Rio Hondo Subacute & Nursing Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure four of five sampled residents (Resident 13, 14, 21, and 124) Advance Directives Acknowledgement Form (ADA-written statement of resident's medical treatment wishes) was offered or obtained and readily accessible in the resident's medical records. These deficient practices had the potential for residents' medical treatment wishes not be honored during emergencies or when incapacitated (the clinical state in which a patient is unable to participate in a meaningful way in medical decisions) and unable to participate in medical decision-making. Findings: During a review of the facility's policy and procedure (P&P) titled Advance Directive, dated 3/23/2022 indicated a copy of the Advance Directive is maintained as part of the resident's medical record. The P&P indicated if the resident has an Advance Directive, admission staff or designee will place a copy or scan of the Advance Directive in the resident's medical record and will notify the Director…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 medications were securely stored, contained inside locked containers properly and disposed appropriately in according with facility's policies and procedures titled Medication Labeling and Storage The facility failed to: 1.Licensed Vocational Nurse (LVN) 6 left one of three sampled residents (Resident 96) medications such as Nitroglycerine (medication used to treat angina or chest pain, Midodrine (medication used to help increase blood pressure) and Depakote (medication used to prevent seizures) were left on top of the medication cart in the hallway unattended. 2. Ensure two of two Medication Carts (MC #1 and #2) were observed with had no pills and capsule on top of the waste container lid attached to the carts. These deficient practices had the potential for drug diversion (misuse of medication) and ingestion of medications that could cause residents clinically significant adverse reactions (undesired effect of medication).…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 observations, interviews, and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety in accordance with the facility's policies and procedures, titled storage of Food and Supplies, Procedures for Refrigerated Storage, and to follow Food Code Cooling Cooked Time/Temperature Control for Safety (TCS- any food that that require time and/or temperature controls to ensure food safety) Foods, to prevent the outbreak of foodborne illness (an infection or irritation of the gastrointestinal tract caused by consuming food or beverages contaminated with bacteria, viruses, parasites, or chemical toxins) for 110 of 149 residents receiving food from the kitchen by failing to ensure: Not to store food beyond the used by date 1/25/2026, such as one case of apples, one case of oranges, one case of onions, one case of iceberg lettuce, eleven cups of vanilla yogurt, one five (5)-lb (pound- unit of measurement for weight) tub of sour cream, four plates of chef salads beyond labeled use-by date in the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure accurate communication, verification and documentation of medical records, in accordance with accepted professional standards and practices, for three of six sampled residents (Residents 106, 176, and 168). 1.For Resident 176, LVN 2 failed to ensure accurate communication and verification of a physician order dated 2/5/2026 when LVN 2 documented an order that was not confirmed with the physician. Record review revealed that LVN 2 documented that Resident 176's attending physician (MD 1) had been informed and had provided an order to extend Resident 176's morning medication pass by two hours on 2/5/2026. Interviews revealed that LVN 2 did not notify MD 1 or the covering provider (MD 2 or NP 1) of the anticipated delay in morning medication administration and did not receive an order to extend the morning medication pass by two hours on 2/5/2026. 2. For Resident 168, LVN 2 failed to ensure accurate communication and verification of a physician…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 implement the facility's infection control policy and procedures by failing to: 1a. Ensure the facility's infection control policies binder is readily available to staff as resources to know the list of reportable communicable diseases to the department of health and the state agencies. 1b. Implement the local county's Department of Public Health's recommendation for Influenza (an infection of the nose, throat and lungs) outbreak: 1c.To offer Tamiflu (an antiviral medication used to treat and prevent influenza A and B) to two of two sampled Residents (Resident 128 and 137), who were in close contact with Resident 96 (who tested positive for influenza). 1d.Test for Influenza and monitor for signs and symptoms of Influenza for six of twenty sampled residents (Residents 137, 128, 8, 14, 99, 100, and 85) who were in close contact with Resident 96 and 99. 1e.Identify Resident 34 with influenza when she had cough and cold like symptoms on [DATE],…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 three sampled residents (Resident 170) who was transferred to the GACH on 12/12/2026 was provided written information regarding the facility and state bed-hold policies which address holding or reserving a resident's bed during periods of absence (hospitalization or therapeutic leave) as indicated in the facility's policy and procedure. As a result of this deficient practice Resident 170's rights to return to the facility after hospitalization could be violated.Findings: During a review of the facility's P&P titled, Bed-Holds and Returns, dated 10/2022, the P&P indicated All residents/representatives are provided written information regarding the facility and state bed-hold policies, which address holding or reserving a resident's bed during periods of absence (hospitalization or therapeutic leave). During a review of Resident 170's admission Record (AR), the AR indicated the facility admitted Resident 170 on 3/19/2025 with diagnoses that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop and implement a baseline care plan within 48 hours of resident's admission to the facility for one of three (3) sampled residents (Resident 176) reviewed for baseline care plans for Type 2 Diabetes Mellitus (DM-an adult-onset disease in which the blood glucose or sugar levels are too high). This deficient practice had the potential for Resident 176 not to receive the appropriate resident specific interventions, treatments and medications necessary for Resident 176's care. Findings: During a review of the facility's policy and procedure (P&P) titled Care Plan-Baseline, dated of 8/25/2021, the P&P indicated The baseline care plan is developed within 48 hours of a resident's admission. The baseline care plan includes the minimum healthcare information necessary to properly care for a resident including, but not limited to: initial goals based on admission orders, Physician orders . During a review of Resident 176's admission Record (AC), the AC…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 and implement a resident specific comprehensive, person-centered care plan (a treatment plan that focused on the needs and preferences of a resident or individual) for three of four sampled residents (Resident 1, Resident 14, and Resident 44) by failing to: a.Develop and implement a care plan for Resident 1 who was receiving Ativan (a prescription medication used for short-term treatment of severe anxiety, panic disorders, and insomnia), trazodone hydrochloride (HCL, a prescription medication primarily used to treat depression), and divalproex sodium (Depakote, a prescription medication used to control seizures [a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness] and treat manic episodes [a period of intense, elevated mood or extreme irritability accompanied by a surge in energy]) and did not address the resident's 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 provide the necessary care and services to assist three sampled residents (Resident 28, 24 and 73) who needed assistance with grooming such as haircut. These deficient practices had resulted in residents not maintaining good personal hygiene and clean appearance which could negatively affected their self-image and dignity. Findings: 1. During a review of Resident 28's admission Record (AR), the AR indicated the facility admitted Resident 28 on 12/4/2024 with diagnoses that include chronic obstructive pulmonary disease (a term for lung and airway diseases that restrict breathing) and hypertension (high blood pressure). During a review of Resident 28's Minimum Data Set (MDS, a resident assessment and care planning screening tool), dated 12/5/2025, indicated Resident 28's had no cognitive impairment (ability to understand and make decisions) and required supervision with personal hygiene. 2.During a review of Resident 24's AR, the AR…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 provide care and services to ensure the licensed staff reviewed Resident 176's General Acute Hospital (GACH) records for all appropriate discharge orders in accordance with professional standards of practice and the facility's policy and procedure (P&P) titled Reconciliation of Medication on Admission. This failure occurred for one of one sampled resident (Resident 176), who had a diagnosis of Type 2 diabetes mellitus (a disease in which blood sugar levels are too high). This deficient practice resulted in Licensed Vocational Nurse (LVN) 3 failing to transcribe three diabetic medications- Glipizide (used to lower blood sugar levels), Alogliptin (used to lower blood sugar levels), and Insulin Lispro (a fast-acting form of insulin, a hormone produced by the pancreas to lower blood sugar)-from the General Acute Care Hospital (GACH) 1 Patient Discharge Instructions upon Resident 176's admission to the facility on 1/30/2026. As a result, multiple doses of…

