Montebello Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the low air loss mattress (LALM, designed to distribute the resident's body weight over a broad surface area and help prevent skin breakdown) for one (1) of three (3) sampled residents (Resident 3) reviewed for pressure ulcer (injury to skin and underlying tissue resulting from prolonged pressure on the skin) was at the correct settings in accordance with the facility's policy and procedure (P&P) and the resident's care plan (CP). Resident 3 weighed 152 pounds (lbs, unit of measurement for weight) but the LALM was set to 180 lbs. This deficient practice has placed Resident 3 at risk for deterioration of the resident's current pressure ulcer.Findings: During a review of Resident 3's admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses that included dementia (a progressive state of decline in mental abilities) and unstageable (a full-thickness pressure injury where the base of the ulcer is…

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

Based on observation, interview, and record review, the facility failed to ensure a safe environment by not properly disposing of a used insulin syringe (specialized, single-use medical device used to inject insulin directly into the fatty tissue just beneath the skin) when one used insulin syringe was observed protruding halfway out of one of four sharps container (a specialized, puncture-resistant, and leak-proof bin used to safely dispose of medical instruments that can cut or puncture the skin).This deficient practice resulted in accident hazard and exposed staff and residents to the risk of needle stick injuries and potential bloodborne pathogen transmission (infectious microorganisms present in human blood that can cause disease in humans). Findings: During a concurrent observation and interview on 5/13/2026 at 11:57 AM with the Licensed Vocational Nurse (LVN) 5 in the hallway, LVN 5 stated that the Station 1 medication cart had been observed with an insulin syringe not fully placed in the sharp container, with half of it poking out of the sharps' container. LVN 5 also stated…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 the necessary respiratory care services for one (1) of 1 sampled resident (Resident 6) reviewed for oxygen, by failing to ensure Resident 6 who was on oxygen therapy had her head of bed (HOB) elevated in accordance with the physician's order. This deficient practice had the potential to result in respiratory distress and had the potential to negatively impact Resident 6's health and well-being. Findings: During a review of Resident 6's admission Record, the admission Record indicated Resident 6 was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses that included unspecified dementia (memory loss and impaired daily functioning), type 2 diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing), and personal history of pneumonia (history of lung infection). During a review of Resident 6's Minimum Data Set (MDS- a resident assessment tool), dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to ensure one (1) of two (2) sampled residents (Resident 5) reviewed for dialysis (a lifesaving treatment for residents with a kidney failure), who was receiving hemodialysis (process of removing waste products and excess fluid from the body) treatment was provided dialysis care according to the resident's care plan by failing to ensure post dialysis weight was obtained on 4/23/2026. This deficient practice had the potential for complications such as blood pressure drop for unnoticed excessive fluid removed during dialysis and/or fluid overload (occurs when the body retains too much water) if fluid is not properly removed.Findings: During a review of Resident 5's admission Record, the admission Record indicated the resident was originally admitted to the facility on [DATE] and was re-admitted on [DATE], with diagnosis of end stage renal disease (ESRD, irreversible kidney failure), congestive heart failure (CHF-a heart disorder which causes the heart to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide pharmaceutical services to meet the needs of one (1) of six (6) sampled residents (Resident 38) when Licensed Vocational Nurse 2 (LVN 2) failed to administer Resident 38's potassium tablet (medication to treat or prevent hypokalemia [low blood potassium levels]) with food or full glass of water on 5/14/2026 as indicated on the facility policy and physician's order. This deficient practice had the potential to result in damaging the esophagus (muscular tube that connects the throat to the stomach) and irritating the stomach lining which may cause nausea, cramps, vomiting, or diarrhea (condition of having loose, watery stool at least three or more times in a single day, or more frequently) to Resident 38.Findings: During a review of Resident 38's admission Record, the admission Record indicated the resident was originally admitted to the facility on [DATE], with diagnosis of muscle weakness, heart failure (a condition where your…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 maintain an accurate and complete record for two (2) of 23 sampled residents (Residents 32 and 72) as indicated in the facility's policy and procedure when: Resident 32's memantine (Namenda, medication used to treat moderate to severe dementia [progressive state of decline in mental abilities] was incorrectly ordered for supplement instead of for dementia.Resident 72's 24-hour intake and output (I&O- the measurement of all fluids that enter and leave the body) was not tallied as ordered by the physician. This deficient practice had the potential to result in miscommunication, improper delivery of care, and inaccurate information of the care provided to Residents 32 and 72.Findings: 1. During a review of Resident 32's admission Record, the admission Record indicated Resident 32 was admitted to the facility on [DATE] and re-admitted on [DATE]. Resident 32's diagnoses included dementia, depressive disorder (a serious mood disorder that causes persistent…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 Resident 102's gastrostomy tube (G-tube a flexible tube surgically inserted through the abdomen into the stomach for feeding, fluid, and medication administration) tip was not placed inside Resident 102's bedside drawer wrapped in tissue paper. This deficient practice had the potential to result in contamination of Resident 102's G-tube and increase the risk for infection.Findings: During a review of Resident 102's admission Record, the admission Record indicated the resident was initially admitted to the facility on [DATE] with diagnoses of gastrostomy (a surgical procedure for inserting a tube through the abdomen wall and into the stomach used for feeding or drainage), end stage renal disease (advanced stage kidney failure) and muscle weakness. During a review of Resident 102's History and Physical Examination (H&P), dated 5/13/2026, the H&P indicated that the resident does not have the capacity to make decisions. During a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to provide supervision, safety measures and monitoring when one (1) of two sampled residents (Resident 1) eloped (exited the facility without the knowledge of facility staff) from the facility on 3/16/2026 around 8 PM and was not returned until 3/16/2026 around 8:45 PM by the police. This failure had the potential to lead to endangerment, accident and injury while outside the facility's premises without supervision from staff.