevention alarm, devises designed to alert a care giver or staff member that a patient attempts to exit the wheelchair) and bed alarms were created and implemented. This failure had the potential to cause emotional or physical harm to Resident 71. Findings: A review of an admission record indicated Resident 71 was re-admitted to the facility on [DATE] with diagnosis that included psychosis ((abnormal condition of the mind that involves a loss of contact with reality), abnormal gait (walking) and lack of coordination. A review of a history and physical, dated 7/15/23, indicated Resident 71 did not have the capacity 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 interview and record review, the facility failed to report 2 of 2 sampled resident's (Resident 1 ' s and Resident 2 ' s) allegation of abuse to the local Ombudsman (an official appointed to investigate individuals ' complaints against facility administration), to the Police, and to the State Survey Agency within two hours by failing to: 1. Report Resident 1 ' s alleged physical abuse on 9/15/2023 by CNA 1 and 2. Report Resident 2's alleged verbal abuse on 10/1/2023 by LVN 1. This failure had the potential to place Resident 1, Resident 2, and other residents of the facility at risks for physical and verbal abuse by Certified Nursing Assistant (CNA 1) and Licensed Vocational Nurse (LVN 1) after being identified as perpetrators of the alleged abuses on 9/15/2023 and 10/1/2023. Findings: a. During a review of Resident 1 ' s admission Record indicated the Resident was admitted to the facility on [DATE] with diagnoses included urinary tract infection (UTI, an infection of the bladder and urinary system),…

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.