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

Based on observation, interview and record review, the facility failed to provide the necessary care and services to prevent pressure injury ( a skin injury due to prolonged unrelieved pressure and friction) for one of three sampled residents (Resident 21), who was unable to carry out activities of daily living (ADLs) to maintain ADLs mobility and assisted with transferring from bed to chair for two hours as tolerated with pressure relieving cushion as ordered by the physician. This deficient practice had the potential for Resident 21 to develop pressure injury, Findings: During a review of Resident 21's admission Record (AR), the AR indicated that the facility originally admitted Resident 21 on 10/15/2025 with diagnoses including post-laminectomy syndrome (any lingering pain of unknown origin following back surgery), spinal stenosis (the narrowing of one or more spaces within the spinal canal), and hypertension (high blood pressure). During a review of Resident 21's Minimum Data Set (MDS - a resident assessment tool) dated 1/16/2026, the MDS indicated that Resident 21 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 observation, interview, and record review, the facility failed to implement interventions to prevent CAUTIs (catheter-associated urinary tract infections, urinary tract infections caused by the improper use of urinary catheters) as indicated in the facility's policy and procedure and resident's care plan for one out of four sampled residents (Resident 151) with suprapubic catheters (a urinary tube inserted through the lower abdominal wall into the bladder that connects to a bag to collect urine) who was observed on top of resident's bed next to his left leg. This deficient practice placed Resident 151 at an increased risk of developing a urinary tract infection. Findings: During a review of Resident 151's admission Record (AR), the AR indicated that the resident was originally admitted on [DATE], and readmitted on [DATE], with diagnoses that included neuromuscular dysfunction of the bladder (occurs when nerve damage disrupts communication between the brain, spinal cord, and bladder muscles, causing…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that post dialysis assessments were conducted and documented in the treatment record, including required vital signs (temperature, pulse, respiration, and blood pressure), for one of two sampled residents (Resident 70). This deficient practice had the potential to delay identification of abnormal vital signs, dialysis access site complications, or adverse treatment reactions-such as untreated hypotension, excessive bleeding, or other serious conditions requiring emergency intervention. Findings: During a review of the facility's policy and procedure (P&P) titled Dialysis Care, dated 8/25/2021, the policy indicated its purpose was To provide dialysis care for residents in renal failure and those residents who require ongoing dialysis treatments. The policy stated, Nursing staff will communicate the following information in writing to the dialysis staff: the resident's current vital signs and any changes of condition specific to the resident 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 the attending physician visit one of three sampled residents (Resident 21) once every 30 days for the first 90 days after admission. This deficient practice had the potential for poor continuity of care and follow-up on Resident 21's status. Findings: During a review of Resident 21's, admission Record (AR) dated 10/15/2025, the AR indicated Resident 21 was admitted to the facility on [DATE] with the diagnoses of paraplegia (loss of movement and/or sensation to some degree, of the legs), acute kidney failure (loss of kidneys' ability to remove waste and help balance fluids), compression fracture of T5-T6 vertebra (break in a bone in your spine). During a review of Resident 1's History and Physical (H&P) dated 10/16/2025, the H&P indicated the Doctor of Nurse Practitioner (DNP) visited Resident 1 on 10/16/2025 and 1/27/2026. During an interview with the Director of Nurse (DON) 1 and concurrent review of Resident 21's H&P on 2/7/2026…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 and interview, the facility did not ensure medications were prepared and administered according to professional standards of practice and in accordance with physician orders, as required under F755 Pharmacy Services. On 2/5/2026, between 8:30 AM and 8:45 AM, during a medication administration observation for Resident 147, LVN 1 prepared 8.5 milliliters (mL) of Levetiracetam oral solution instead of the prescribed 5 mL. The surveyor intervened prior to administration. In addition, LVN 1 did not follow the physician ordered G tube flushing protocol. Required water flushes of 30 mL prior to medication administration and at least 15 mL after each medication were not performed during the administration of Amlodipine, Cholecalciferol, Lisinopril, Multivitamin liquid, and a probiotic capsule. Out of six medication administration opportunities observed, two instances did not follow physician orders: One instance involving preparation of an incorrect dosage of Levetiracetam. One instance involving…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that licensed nursing staff and the attending physician acted upon the Pharmacist Consultant's recommendations identified during the monthly Medication Regimen Review (MRR, a comprehensive evaluation of a resident's medication regiment intended to promote positive outcomes and minimize adverse effects)) for one of two sampled residents (Resident 1). Specifically, the facility did not: Update Resident 1's physician orders to include administration instructions for carvedilol (Coreg) to give with food/meals, as recommended by the pharmacist. Obtain current informed consents for the use of trazodone hydrochloride (HCL) and Ativan, as identified by the pharmacist. These failures had the potential to place Resident 1 at risk for adverse drug effects and violation of resident's rights to be informed of treatments. Findings: During a review of Resident 1's admission Record (AR), the AR indicated the resident was admitted to the facility on [DATE] 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 honor Resident 3's right to exercise choice and autonomy when staff did not provide the resident with a shower on her regularly scheduled shower date (1/13/2026). This failure interfered with Resident 3's ability to participate in decisions about her daily routine and preferences and resulted in the resident expressing feelings of neglect and sadness. Findings: A review of the facility's policy and procedure titled Activities of Daily Living (ADLs), Supporting, undated, indicated: Residents will be provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene. A review of Resident 3's admission Record (AR) indicated that Resident 3 was originally admitted to the facility on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to monitor and establish a system to implement the facility's policy and procedure (P&P) titled Visitation which indicated that visitation may be subject to reasonable clinical and safety restrictions to protect residents, including denying or limiting access to individuals suspected of bringing illegal substances into the facility for one of three sampled residents (Resident 1), who has a history of alcohol and substance abuse (harmful or hazardous use of psychoactive substances [any chemical that changes brain function, affecting mood, perception, consciousness, and behavior]). The facility failed to increase supervision and reassess visitation access for Resident 1's family member (FM 2) or other visitors of Resident 1, despite previous incidents of visitor-introduced contraband on 7/15/2025, 11/27/2025, and 1/4/2026. Despite this, the facility continued to allow Resident 1's visitor (FM 2) unsupervised and unrestricted visits during another visitation…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 prompt efforts were made to resolve a grievance for one of two sampled residents (Resident 3) reviewed for resident's rights under the grievance process. Furthermore, the