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 that included diverticulitis of the intestine (inflammation or infection of small, bulging pouches that form in the lining of the lower intestines), other abnormalities of gait (manner of walking) and mobility, and muscle weakness. During a review of Resident 1's Minimum Data Set (MDS- a Resident assessment tool), dated 3/5/2026, the MDS indicated Resident 1 was assessed having…

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

Based on interview and record review, the facility failed to ensure one of two sampled residents (Resident 6) received treatment and care in accordance with professional standards of practice (guidelines and expectations that define competent and ethical conduct within specific profession) by failing to complete medication reconciliation (the process of verifying and updating a patient's medication list during the transition from hospital to home or another care setting) of Resident 6's Discharge Medication List from General Acute Care Hospital (GACH 2) to administer the resident's Terazosin (a medication used in men to treat symptoms of benign prostatic hyperplasia [BPH-also known as an enlarged prostate], which include difficulty urinating, painful urination, and urinary frequency and urgency) once a day to start on 1/28/2025 at 9 PM. This failure could lead to worsening of the Resident 6's BPH and hospitalization.Findings: During a review of Resident 6's admission Record, the admission Record indicated the facility admitted Resident 6 on 1/28/2025, with diagnoses including but…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 prevent accidents to one of four (Resident 1) sampled residents who was identified at risk for falls and had a history of falls in accordance with the facility's policy and procedure (P&P) titled, Fall Management by failing to:1. Ensure adequate supervision of Resident 1 was provided to prevent accidents and injury on 7/16/2025.2. Create a comprehensive resident - centered care plan (a care plan developed and implemented to meet his or her preferences and goals, and addressed the resident's medical, physical, mental, and psychosocial needs) for Resident 1's long term care plan with focus on Resident 1's risk for fall/injury which includes intervention to supervise the resident every hour from 4/1/2025 to 7/16/2025. This deficient practice resulted in Resident 1 found on the floor near the Nurse's Station and the resident lying on her right side next to her on 7/16/2025 at 4:45 AM. Resident 1 was noted to have a small skin tear on the right temple (the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one (1) of 2 sampled residents (Resident 1) who was unable to carry out Activities of Daily Living (ADL - activities such as bathing, dressing and toileting a person performs daily) was provided care and services to maintain good grooming and personal hygiene. This deficient practice resulted in Resident 1's fingernails being untrimmed with sharp edges which potentially resulted in the pea size bruise on the inner corner of the resident's left eye and scratches measuring 1/4 to 1 inch to the resident's right forehead. Findings: During a review of Resident 1's admission Record, the admission Record indicated the resident was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses that included autistic disorder (a complex developmental condition involving persistent challenges with social communication, restricted interests and repetitive behavior) and dementia (a progressive state of decline 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 observation, interview, and record review, the facility failed to develop/implement comprehensive care plan for Resident 1's Foley catheter care which was order physician on [DATE]. This failure had the potential to negatively affect the provisions of care and services for Residents 1 and had the potential to place Resident 1 at risk for left buttock pressure ulcer wound become worse, cause urine blockage, and risk of urinary tract infection. Findings: During a review of Resident 1's admission Record indicated Resident 1 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included fracture of unspecified part of neck of left femur (a break in the bone at the base of the left thigh bone, specifically in the neck region, but the exact location of the fracture within that area isn't specified. It's a hip fracture), presence of left artificial hip joint (a person has undergone a hip replacement surgery on the left side of their body, where the natural hip joint has been…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure concise, and accurate document what happened on 4/17/2025 on Weekly Summary Documentation for one (1) of two (2) sampled residents (Resident 1). This deficient practice had the potential to cause delay of precaution and care for pressure ulcer and potentially cause worsening of wounds. Findings: During a review of Resident 1's admission Record indicated Resident 1 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included fracture of unspecified part of neck of left femur (a break in the bone at the base of the left thigh bone, specifically in the neck region, but the exact location of the fracture within that area isn't specified. It's a hip fracture), presence of left artificial hip joint (a person has undergone a hip replacement surgery on the left side of their body, where the natural hip joint has been replaced with a prosthetic implant) and unspecified fall (descend freely by the force of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide the appropriate care and services for one (1) of two (2) sampled residents (Resident 1) who was admitted with indwelling catheter (a tube that helps drain urine from the bladder [organ inside the body that stores urine] through a drainage tube [indwelling catheter tube] into a drainage collection bag) by failing to monitor Resident 1 for signs and symptoms of urinary tract infection (UTI, an infection in the bladder/urinary tract) in accordance with the care plan and facility policy on catheter care. This deficient practice had the potential to result in the delay of treatment and care in the event Resident 1 develops a catheter associated urinary tract infection (germs enter the urinary tract through the urinary catheter and cause infection) which could result in harm, hospitalization, and death. Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was originally admitted to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide care in a manner that maintained or enhanced dignity and respect in full recognition of the individuality for two (2) of three (3) sampled Residents (Residents 70 and 198) by failing to ensure the residents' urinary collection bag (a medical device used to collect urine that is drained from the bladder, typically via a urinary catheter [a thin, flexible tube {usually made of silicone or plastic} inserted into the bladder to drain urine]) was covered with a privacy bag. This deficient practice violated Resident 70 and 198's right for privacy and had the potential to affect the residents' self-esteem, self-worth, sense of independence, and psychosocial well-being (an individual's mental, emotional, and social health, encompassing aspects like happiness, life satisfaction, self-esteem, social functioning, and a sense of purpose, all of which are interconnected and influence overall functionality). Findings: 1. During a review of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide an environment free from accident (any unexpected or unintentional incident, which results or may result in injury or illness to a resident) hazards for two of two sampled residents (Residents 81 and 198) when: 1. A razor blade was found on the floor in Resident 81's room. This failure had the potential to cause injury to Resident 81. 2. Medication was observed left unattended at Resident 198's bedside table. This deficient practice had the potential for Resident 198 or other residents to get hold of the medication and if ingested (swallowed), had the potential for complications. Findings: 1. During a review of Resident 81's admission Record, the admission record indicated Resident 81 was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE], with diagnoses that included acute on chronic systolic heart failure, (sudden and life-threatening condition, a pre-existing, long-term condition, where the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure safe provision of pharmaceutical services as indicated in the facility policy by failing to: 1. Remove and discard one expired insulin (medication used to regulate blood sugar levels) Humulin R (short-acting insulin) vial, three expired suppositories (medications inserted into the rectum), one expired topical ointment (medication or cream applied directly to the skin), and two expired enemas (liquid to help relieve constipation [infrequent or difficult bowel movements]) from the medication cart. 2. Remove and discard eye drops according to label 3. Store insulin Lispro (short-acting insulin) and insulin Lantus (long-acting insulin) in the refrigerator. 4. Remove and discard three expired Vitamin D bottles from the medication storage room. These deficient practices increased the risk of the residents to be administered medications that have become ineffective or toxic which could result in adverse reactions (any unexpected or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide menus and nutritional adequacy for three (3) of 3 sampled residents (Residents 198, 84, and 35) in the food care area by failing to: 1. Provide Residents 198, Resident 84 and Resident 35 with a facility meal menu in advance 2. Follow the menu as written for Resident 198 on large and double portion (A large portion refers to a quantity that is bigger than average or standard, while double portion implies a quantity that is twice as large as the original or a standard amount) diets and were served incorrect amounts of food. These deficient practices had the potential to result in weight loss due to inadequate calories in residents who did not receive the correct amount or food items of their choices of their preference. Findings: 1. During a review of the admission Record, the admission Record indicated Resident 198 was initially admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included but not…

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

Based on observation, interview, and record review, the facility failed to follow proper food storage handling practices in accordance with its policy and procedure (P&P) by failing to label and discard expired food items stored in the facility's kitchen refrigerators, freezers, and dry storage by failing to ensure: 1. 17 pre-filled orange juice cups and two (2) orange juice pitchers inside refrigerator 3 were labeled with a use by or expiration date. 2. Conventional oven temperature was accurate since its oven knobs have no temperature settings. 3. 18 Large metal baking trays were free of grease build-up 4. Two (2) large food pans were free from dents. 5. One (1) blender used in the preparation of mechanical soft diet (foods that are easy to chew and swallow, requiring minimal chewing, and includes foods that are cooked, shredded, blended, chopped, or ground to a soft consistency stand was clean and free from scratches and cracks. 6. The dishwasher machine was free from dirt, corrosion (the gradual breakdown or eating away of a material, especially metals, due to a reaction 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 4. During a review of Resident 248's admission Record, the admission record indicated Resident 248 was admitted to the facility on [DATE] with diagnosis that included chronic obstructive pulmonary disease (COPD, a progressive lung disease characterized by persistent airflow limitation and difficulty breathing due to narrowed or damaged airways). During a review of the MDS, dated [DATE], indicated Resident 248 had modified independence (some difficulty in new situations) for cognitive skills for daily decision making. Resident 284 need partial or moderate assistance with the eating, oral hygiene and personal hygiene. Resident 284 was dependent with the toilet, upper and lower body dressing, change of position, and transfer. During a review of Resident 284's Physician Orders, dated 3/14/2025, the physician's orders indicated the following: 1. Oxygen at 2 liters per minute (2L/min) via nasal canular (NC, a device that delivers extra oxygen through a tube and into the nose continuously) to keep oxygen level above…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to accommodate the needs of one (1) of 21 sampled residents (Resident 9) in accordance with the facility policy by failing to ensure: 1. Resident 9's call light (device used by residents to call staff for assistance) was within reach. 