facility failed to keep Resident 3 informed of progress toward resolution of the grievance from 12/22/2025 and provide a written resolution within 72 hours, in accordance with the facility's policy and procedure titled Grievance/Concern. This deficient practice violated the resident's right to be informed of the resolution of a grievance filed by the resident and had the potential to negatively impact Resident 3's psychosocial well-being and quality of life. Findings: During a review of the facility's policy and procedure (P&P) titled Grievances/Concerns, dated 8/25/2021, the P&P indicated: Upon receipt of the grievance/concern, the grievance/concern form will be initiated by the staff member receiving the concern and documented on the Grievance/Concern Log. The policy further…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 identify, investigate, report to appropriate agencies, and initiate protective measures for an allegation of abuse for one of two sampled residents (Resident 2) reviewed for abuse, in accordance with the facility's policy and procedure titled Abuse Prohibition Policy and Procedures. On 1/11/2026, Resident 2's family member (FM 4) reported to Licensed Vocational Nurse (LVN 5) that Certified Nursing Assistant (CNA 2) had handled Resident 2 roughly during care and requested that CNA 2 not be reassigned to Resident 2. The facility did not identify the allegation as potential abuse, failed to initiate protective measures, and reassigned CNA 2 to care for Resident 2 the next day, on 1/12/2026, before completing an investigation. These failures placed Resident 2 at risk for further abuse, retaliation, and psychosocial harm. Cross Referenced to F609 Findings: During a review of the facility's policy and procedures (P&P) titled Abuse Prohibition Policy 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 interviews and record reviews, the facility failed to report an allegation of abuse within two hours after the allegation was made for two of two sampled residents (Resident 2), as required by the facility's policy and procedure (P&P) titled Abuse Prohibition Policy and Procedures. The allegation should have been reported to the California Department of Public Health (CDPH) and other state agencies (local law enforcement, Ombudsman). On 1/11/2026 at 10:00 AM, Resident 2 and Resident 2's family member (FM 4) reported to Licensed Vocational Nurse (LVN) 5 that Certified Nurse Assistant (CNA) 2 was rough during care and hurt Resident 2. LVN 5 failed to report the allegation of abuse to CDPH and other state agencies as required by the facility's P&P. This deficient practice resulted in the facility underreporting allegations of abuse and Resident 2 being reassigned to CNA 2 after FM 4 had reported rough handling by CNA 2 and requested that CNA 2 not be assigned to care for Resident 2 again. Cross Referenced…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 resident environment was as free of accident hazards as possible and that residents received adequate supervision and assistance. This failure affected one of 15 residents (Resident 1) reviewed for accidents. Resident 1 was admitted to the facility on [DATE] with a history of alcohol abuse and fentanyl overdose (an excessive amount of a potent drug that could lead to death). The facility did not identify potential hazards, implement interventions to provide supervision and increased monitoring, or establish a system to limit and supervise access to an individual (Family Member [FM] 2) with a history of bringing illegal substances into the facility. These failures placed Resident 1 at risk for accidental illegal substance use and alcohol intoxication while in the facility. Additionally, the facility failed to: 1. Ensure Resident 1 was assessed for continued substance use and abuse as required by the facility's policy 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 medically related social services support to one of three sampled residents (Resident 1), a paraplegic resident who requested and had a physician order for an electric wheelchair to maintain or improve resident mobility. The facility's failure to obtain and provide the prescribed electric wheelchair limited Resident 1's freedom of movement, increasing risk of isolation and compromising his right to functional mobility Findings: During a review of the facility's policy and procedure (P&P) titled Social Services dated September 2021, the P&P indicated that medically related social services are provided to maintain or improve each resident's ability to meet everyday physical needs, including equipment for ambulation. During a review of Resident 1's admission Record (AR), the AR indicated the facility originally admitted Resident 1 on 11/27/2023, and readmitted on [DATE] with diagnoses including paraplegia (inability to voluntarily…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 treat one of three sampled residents (Resident 2) with respect and dignity when Certified Nursing Assistant (CNA) 2 and 3 made derogatory (offensive and disrespectful) comments around Resident 2 while CNA's 2 and 3 were assisting Registered Nurse (RN) 1 perform disimpaction (the manual removal of hardened stool from the rectum using a gloved, lubricated finger, usually performed when severe constipation or fecal impaction cannot be relieved by other methods) procedure on Resident 2. This deficient practice resulted in the violation of the resident's rights for Resident 2 who reported feeling uncomfortable, upset and yelling at the staff, which could significantly compromise Resident 2's psychosocial well-being. Findings: During a review of the facility's Policy and Procedure (P&P) titled Resident Rights, dated December 2021, the P&P indicated Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 observations, interview and record review the facility failed to implement the care plan of one of three sampled residents (Resident 3) to ensure placement of bolster pillows (a long firm and raised pillows placed on the edges of the bed) on the mattress while in bed to prevent the resident from recurrent fall. Resident 3 had a history of unwitnessed falls from bed on 8/17/2025 and 9/22/2025. As a result of this deficient practice Resident 3 had the potential for recurrent falls that could result in pain, major injuries and a decline in residents' wellbeing. Findings: During a review of the facility's P&P titled Fall Management, dated 5/26/2021, the facility's P&P indicated that residents who were determined to be at risk for falls will receive the appropriate interventions to reduce risk and minimize injury and the residents who experienced falls will receive the appropriate care and investigation of the case. During a review of the facility's P&P titled Care Plan Comprehensive, dated 8/25/2021, the facility's P&P indicated the facility will identify problem areas, their…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 reviews, the facility failed to ensure the resident's responsible party (RP) was informed and participated in the plan of care meetings for one of three sampled residents (Resident 1) reviewed for pressure ulcers and developed a Stage 4 pressure ulcer (a skin damage resulting from prolonged unrelieved pressure that is very deep, open sore to the skin tissue down to the muscle, bone, or tendon) in the facility. This deficient practice violated the residents' rights to be an active participant and be fully informed of Resident 1's care. Findings: A review of the facility's policy and procedure (P&P) titled Skin Integrity Management dated 5/26/2021, the P&P indicated to Notify patient, resident representative of plan of care. Review care plan and revise as indicated. A review of the facility's P&P titled Care Plan Comprehensive dated 8/25/2021, the P&P indicated The facility's Interdisciplinary Team, in coordination with the resident and/or his/her family or representative, must…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to administer nystatin (a skin cream with a specific dose of medicine that was used to treat fungal infections), Zoryve (Roflumllast, a prescription medication, in the form of a cream or foam that treated inflammatory skin conditions reducing inflammation instead of using steroids), and normal saline (NS, a sterile, medical-grade saltwater solution) medications as ordered by the physician for one of three sampled residents reviewed for medication and treatments administration (Resident 2). As a result, Resident 2 did not receive his scheduled wound medication and treatment which could have resulted in the resident's wound worsening and the peripherally inserted central catheter (PICC, a long, thin tube inserted into a vein in our upper arm that extended to a large vein near your heart) to become occluded (stop, close up, or obstruct an opening). Findings: A review of the facility's undated policy and procedure (P&P) titled, Administering Medications,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 current detailed and consistent medical records readily available for one of three sampled residents reviewed for documentation (Resident 1), who did not have a documented evidence of turning and repositioning every two hours to prevent worsened pressure ulcer ( skin injury resulting from prolonged unrelieved pressure on the skin) in accordance with the physician's order to turn resident on the side every two hours, document and chart in the folder at bedside, every shift for wound healing. This deficient practice had the potential to have a negative impact on the residents' healing process and for Resident 1's wound to worsen. Findings: A review of the facility's undated policy and procedure (P&P) titled Turning a Resident on His/Her Side Away From You, the P&P indicated The purposes of this procedure was to provide comfort to the resident, to prevent skin irritation and breakdown, and to promote good body alignment. The P&P 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 maintain an effective pest control program to ensure a pest-free environment for one of two resident rooms (Resident 3's room) sampled for pest infestation. Specifically, the facility failed to prevent and promptly address a fly infestation in Resident 3's room. This failure had the potential to compromise Resident 3's health, safety, and quality of life and posed a risk for infection.During a review of the facility's policy and procedure (P&P) title Pest Control dated May 2008, the P&P indicated, This facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents and garbage and trash are not permitted to accumulate and are removed from the facility daily. During a review of Resident 3's admission Record, the record indicated Resident 3 was initially admitted to the facility on [DATE] with diagnoses including paraplegia (loss of movement and/or sensation, to some degree, of the legs)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 observations, interviews and record reviews, the facility failed to ensure that accurate and current nurse staffing data [total number and actual hours worked by licensed (Registered Nurses [RNs], License Vocational Nurses [LVNs]) and unlicensed nurses (Certified Nursing Assistant [CNAs])] were posted daily at the beginning of each shift (11 PM - 7 AM, 7 AM - 3 PM, and 3 PM - 11 PM). These deficient practices of posting inaccurate and outdated nurse staffing data had the potential to mislead and prevent residents and families from verifying the facility's daily staffing levels. This could result in distrust and a perceived lack of accountability in maintaining accurate and adequate staffing necessary for timely resident care. Findings: During a review of the facility's Policy and Procedure (P&P) Posting Direct Care Daily Staffing Number, with a revision date of August 2022, the P&P indicated the following information: -The P&P indicated that within two hours of the beginning of each shift, the number of licensed nurses (RNs and LVNs) and the number of unlicensed nursing…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, observations, and record reviews, the facility failed to treat residents with dignity and respect for 2 of 3 sampled residents (Resident 3 and Resident 4) reviewed for resident's rights by failing to: 1. Ensure timely staff response after Resident 3 activated the call light. Resident 3, who is cognitively intact but physically dependent on staff for all activities of daily living (ADL), was observed waiting at least 19 minutes for assistance after pressing the call light on 9/16/2025. During this time, facility staff were observed standing at the Nurses' Station while the call light remained illuminated. Resident 3 reported frequent delays in staff response-sometimes waiting up to an hour-and stated that he often had to rely on his roommate to leave the room to seek help. This delay, combined with the resident's report of frequent prolonged waits, demonstrates a lack of respect for the resident's dignity and needs and compromised the resident's physical safety. 2. Ensure respectful…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to develop and implement comprehensive care plans, in accordance with the facility's policy and procedure (P&P) titled Care Plan Comprehensive, for 1 of 3 sampled residents (Resident 2) reviewed for comprehensive care plans. The facility failed to: Develop and implement a comprehensive person centered care plan to address Resident 2's inappropriate physical contact with other residents and clearly define the behaviors to be monitored during one-to-one (one-to-one) supervision; 2. Consistently implement the one-to-one supervision as outlined in Resident 2's care plan until it could be modified or discontinued. These deficient practices had the potential to result in Resident 2 not receiving the supervision necessary to ensure his safety and well-being. Additionally, the failure to implement the care plan interventions could compromise Resident 2's medical, physical, mental, and psychosocial health, and prevent him from attaining 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 ensure that pain management was provided to one of three sampled residents (Resident 1), consistent with professional standards of practice and in accordance with its policy and procedure titled Pain Management. The facility failed to: 1. 1. Ensure Resident 1's pain was accurately assessed for the type, frequency, intensity, and duration of the pain, re-evaluate the effectiveness of the intervention to determine what increase or decrease in the frequency, intensity, duration of pain after the resident's fall on 7/28/2025. 2. 2. Ensure that Resident 1 was accurately assessed and evaluated for continued complaints of right leg pain and refusal to ambulate due to pain during Physical Therapy (exercise to promote, maintain, and restore physical movement and function) from 8/2025 to 9/2025. 3. 3. Inform the Nurse Practioner (NP)1 or the Physician (MD)1 that Resident 1 had persistent right leg pain during ambulation and refused to participate in 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 ensure the standardized recipes for lunch menu were followed on 8/19/2025 when food items listed on the resident menu were not available and were replaced by alternative menu without the Registered Dietician's (RD) approval for 21 of 21 residents who did not receive the roasted cauliflower listed in the menu item in the residents meal trays during lunch. This deficient practice had the potential to result in residents dissatisfaction with the meal, not receiving the basic nutritional needs and/or receiving food preferences. Findings: During a review of the facility's P&P titled Menus, revised on 10,2022, the P&P indicated Menus will be planned in advance to meet the nutritional needs of the residents/patients in accordance with the established national guidelines. Menus will be developed to meet the criteria through the use of an approved planning guide. During a review of the facility lunch menu for 8/19/2025, the following food items would be served. Regular diet: baked ziti/meat sauce, roasted cauliflower,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 identify and monitor three of four sampled residents (Resident 84, 27, 26 and 103) with indwelling catheter (foley catheter, a thin, flexible tube that goes into the bladder to drain urine into a collection bag outside of the body) for sediments (free floating solid particles in the urine) in the drainage tubing and drainage bag as indicated in the resident's plan of care, the physician's order and the facility's policy and procedures. In addition, for Resident 26 and Resident 103 with suprapubic catheter drainage bag (a medical device, typically a bag with a tube, that collects urine) the facility failed to ensure the catheter bag was kept below the level of the residents bladder. These failures had the potential for the residents not to receive necessary care timely and for the supra pubic and indwelling catheter becoming occluded with sediment which may lead to a urinary leakage, bladder distention, urinary tract infection (UTI, an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the licensed nursing staff and physician failed to act upon the Pharmacist's recommendations documented in the Medication Regimen Review (MRR)-a comprehensive evaluation of a resident's medication regimen intended to promote positive outcomes and minimize adverse effects-for four of seven sampled residents (Residents 4, 7, 8, and 100 ) reviewed for MRR. The facility failed to: 1.Follow the pharmacist's recommendation to include the manifested behavior related to the use of Escitalopram (a type of antidepressant medication, used to treat depression and anxiety) for Resident 100. 2.Follow the pharmacist's recommendation to monitor orthostatic hypotension (a sudden drop in blood pressure that occurred when one stood up from lying or sitting, causing symptoms like lightheadedness or dizziness) for Resident 4 in relation to Risperdal use. 3. Follow the pharmacist's recommendation for Resident 8's Neurontin (gabapentin - medication that calmed overactive nerves in the body) 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.