2. Resident 9 was provided a touch pad call light (device used by residents to call staff for assistance with a gentle touch) appropriate for the resident's condition/needs. This deficient practice has the potential to delay in the provision of Resident 9's necessary care and services, which could negatively affect the overall condition of the resident. Findings: During a review of Resident 9's admission Record, the admission Record indicated the resident was admitted to the facility on [DATE] with the diagnoses of ptosis (drooping of the eyelid) of left eyelid, cataract (lens of eyes becomes opaque [not letting light through] resulting in blurred vision) of both eyes, and muscle weakness. 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 observation, interview and record review, the facility failed to ensure accurate assessment of resident's functional ability for personal hygiene on the Minimum Data Set (MDS, a resident assessment tool) for one (1) of 1 sampled resident (Resident 9) as indicated on the facility policy. This deficient practice had the potential for the facility to not develop and implement a resident centered care plan for Resident 9 to receive care and services to maximize or improve Resident 9's functional ability in personal hygiene. Findings: During a review of Resident 9's admission Record, the admission Record indicated the resident was admitted to the facility on [DATE] with the following diagnoses of osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage), contracture (a stiffening/shortening at any joint, that reduces the joint's range of motion), muscle weakness, and dementia (a progressive state of decline in mental abilities). During a review of Resident 9's MDS, 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 develop a care plan for two of 21 sampled residents (Residents 28 and 86) in accordance with the facility policy by failing to ensure a care plan reflected: 1. Resident 28's smoking and refusal to wear a smoker's apron (prevents burns in clothing and keep hot ashes from burning the skin) while smoking. This deficient practice had the potential to place Resident 28 at risk for injury, accidents, and harm. 2. Resident 86's fluid restriction as indicated on the physician's order, dated 3/1/2025. This failure had the potential to place Resident 86 at risk for fluid overload (too much fluid in the body which can raise the blood pressure and force the heart to work harder), edema (swelling caused by too much fluid trapped in the body's tissues), and dehydration (a dangerously loss of body fluid caused by illness, sweating, or inadequate intake). Findings: 1. During a review of Resident 28's admission Record, the admission Record indicated the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to set the low air loss mattress (LALM, pressure relieving mattress that operates using a blower based pump that is designed to circulate a constant flow of air through the mattress, commonly used to heal pressure ulcers [wound that occurs as a result of prolonged pressure on a specific area of the body]) at the correct setting for one (1) of six (6) sampled resident's (Resident 51) in accordance with the facility's policy and procedure (P&P) titled, Skin Integrity Management and physician's order. This deficient practice had the potential to result in Resident 51's pressure ulcers to worsen. Findings: During a review of Resident 51's admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses that included pressure ulcer Stage 4 (Full-thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage, or bone) of sacral region (lower back), and diabetes mellitus (DM a disorder characterized by…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to label the enteral feeding (form of nutrition that is directly delivered into the digestive system (a group of organs that work together to digest and absorb nutrients from the food eaten) as a liquid) for one (1) of two (2) sampled resident's (Resident 80) in compliance with the facility's Enteral Feeding policy and procedure. Findings: During a review of Resident 80's admission Record, the admission record indicated Resident 80 was admitted on [DATE] with diagnosis that included malnutrition (poor nutrition), muscle weakness, and diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 80's Minimum Data Set (MDS, resident assessment tool) dated 3/13/2025, the MDS indicated the resident had an intact cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. Resident 80 required substantial/maximal assistance…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to accurately monitor the fluid intake for one of one sampled resident (Resident 86) who was on fluid restrictions, as indicated on the physician's order. This deficient practice had the potential to place Resident 86 at risk for fluid overload (too much fluid in the body which can raise the blood pressure and force the heart to work harder), edema (swelling caused by too much fluid trapped in the body's tissues), and dehydration (a dangerously loss of body fluid caused by illness, sweating, or inadequate intake). Findings: During a review of Resident 86's admission Record, the admission record indicated Resident 86 was admitted to the facility on [DATE], with diagnoses that included stage 4 chronic kidney disease ( the kidneys are moderately or severely damaged and are not properly filtering waste from the blood), type 2 diabetes (a chronic condition where the body does not use insulin [hormone that helps sugar from food enter cells for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide pharmaceutical services including procedures to ensure administering of all drugs and biologicals to meet the needs of one (1) of five (5) sampled residents (Resident 149) in accordance with the facility's policy and procedure (P&P) by failing to completely administer two (2) medications mixed in water to Resident 149. This deficient practice resulted to Resident 149 not receiving the full amount of 2 medications as prescribed by the physician, which could affect the resident's well-being. Findings: During a review of Resident 149's admission Record, the admission record indicated the resident was originally admitted to the facility on [DATE] and was readmitted on [DATE] with the diagnoses of urinary tract infection (UTI, an infection in the bladder/urinary tract) and congestive heart failure (CHF, a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling). 