Based on observation and interview and record review the facility failed to ensure food are stored properly for one of one of the facility's kitchen, in accordance with the facility's policy and procedure titled Food Storage- Cold Foods, by failing to label the ice cream with an open and used by date and storing onions properly to prevent mold growth and fruit flies. This deficient practice had the potential to cause food stored past safe storage time/ period, and place residents who consume this food at risk for foodborne illness (food poisoning or food illness due to pathogens [harmful organisms that cause illness such as bacteria, viruses, or parasites] and toxins that contaminate food). Findings: During a review of the facility's policy and procedures (P&P) titled Food Storage- Cold Foods revised 2/2023, the P&P indicated the following: All Time/ Temperature Control for Safety (TCS) foods, frozen and refrigerated, will be appropriately stored in accordance with the guidelines of the FDA (Food and Drug Administration- An agency in the U.S. federal government who protects public…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure the facility obtained an informed consent (a written document signed by the physician or designee that indicated the resident/responsible party was informed about the risk and benefit of the proposed treatment) with the use of psychotropic medications (medications that affects mood and behavior), from two of two sampled residents (Resident 8 and 100) reviewed for the use of psychotropic medications by failing to: 1.Obtain a consent from Resident 8 or the resident's responsible party prior to administration of Mirtazapine (a medication used to treat depression or an antidepressant). 2. Obtain a consent from the Resident 100 or the responsible party prior to administration of Ativan (a medication used to treat anxiety [the fear of the unknown that interfere with one's daily activities}). This deficient practice violated the residents right to make an informed decision regarding the use of psychotropic medications (Ativan and Mirtazapine). During a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the resident's needs were accommodated by the facility staff according to resident's needs and preferences for one out of 9 sampled residents (Resident108) reviewed for accommodation of needs, by failing to ensure Resident 108's call light was in reach while in bed for for call light observation, in accordance with the facility's policies and procedures (P&P) titled Answering the Call Light. This deficient practice had the potential to prevent Resident 108 from receiving personal and medical assistance when needed. Findings: A review of the facility's P&P titled, Answering the Call Light dated 10/24/2024 indicated to ensure timely responses to the resident's requests and needs, the call lights are accessible to the resident when in bed. During a review of Resident 108's admission Record, the admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses that included type 2 Diabetes (a disease in which your 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement the facility's policy and procedure (P&P) titled Notification of Change in Condition to notify the physician for one of five sampled residents (Resident 84) with significant change of condition related swelling on bilateral lower extremities (edema) and presence of urine sediment (solid particles like crystals, cells, or debris, which can be caused by dehydration, a urinary tract infection (UTI), kidney stones, or other underlying health conditions). This deficient practice had the potential for Resident 84 not to receive care and services needed for the significant change in condition and for the representative party to be unaware of the significant change of condition. Findings: During a review of the facility's policies and procedures (P&P) titled Change in Condition: Notification of, dated 8/25/2025, indicated the facility must immediately inform the resident, consult the resident's physician and/or nurse practitioner, and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the proper documentation, tracking, and safeguarding of residents' personal property for one (1) of two (2) sampled residents (Resident 71 ) reviewed for concerns related to personal property. Specifically, the facility failed to ensure that residents' personal belongings were properly documented and safeguarded in accordance with facility policy and Procedure (P&P) titled Resident's Personal Property. For Resident 71, the facility failed to update the Inventory of Personal Effects form to include personal belongings brought into the facility after admission by failing to ensure that Resident 1's hearing aids (electronic devices designed to amplify sound for individuals with hearing loss) were properly accounted for and replaced in a timely manner. These failures resulted in unaccounted-for loss or theft of personal property for Resident 71 and reflected a systemic breakdown in the facility's responsibility to maintain accurate…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 seven sampled residents reviewed for unnecessary medications are free from unnecessary use of psychotropic medications (any drug that affects brain activities associated with mental processes and behavior) by failing to: 1.Ensure that PRN (as needed) orders for psychotropic medications were limited to a duration of 14 days, for Resident 80 who was receiving psychotropic medications, specifically an active order of Ativan (lorazepam- a medication used to treat anxiety) initiated on 7/27/2025, with no documented stop date or evidence of physician re-evaluation to justify continued use beyond 14 days. 2. Ensure a specific behavior was assessed and documented for Resident 100, who had a diagnosis of depression (mood disorder that causes a persistent feeling of sadness and loss of interest that can interfere with daily life). 3. Ensure to monitor and document the side effects and effectiveness of Escitalopram (a psychotropic medication)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 complete a Pre admission Screening and Resident Review II (PASARR 11- a follow up assessment that ensures residents with mental disabilities receive appropriate care) after the PASARR I (initial PASARR assessment) was completed for one (1) out of three (3) sampled residents (Resident 27) reviewed for PASARR completion. This deficient practice had the potential to put Resident 27 at risk of not receiving appropriate mental health care and placement to appropriate facility.Findings: During a review of the facility's P&P titled, PASARR Completion Policy dated 9/30/2024 indicated the facility will make sure that all admissions have the appropriate PASARR completed; the ADM is accountable for monitoring the process of completing the necessary paperwork for admissions and; the facility will follow the State's specific guidelines for completion. During a review of Resident 27's admission Record, the admission Record indicated the resident was 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 ensure that two of two sampled residents (Resident 71 and 84) reviewed for comprehensive, person-centered care planning had their medical, nursing, mental, and psychosocial needs appropriately identified, assessed, and addressed through individualized care plans. 1.For Resident 71, the facility failed to develop and implement a comprehensive care plan to address the resident's hearing impairment. Resident 71 used bilateral hearing aids but was unable to independently insert or manage them and the facility had no interventions to address the need of the resident. As a result of this deficient practice Resident 71 had difficulty communicating with staff his needs that could lead to not receiving the needed care and assistance. In addition, the resident had increased dependence on family members for basic communication support. 2. For Resident 84, the facility failed to implement the resident's care plan interventions related to Fournier…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 licensed nursing staff followed the facility's own Policy and Procedure (P&P) titled Blood Pressure, Monitoring and the professional standard of practice when measuring blood pressure for one of four sampled residents (Resident 1) observed during medication pass. This failure placed Resident 1 at risk for inaccurate blood pressure readings, which could result in inappropriate medication administration, discomfort, or potential harm. Findings: During a review of the facility's undated Policy and Procedure (P&P) titled, Blood Pressure, Measuring dated 9/2010 indicated, the purpose of this procedure is to measure the pressure exerted by the circulating volume of blood on the walls of the arteries, veins and chambers of the heart and the procedure to take the blood pressure are: 1. Wrap the blood pressure cuff evenly around the upper arm, approximately one (1) inch from the elbow. (Note: The cuff should fit snugly, but not so…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 provision of care and services in accordance with professional standards of practice for one of one sampled resident, reviewed for physical restraints (Resident 80). Resident 80 was found to have a Wanderguard device applied to his wrist without a physician's order, a documented risk assessment, or an individualized care plan to justify its use. The absence of clinical justification and interdisciplinary care planning for the use of a device that may potentially restrict freedom of movement failed to meet professional standards of practice and placed the resident at risk for unnecessary restriction, and psychosocial harm Findings: During a review of the facility's Policy and Procedure (P&P) Tab Alarms, Bed alarms, Wander guard System, with a revision date of 12/12/2024, the P&P indicated nursing assessment of each resident must be done on admission and change in status to evaluate if he/she is at risk for falls or elopement.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to adequately assess one of two sampled residents (Resident 8) reviewed for Restorative Nurse Assistant (RNA - help patients recover after an illness or injury by working to restore their physical abilities and independence) Services, in accordance with the physician's order, by not evaluating and documenting the resident's tolerance and wear time (in hours) during the provision of RNA services. This deficient practice had the potential to negatively impact Resident 8's plan of care, interventions, that included increased risk of injury or fatigue, unnoticed pain or discomfort, and/or incomplete resident's records that could compromise interdisciplinary communication and decision making. Findings: During a review of the facility's policy and procedure titled, Restorative Nursing Services dated July 2017, the P&P indicated, Residents will receive restorative nursing care as needed to help promote optimal safety and independence. Restorative goals and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide a hazard free environment and implement the facility's policy and procedure titled Falling Star Program Protocol (a measure used by the facility to identify residents at risk for fall with the use of star) and implement documented interventions by placing a floor mat next to the resident's bed for one of two sampled residents (Resident 31) reviewed for accident and supervision due to being identified as high risk and with history of falls. This deficient practice had the potential to cause a repeat fall and safety risks for Resident 31. Findings: During a review of the facility's policy and procedure (P&P) titled Fall Management dated 5/26/2021 indicated to reduce risk for falls and minimize the actual occurrence of falls the facility will address injury and provide care for a fall and develop or update a care plan to reflect new interventions. During a review of the facility's undated policy and procedure titled Falling Star…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 failed to promote resident safety in administering oxygen for two (2) of 2 sampled residents (Resident 103 and 133) reviewed for oxygen therapy, in accordance with the facility's policy and procedure by failing to: Ensure the oxygen tubing (flexible plastic tubing used to deliver oxygen through nostrils and the tubing is fitted over the patient's ears) was changed every 7 days per Physician's order for Resident 100. 2. Ensure Resident 103's nebulizer mask was stored in a plastic bag with residents name and dated with open date, in accordance with facility policy titled Administering Medications through a Small Volume(Handheld) Nebulizer. This deficient practice had the potential for Resident 103 and 133 to contract infection when receiving oxygen therapy which could increase the risk of the spread of infection to the residents, staff, and other visitors in the facility. Findings: 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.

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 24) observed during medication pass was administered Carvedilol (medication used to treat high blood pressure) with food, as ordered by the physician. In addition, the facility failed to have systems ensuring records of disposition of drugs in sufficient detail to enable an accurate reconciliation in accordance with the facility's policy and procedure for Medication Destruction. This failure increased the risk of Resident 24 experiencing side effects (undesirable effect of a drug or medical treatment) from Carvedilol, that include sudden drop in blood pressure (orthostatic hypotension) which may lead to dizziness, light-headedness, fatigue (tiredness) and fainting. Findings: During a review of the facility's undated Policy and Procedure (P&P) titled, Administering Medications, the P&P indicated, Medications are administered in accordance with prescriber orders, including any required time…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 document complete and accurate information on the informed consent (a process in which a healthcare professional educates a patient about the risks, benefits, and alternatives of a given procedure or intervention) form about psychotropic medications (medications that affects mood and behavior), in accordance with accepted professional standard of practice for four of four sampled residents (Residents 7, 57, 83, and 100) reviewed for resident's rights by failing to ensure: Resident 100's, informed consent for the use of Escitalopram (medication used to treat depression [feeling of severe sadness and hopelessness and anxiety [the fear of the unknow] was signed by the healthcare practitioner who discussed the risks and benefits of the medication with the resident or responsible party. 2. Resident 57 and Resident 83's, informed consent for the use of Duloxetine (medications used to treat depression and anxiety) was signed by heath practitioner that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement the facility's infection control program to prevent, identify, report, investigate an infection outbreak (OB-an unusual increase of disease among a specific population in a geographic area during a specific period) for 9 out of 22 sampled residents (Resident 6, 7, 8, 9, 10, 11, 12, 13, 14) in accordance with the facility's policy and procedures and standard of professional practice. The facility failed to: 1. Identify scabies OB (an increased number of skin infection caused by infestation of the human itch mite that burrow under the skin where it lives and lays its eggs that can cause intense itching, especially at night, and a pimple-like rashes that spread through prolonged, direct skin-to-skin contact with an infected person) when Resident 6 was diagnosed with scabies on 7/23/2025 and when (Residents 7, 8, 9 and 10) were suspected and exhibited signs and symptoms consistent of scabies such as rashes and were treated 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.