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 conduct a monthly Medication/Drug Regimen Review (MRR, a monthly thorough evaluation by the consulting pharmacist of a resident's medication regimen, with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medication) in the month of 2/2025 for one (1) of five (5) sampled residents (Resident 47) in accordance with the facility's Medication Regimen Reviews policy and procedure (P&P). This deficient practice had the potential to cause Resident 47 to receive unnecessary medication and to potentially have adverse reactions (harmful effects) from medications. Findings: During a review of Resident 47's admission Record, the admission record indicated Resident 47 was admitted on [DATE] with diagnosis that included cerebral infarction (loss of blood flow to a part of the brain), unspecified psychosis (a severe mental condition in which thought and emotions are so affected that contact is lost with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure its medication error rate was less than five (5) percent (%). There were two (2) medications errors (the observed or identified preparation or administration of medications or biologicals which is not in accordance with the prescriber's order/ manufacturer's specifications / accepted professional standards and principles) out of 25 opportunities (observed administered medications) for error, which yielded a facility medication rate of eight (8) % for one of five (5) sampled residents (Resident 149) observed during medication administration. This deficient practice had the potential for harm to Resident 149 due to the resident not receiving the full amount of each medication as prescribed by the physician. Findings: During a review of Resident 149's admission Record, the admission record indicated the resident was originally admitted to the facility on [DATE] and was readmitted on [DATE] with the diagnoses of urinary tract infection…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 properly contain waste and cover two (2) of 2 large trash bins with lids as indicated on the facility policy. This deficient practice had the potential to attract vermin (animals that are believed to be harmful, carry diseases such as rodents, parasitic worms, or insects), pests (any living thing that has a negative effect on humans), and wildlife (undomesticated animal species) that could potentially infiltrate the facility, affect the resident care areas, and pose a disease threat to the residents and staff of the facility. Findings: During initial visit on 4/01/2025 at 8:01 AM, observed two large trash bins in the facility parking lot area with open lids and there was also visible trash on the floor surrounding the parking lot area. During an observation and interview with Dietary Staff 1 (DS1) on 4/01/2025 at 8:03 AM, DS1 confirmed both trash bins were open and not covered with a lid. DS1 stated the trash bins are picked up weekly but the trash lids should be closed to prevent any type of contamination or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide nutritional care services for one of two sampled residents (Resident 1) who is experiencing impaired nutrition by: a. Failing to ensure Resident 1's primary physician and Registered Dietician (RD) were notified regarding Resident 1's change of condition (COC, a sudden, clinically important deviation from a patient's baseline in physical, cognitive, behavioral, of functional domains) of weight loss of six (6) pounds (lbs., unit of measurement) noted on 7/3/2024. b. Failing to ensure Resident 1's primary physician and RD were notified regarding Resident 1's meal intake of 50% or less noted on 7/3/2024, 7/5/2024, 7/6/2024, 7/7/2024, 7/8/2024 and 7/9/2024 (total of 6 days). c. Failing to initiate a resident centered care plan and provide interventions to address Resident 1's weight loss noted on 7/3/2024 and poor meal intake that was noted on 7/3/2024 to 7/9/2024. These deficient practices placed Resident 1 at risk for further weight loss. 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 maintain a sanitary environment by failing to prevent the accumulation of dust and lint, and dispose dead cockroaches found in the facility's laundry room. This deficient practice had a high potential to encourage pest activity and infection. Findings: During a concurrent observation of the facility's laundry room and interview with maintenance assistant (MA) on 8/1/2024 at 10:58 AM, two cockroach traps were observed behind the two dryer machines. The surrounding area where the cockroach traps were located was observed dusty and with lint accumulation. MA stated that these cockroach traps appear old. MA stated the cockroach traps were covered with lint. MA stated that one cockroach trap had six (6) dead insects and the other cockroach trap had five (5) dead insects. MA stated, These insects are not cockroaches, these are American water bugs. MA stated he did not know when these cockroach traps were placed in the laundry room. MA verified that these cockroach traps were not dated. MA stated that he did not…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 an observation, interview, and record review, the facility staff failed to ensure one of four sampled residents (Resident 4) was free of accident hazards by leaving an unattended bottle of cleaning solution in the shower and failing to supervise Resident 4 who had a history of wandering (when a resident roams around and becomes lost or confused about his/her location). This deficient practice resulted in Resident 4 to gain access to the bottle of cleaning solution on 5/2/24 and was observed holding the bottle tilted towards the resident's mouth. This failure also had the potential for other residents to have access to the bottle of cleaning solution and risk for ingesting the cleaning solution, which could lead to harm and hospitalization. Findings: A review of Resident 4's admission Record indicated Resident 4 was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses that included hypercalcemia (a condition in which the calcium level in the blood becomes too high),…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 observe infection control measures as indicated on the facility policy when facility staff failed to: 1. Wear Personal Protective Equipment (PPE, protective clothing such as gown, gloves, goggles, mask) when entering an Enhanced Standard Precaution (reducing transmission of organisms through health provider with the use of gown and gloves when caring for the resident) room. This deficient practice has the potential to spread infection to other residents. 