Based on interviews and record reviews, the facility failed to ensure one of five sampled residents (Resident 1) reviewed for falls, who was identified at risk for falls, and assessed as dependent for bed mobility with the use of a mechanical lift (a sling placed under or around the resident to lift or transfer a resident using a mechanical equipment), received adequate assistance to prevent accidents while laying on a low air loss mattress (LAL; a special type of mattress) for alternation therapy (also called alternating pressure therapy on a LAL mattress that involves a system that inflate [increase in size when filled with air] and deflate [decrease in size when filled with air] in cycles, redistributing pressure across the patient's body), by failing to: 1. Ensure Certified Nurse Assistant (CNA) 1 implement Resident 1's care plan to utilize the mechanical lift during bed mobility when CNA 1 repositioned Resident 1 in bed on 7/21/2025, during the nightshift (11 PM to 7 AM). 2. Ensure CNA 1 asked for staff assistance to ensure at least two people assisted Resident 1 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 observation, interview, and record review, the facility failed to ensure medications were administered as prescribed and appropriately monitored for one of six sampled resident's (Resident 2) reviewed for medication administration. During an observation conducted on 6/30/2025 at 11AM, a plastic medication cup containing unadministered medications was found on the resident's bedside table. Review of the Medication Administration Record (MAR) indicated that the medication had been documented as administered at 9:23AM, although it remained untouched over 90min later. This deficient practice had the risk of medication errors, missed doses, and adverse health outcomes. Findings: During a review of Resident 2's admission Record indicated Resident 2 was admitted to the facility on [DATE] with a primary diagnosis of anemia (a condition when the red blood cells carrying oxygen is not sufficient) and displacement of nephrostomy catheter (a tube from kidney has been moved out of its correct place and is no longer…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 observations, Interviews and record review the facility failed to ensure that trash, debris and clutter did not accumulate for one of six sampled residents' (Resident 5) rooms observed for clean and sanitary environment, in accordance with the facility's policy and procedures (P&P) titled Homelike Environment.This failure had the potential to increase the risk of infection, attract pests such as ants, and cockroaches, and increased Resident 5's fall risk which could compromise the resident's health, safety, and overall quality of life. Findings: During an observation on 6/30/2025 at 11:35 AM, in Resident 5's room, Resident 5's environment was observed to be cluttered and unsanitary. During the observation, trash and debris were piled up across the floor consisting of a used cover (lid used to cover meal plate) from a breakfast tray on top of a pile of empty boxes, used plastic bottles, and empty drink cartons. There were also used eating utensils observed on Resident 5's bedside table. During a review of Resident 5'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 five of five sampled certified nurse assistants (CNAs 1, 2, 3, 4 and 7) reviewed for skills competencies, were trained and competent in using the mechanical lift device (a piece of equipment designed to safely and easily take the whole weight of an individual with limited mobility from one place to another), in accordance with the facility ' s Policy and Procedure (P&P) titled, Lifting Machine, Using a Mechanical. As a result, Certified Nurse Assistants (CNAs) 2 and 3 did not provide Resident 1 with the correct sling (a flexible strap or belt used in the form of a loop to support or raise a weight), in accordance with Resident 1 ' s assessment. CNAs 2 and 3 used a small sling, instead of a full body, extra-large size sling, while using the mechanical lift during the resident ' s transfer from chair to bed on 5/16/2025. Resident 1 slipped out from the small sling that was used by CNAs 2 and 3 to transfer the resident with 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 develop and implement comprehensive care plans for two of two sampled residents (Resident 1 and 2), who required the use of a mechanical lift (device used to assist with transfers and movement of individuals who require support for mobility beyond manual support) for transfers. Resident 1 had experienced a fall from the mechanical lift on 5/16/2025 when Certified Nurse Assistants (CNAs) 2 and 3 did not provide Resident 1 with the correct sling (a flexible strap or belt used in the form of a loop to support or raise a weight), in accordance with Resident 1 ' s assessment. The facility failed to develop a comprehensive care plan for Resident 2 ' s use of the mechanical lift for transfers, in accordance with the resident assessment and the mechanical lift ' s manufacturer ' s manual titled, Battery Operated Patient Lift. Resident 2 had the potential to experience a fall on 6/10/2025 when CNA 1 did not follow the facility ' s policy and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure that Potassium Chloride (KCL-a mineral supplement to replenish the loss of potassium in the body to maintain normal body function) was administered for one of two sampled residents reviewed for medication administration (Resident 5) as ordered by the physician and in accordance with the facility ' s policy and procedure titled, Administering Medications. The facility documented KCL was administered on 6/5/25 to 6/9/25 but there were three KCL packets remaining in Resident 5 ' s supply that were not administered. These deficient practices had potential for Resident 5 to be at risk for medication error or hypokalemia (low KCL level in the blood) that can lead to cramping, irregular heartbeat and cardiac arrest (heart ceases in functioning). Findings: During a review of Resident 5 ' s admission Record indicated the facility originally admitted Resident 5 on 11/23/19 and readmitted on [DATE] with diagnoses that included seizure (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 safely store and discard drugs and biologicals in accordance with the professional standard of practice for one of eight sampled residents reviewed for medication storage (Resident 4) who expired on [DATE]. Resident 4 who was no longer at the facility but medications were still stored in the Medication Room in a locked box with code that the facility could not unlock and the facility had no record of the drug contents in the box. This deficient practice had potential to lead to drug diversion and/or misuse of Resident 4's medications. Findings: During a review of Resident 4's admission Record (AR), the AR indicated the facility admitted Resident 4 on [DATE] and readmitted on [DATE] with diagnoses that included sepsis [a body's overwhelming and life-threatening response to infection (the invasion and growth of germs in the body)], type 2 diabetes mellitus (DM2 - condition that results in too much sugar circulating in the blood), end stage…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 complete Inventory of Personal Effects (form used that list the personal belongings that was [NAME] in by the residents in the facility), upon admission and discharge from the facility, of one of three sampled resident's (Resident 1) by failing to ensure Resident 1 have signed the Inventory of Personal Effects. This deficient practice had resulted to inaccurate inventory of Resident 1's belongings and placed the resident potential for theft and loss of property. Findings: During an observation of the facility's parking lot on 5/15/2025 at 7:52 AM, the facility's private parking lot was observed with white/beige colored residue that covered the entire ground of the assigned parking spot of the facility's Business Office Manager (BOM) located at the south end of parking lot. During a review of Resident 1's admission Record [AR], the AR indicated Resident 1 was originally admitted to the facility on [DATE], with diagnoses that included a history…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility staff failed to provide a safe and comfortable environment for residents, when one of three sampled residents' (Resident 1) abandoned car was left unattended for an extended period (approximately two years) in