2. Ensure the Legionella (a type of bacteria spread through small droplets of water that can cause legionellosis [Legionnaires' Disease, a serious and potentially deadly lung infection]) Water Management Program policy and procedure was fully implemented. This deficient practice had the potential to result in the infection (a process when a microorganism, such as bacteria, fungi, or a virus, enters a person's body and causes harm) and a spread waterborne illness in the facility. Findings:…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 Findings: 1.b. A review of Resident 24's admission Record indicated Resident 24 was initially admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included history of fall, history of transient ischemic attack (a temporary disruption in the blood supply to part of the brain), generalized muscle weakness, and other lack of coordination. During a review of Resident 24's Minimum Data Set (MDS- a comprehensive assessment and screening tool) dated 2/20/2024, the MDS indicated Resident 24 was unable to follow commands, and required maximum assistance with the toilet, personal hygiene, change of position and transfer. A review of Resident 24's care plan titled At risk for falls, injury related due to fall related to impaired safety judgment, impaired gait and mobility weakness dated 10/25/2021, revised on 02/20/2024, indicated Resident 24 required assist with transfer and mobility as needed (PRN) and Resident 24 also required monitoring of fall. The care plan indicated interventions included…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the Minimum Data Set (MDS, an assessment and care screening tool) accurately reflected the status of two (2) of 2 sampled residents (Residents 77 and 31) by failing to: 1. Resident 77 did not have an accurate assessment for falls. 2. Resident 31 did not have an accurate assessment for restorative nursing program (a program that helps residents maintain any progress made during therapy treatments, enabling them to achieve their highest practicable level of functioning) received. This deficient practice had the potential for the facility to not develop and implement an individualized care plan, which could negatively affect Resident 77 and 31's overall well-being. Findings: 1. A review of Resident 77's admission Record, indicated resident was originally admitted on [DATE] with the following diagnoses of muscle weakness and dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 did not provide the necessary care and services for (two) 2 of (three) 3 residents (Residents 77 and 82) who were at risk for falls by failing to: 1. Modify the fall/injury care plan for Resident 77 after episodes of multiple falls. Facility also failed to provide supervision to Resident 77. 2. Ensure Resident 82's floor mat was placed on the floor as indicated on the care plan. This deficient practice had the potential for injury to Resident 82 in an event of a fall. This deficient practice has the potential for Resident 77 and 82 to have further falls which could result to harm, hospitalization, and/or death. Findings: 1. A review of Resident 77's admission Record indicated resident was originally admitted on [DATE] and was readmitted on [DATE] with the following diagnoses of muscle weakness and dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities. A review of Resident 77's History and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide pharmaceutical services to meet the needs of two (2) of seven (7) sampled residents (Resident 16 and 48) as indicated on the facility policy by: a. During a Medication Pass observation, Licensed Vocational Nurse 7 (LVN 7) failed to administer Resident 16's medications within 60 minutes of scheduled time of 9 AM on 4/24/2024. This deficient practice had the potential for Resident 16's health and well-being to be negatively impacted due to unintended consequences, such as decreased effectiveness of the medications and adverse reactions (an unwanted effect caused by the administration of a drug) from the medications. b. During a Medication Pass observation, LVN 7 failed to check Resident 48's blood glucose (blood sugar, main sugar found in the blood) and administer insulin (medicine to lower the level of glucose [type of sugar] in the body) before lunch meal on 4/24/2024. This deficient practice had the potential for Resident 48's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that its medication error rate was less than five (5) percent (%). 10 medication errors out of 33 total opportunities for error, to yield an overall medication error rate of 30.3 % for two (2) of seven (7) residents observed for medication administration (Residents 16 and 48). The medication errors were as follows: 1. During a Medication Pass observation, Licensed Vocational Nurse 7 (LVN 7) failed to administer Resident 16's medications within 60 minutes of scheduled time of 9 AM on 4/24/2024. 2. During a Medication Pass observation, LVN 7 failed to check Resident 48's blood glucose (blood sugar, main sugar found in the blood) and administer insulin (medicine to lower the level of glucose [type of sugar] in the body) before lunch meal on 4/24/2024. These deficient practices had the potential to result in Resident 16 and 48 to experience medication adverse effects (unwanted, uncomfortable, or dangerous effects that a medication may…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 label foods in the kitchen with item name, 'use by' date (the last date recommended for the use of the product) and failed to discard expired food as indicated in the facility's policy and procedure. These deficient practices had the potential to result in pathogen (germ) exposure to residents and placed residents at risk for developing foodborne illness (food poisoning) with symptoms including upset stomach, stomach cramps, nausea, vomiting, diarrhea, and fever and can lead to other serious medical complications and hospitalization. Findings: During a concurrent observation in the facility kitchen and interview on 4/22/2024 at 8:02 AM with the Accounts Manager (ACM), the kitchen was observed with food items not labeled to indicate the food item names and use by date. The ACM stated all food items were supposed to be labeled with food item name, use by date, and food must be discarded when expired. ACM stated. the following were found in the kitchen's refrigerators and/or freezer: a. Open bag of fries not…

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

Based on observation and interview, the facility failed to maintain a safe environment by failing to fix the broken tile around two uncovered sewer drains on the floor, in the hallway, causing the floor to be uneven. This deficient practice had the potential for residents, visitors, and staff to be placed at risk for fall and injury. Findings: During a concurrent observation at the hallway where the rehabilitation room was located and hallway infront of the kitchen and activity/dining room and interview with the Maintenance Director (MED) on 4/25/24 at 8:25 AM, the MED stated there was an uncovered sewer drain, in each area, about four (4) inches in circumference with a broken tile around the hole. MED stated all the sewer drains were supposed to be covered and the broken tile was supposed to be fixed to prevent residents, visitors, and staff from falling. MED stated housekeeping usually checks the floors and the maintenance department is responsible for repairs. MED stated he did not receive any reports for floor repairing. During an interview on 4/25/24 at 8:27 AM, in front of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility staff failed to ensure one (1) of 22 sampled residents (Resident 18) was cared for in a dignified way by failing to sit and be at eye level while feeding Resident 18 on 4/22/2024. This failure had the potential to negatively affect Resident 18's dignity and self-worth. Findings: A review of Resident 18's admission Record, indicated Resident 18 was admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses including, but not limited to Parkinson's disease (a condition that causes nerve damage in the brain that affects, speech and movement) and dementia (the loss of cognitive functioning - thinking, remembering, and reasoning - to such an extent that it interferes with a person's daily life and activities). A review of Resident 18's Physician's Orders, dated 3/30/2023, indicated the resident should receive a regular dysphagia (difficulty swallowing foods or liquids) puree (a smooth, creamy substance) texture, thick liquids- nectar…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 five (5) sampled Residents (Resident 107) was given information to formulate an advance directive (written statement of a resident's wishes regarding medical treatment, often including a living will, made to ensure those wishes are carried out should the resident be unable to communicate them to the doctor). This deficient practice had the potential to cause conflict in carrying out the Resident 107's wishes for medical treatment and health care decisions. Findings: A review of Resident 107 admission Record indicated resident was admitted on [DATE] with the following diagnoses of arthritis (joint inflammation) and sciatica (pain, weakness, numbness, or tingling in the leg). A review of Resident 107's History and Physical (H&P), dated 4/5/2024, indicated resident has the capacity to understand and make decisions. A review of Resident 107's Minimum Data Set (MDS, a standardized care screening and assessment tool), dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to notify the resident's physician/ medical doctor (MD) when there was a delay in discharging one (1) of 22 sampled residents (Resident 108) to home from 3/8/2024 to 3/9/2024. This deficient practice had the potential to result in an unsafe discharge. Findings: A review of Resident 108's admission Record indicated Resident 108 was admitted to the facility on [DATE], with diagnoses of generalized osteoarthritis (the cartilage within a joint begin to break down and the underlying bone begins to change causing reduced function and disability), syncope (fainting) and collapse, and history of falling. A review of the Resident 108's Physician Order Summary Report, dated 2/29/2024, indicated Resident 108's last covered day (LCD, the last day insurance company pays for in full or in part) on 3/7/2024 and discharge home on 3/8/2024. A review of Resident 108's Minimum Data Set (MDS, a comprehensive standardized assessment and screening tool), dated 3/1/2024,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to revise the care plan for (one) 1 of 22 residents (Resident 77) who had multiple falls. This deficient practice has the potential for Resident 77 to have further falls, which could result in harm, hospitalization, and death. Findings: A review of Resident 77's admission Record, indicated resident was originally admitted on [DATE] and was readmitted on [DATE] with the following diagnoses of muscle weakness and dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities. A review of Resident 77's History and Physical, dated 10/11/2023, indicated resident does not have the capacity to understand and make decisions. A review of Resident 77 Minimum Data Set (MDS; a standardized assessment and care screening tool), dated 2/8/2024, indicated resident is severely impaired (never/rarely made decisions) with cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 clean one of one sampled resident (Resident 36) face and gown after having breakfast. This deficient practice resulted in not meeting the resident ' s needs and had the potential for compromised dignity. Findings: A review of Resident 36 ' s admission record indicated resident was initially admitted on [DATE] and readmitted on [DATE] with diagnoses including dysphagia (difficulty swallowing) following cerebral infarction (occurs as a result of disrupted blood flow to the brain), hemiplegia (complete paralysis) and hemiparesis (partial weakness) following cerebral infarction affecting the left side of the body, dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities). A review of Resident 36 ' s Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 4/9/2024, indicated Resident 36 had difficulty communicating some words or finishing thoughts but is able if…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 to insert an indwelling foley catheter (a hollow tube inserted though the urethra [a tube through which urine leaves the body] into the urinary bladder to collect and drain urine) for wound management for one of 22 sampled Residents (Resident 39). This deficient practice had the potential for Resident 39's wound to get worse. Findings: A review of Resident 39's admission Record indicated resident was admitted on [DATE] with the following diagnoses of pressure ulcer (PU, localized skin and soft tissue injuries that form as a result of prolonged pressure and shear, usually exerted over bony prominences) and muscle weakness. A review of Resident 39's History and Physical (H&P), dated 1/13/2024, indicated resident has the capacity to understand and make decisions. A review of Resident 39's Minimum Data Set (MDS, a standardized care screening and assessment tool), dated 1/11/2024, indicated resident was moderately…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 necessary respiratory care services for one (1) of 1 sampled resident (Resident 17) for respiratory care area by failing to ensure Resident 17's nasal cannula (NC, device used to deliver supplemental oxygen placed directly on a resident's nostril) tubing was changed weekly per facility's policy. This deficient practice had the potential for Resident 17 to develop a respiratory infection. Findings: A review of Resident 17's admission Record indicated Resident 17 was initially admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses of pleural effusion (fluid buildup in the space between the lung and the chest wall), hypertensive heart (heart problems caused by high blood pressure) and chronic kidney disease (gradual loss of kidney damage where kidneys cannot filter the blood the way they should) with heart failure (a lifelong condition in which the heart muscle cannot pump enough blood to meet 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 observation, interview and record review the facility failed to ensure for one of seven sampled residents (Residents 48) was free from significant medication error (the observed or identified preparation or administration of medications or biologicals which is not in accordance with the prescriber's order; manufacturer's specifications [not recommendations] regarding the preparation and administration of the medication or biological; or accepted professional standards and principles) by failing to check blood sugar and administer insulin (medicine to lower the level of glucose [type of sugar] in the body) before meals in accordance with the physician's order. On 4/24/2024, Resident 48's blood sugar was checked after the insulin was administered and after the resident already consumed a portion of his lunch meal. This deficient practice had the potential for the resident to experience unwanted side effects of the medication including drowsiness, trouble breathing, hypoglycemia (low blood sugar), mental…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 clinical records in accordance with accepted professional standards and practices for three out of 22 sampled residents (Resident 18, 41 and 78) by failing to accurately document the administration of antibiotic (medicine to treat infection) and narcotics (drug or controlled substance that affects the mood or behavior and if consumed for nonmedical purposes or not prescribed by the doctor can cause serious harm) count in the narcotic drug record (narcotic count sheet is a document used to document and track the administration of controlled substance to ensure accurate dispensing and administration of medications, as well as to provide a record of how much of a controlled substance has been used and when). This deficient practice had the potential to negatively impact the delivery of services. Findings: 1. A review of Resident 18 admission Record indicated resident was originally admitted on [DATE] and was readmitted on [DATE] with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure one of 22 sampled resident's (Resident 80) call light was within reach. This failure had the potential to result in Resident 80's not receiving assistance when needed from facility staff. Findings: A review of Resident 80's admission Record indicated Resident 80 was admitted to the facility on [DATE] with the diagnoses including but not limited to hemiplegia (an inability to move one side of body) and hemiparesis (an inability to move the arm, leg and sometimes face on one side of the body) following a cerebral infarction (lack of blood flow resulting in severe damage to some of the brain tissue) affecting left non-dominant side. A review of Resident 80's Minimum Data Set (MDS, a comprehensive assessment and care screening tool), dated 4/06/2024, the MDS indicated Resident 80 had an impairment on one side of upper and lower extremity and required moderate to maximal assistance from staff for activities of daily living (ADLs,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 a safe and functional environment for residents, staff, and the public, due to an unapproved repair project, and non-compliance with the State building codes. This deficient practice of has the potential to have negative effects to the safety, welfare and health of the residents, staff, and the public. Findings: On 9/7/23, at 1:30 pm, a complaint investigation was initiated regarding the facility's unapproved repair project at the facility. The administrator-in-training (AIT) was informed of the visit and called for the maintenance supervisor. During a general observation with the maintenance supervisor, at 2:00 pm, two washing machines were observed in the laundry room. One washing machine was shiny and new, and the other washing machine was not shiny and old. During an interview, at 2:20 pm, the maintenance supervisor stated that the new washing machine was installed about 3 or 4 months ago because one of the two old washing machines stopped working. The maintenance supervisor added that 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.

Based on interview and record review, the facility failed to ensure the Change of Shift Narcotics (drug that produces analgesia [pain relief], narcosis [state of stupor or sleep], and addiction [physical dependence on the drug]) Reconciliation Records contained two Licensed Nurses' signatures for one (1) of four (4) medication carts (Station 1 Cart1) in accordance with the facility's policy and procedure. This deficient practice had the potential for the diversion (illegal distribution or abuse of prescription drugs or their use for unintended purposes) of controlled substance (medications with a likelihood for physical and mental dependence.) medications. Findings: On 8/29/23 at 10:54 AM, a review of the facility's Station 1 Cart 1's Change of Shift Narcotics Reconciliation Records titled, Narcotic Log, for the month of July 2023, indicated missing Licensed Nurse's signature on the following dates: 1. Outgoing (going off duty-leaving the shift) Licensed Nurse on 7/28/23 who worked the 7 AM to 3 PM (day) shift. 2. Outgoing Licensed Nurse on 7/30/23 who worked day shift. During a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide a nourishing, well-balanced diet and dietary needs and choices for 87 of 89 residents when: 1. Second (2nd) menu options were not prepared for lunch on 8/30/2023 due to food items were not purchased 2. There were no available fresh fruits and vegetables on 8/30/2023. 3. Menu and standardized recipes were not followed on 8/30/2023 due to unavailable food supplies such as sausages, powdered onions and powdered garlic. 4. Available food supplies were limited to one (1) day at hand. 5. 20 menu substitution from 8/4/2023 to 8/29/2023, 1 menu substitution for 8/30/2023, four (4) menu substitution for 8/31/2023 were made due to food items not purchased. 6. Insufficient silverwares for residents use in lunch service on 8/30/2023. These deficient practices placed the residents on regular (diet with no restrictions) and therapeutic diets (meal plan that controls certain foods and nutrients) at risk of potential decreased nutrient intake…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 there is a functioning call system (call light, device used by a patient to signal his or her need for assistance from professional staff. It typically consists of a remote control at the bedside)at the resident ' s bedside for three (3) of five (5) sampled residents (Resident 1, 3, and 4) in accordance with the facility's Policy and Procedure. This deficient practice had the potential for Resident 1, 3, and 4 not being able to call the facility's staff for help or assistance especially during an emergency. Findings: A review of Resident 1's admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses that included history of fall and displaced fracture (the bone snaps into two or more parts and moves so that the two ends are not lined up straight) of the left lower leg. A review of Resident 1's History and Physical (H&P), dated 8/3/23 and signed by Resident 1's attending physician (MD), 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.