a state of disrepair and neglect at the facility parking lot. As a result, Resident 1's abandoned car caught on fire on 5/13/2025 at 4 pm. The facility staff and the Fire Department responded immediately to extinguish the fire. This deficient practice placed 159 residents, facility staff and visitors at risk for injury from burns due to a fire hazard (anything, including actions, materials, or conditions, that can start or contribute to the spread of a fire). Findings: During an observation of the facility's parking lot on 5/15/2025 at 7:52 AM, the facility's private parking lot was observed with white/beige colored residue that covered the entire ground of the assigned parking spot of the facility's Business Office Manager (BOM) located at the south end 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 develop, revise and implement an individualized comprehensive care plan that included measurable and timetables to meet the resident's medical, physical, mental, and psychosocial needs, with an ongoing resident assessments and revisions as information about the resident and the resident's condition changed in accordance with the facility's policy and procedures for: 1a. Resident 3 with chronic obstructive pulmonary disease (COPD, a chronic lung disease causing difficulty in breathing)/oxygen (O2) therapy. 1b. Resident 3 with reddish/purplish discoloration/hematoma (a collection of blood outside of a blood vessel caused by a broken blood vessel) to her right trunk area upon readmission to the facility from the General Acute Care Hospital (GACH) on 4/12/2025. 2.Resident 1 with moisture associated skin damage (MASD- caused by prolonged exposure to a source of moisture such as urine, stool, sweat, wound drainage, saliva, or mucus) and 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 provide care and services for prevention and management of skin breakdown in accordance with the resident's care plan, standard of practice, care plan and facility's policy for two of two sampled residents (Resident 1 and 3) who were at risk for skin breakdown by failing to ensure: 1a. Resident 1 was checked for incontinence (involuntary loss control of urination or bowel movement) and changed as needed due to moisture associated skin damage (MASD- caused by prolonged exposure to a source of moisture such as urine, stool, sweat, wound drainage, saliva, or mucus) upon re-admission to the facility. 1b. Resident 1 with Stage 3 Pressure injury (full thickness tissue loss where the skin and underlying subcutaneous fat are damaged, but the bone, tendon, or muscle is not exposed) was turned and repositioned as needed and/or every two hours. 2. Resident 3's was assessed, documented and implemented interventions for the reddish/purplish…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement the facility ' s infection prevention and control program (IPCP) to prevent the development and transmission of communicable disease and infections for one of two sampled residents (Resident 4) who has diagnosis of Extended Spectrum Beta Lactamase (ESBL - an enzyme produced by bacteria that are resistant to a wide range of antibiotics making the bacteria more difficult to treat and transmitted through direct contact with infected individuals or by touching contaminated surfaces) resistance in the urine by failing to: 1. Communicate to facility staff that Resident 4 required the use of EBP Enhanced Barrier Precaution (EBP, infection control practices, designed to reduce the spread of multidrug-resistant organism [MDRO - multidrug-resistant organisms]) to wear appropriate personal protective equipment [PPE- specialized clothing or equipment worn to protect workers from work-place hazards)] during high contact resident care…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to report an allegation of physical abuse, for one of three sampled residents (Resident 2) who reported being punched on the leg by an unnamed nurse on 4/5/25, to the California Department of Public Health (CDPH), Ombudsman (a person who investigates, reports on, and helps settle complaints) and local law enforcement immediately or within two (2) hours in accordance to the facility ' s Policy and Procedure titled Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating. This deficient practice had the potential for facility staff to under report allegations of abuse placing Resident 2 at risk for further abuse and resulted in a delay in the investigation for Resident 2 ' s abuse allegation. Findings: During a record review of Resident 2 ' s admission Record, the admission Record indicated Resident 2 was admitted to the facility on [DATE] with the diagnoses including but not limited to infection of amputation stump (part of a limb…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to prevent accident and hazard as indicated in the facility's policy and care plan by ensuring the wheelchair was properly locked to prevent accidental fall and ensure the resident was assessed for pain and injury after a fall of one of three sampled residents (Resident 3). As a result of this deficient practice Resident 3 had a fall without major injury but the deficient practice had the potential to result in the resident to have major injury or delayed and/or no care and treatment after the fall. Findings: During a review of Resident 3 ' s admission Record (AR), the AR indicated the resident was admitted to the facility on [DATE] and readmitted back to the facility on 4/12/2025, with diagnoses that included morbid obesity (a severe form of obesity where a person ' s Body Mass Index [BMI, a number calculated from your height and weight that was used to classify people as underweight, healthy weight, overweight, or obese] was 40 or higher),…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 and services in accordance with the facility's policy and procedures and standards of practice for one of three sampled residents (Resident 3) with COPD (Chronic Obstructive Pulmonary Disease- a progressive lung disease that causes shortness of breath and difficulty breathing), congestive heart failure (CHF, a heart disorder which caused the heart to not pump the blood efficiently causing shortness of breath) by failing to: 1. Indicate the justification for the use of Resident 3's oxygen therapy. 2. Ensure physician's order for prn (as needed) oxygen therapy outlines oxygen parameters to determine the appropriate level of supplemental oxygen to be delivered to Resident 3. 3. Develop and implement a comprehensive and resident centered care plan for Resident 3 with chronic obstructive pulmonary disease (COPD, a chronic lung disease causing difficulty in breathing)/oxygen (O2) therapy. These deficient…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 identify, assess, treat, and evaluate pain for one of two sampled residents (Resident 4), who showed signs of pain and verbalized severe pain to the left leg on 4/21/2025 at 9:22 PM and up to 2:10 PM the next day on 4/22/2025 (16 hours), in accordance with the facility ' s policy and procedure (P&P) titled Pain Management. As a result, Resident 4 verbalized hopelessness for experiencing horrific pain and sleeplessness on 4/21/2025 until the next day on 4/22/2025. This has the potential to result in Resident 4 ' s unmet needs and affect the resident ' s cognitive processes and significantly affect quality of life. Findings: During a review of Resident 4 ' s admission Record (AR), the AR indicated the resident was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included chronic pain syndrome (ongoing pain that lasted longer than expected, often for months or years, and could affect daily life),…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, the facility failed to ensure adequate supervision is provided and residents are free of accident hazards to prevent injuries for 5 of 13 sampled residents (Residents 7, 8, 9, 10 and 11) in accordance with the facility's policy and resident's care plan for smoking by failing to: 1. Prevent a smoking-related incident in which Resident 7's linens were burned inside the resident's room while three roommates were in the room. 2. Provide supervision and monitoring to Residents 3, 4, 5 and 6 for safely smoking by conducting an Interdisciplinary Team (IDT- a group of facility staff that plan the care for the residents) to discuss about risk and benefit of smoking safely prior to allowing the residents keep in their possession and/or access to smoking materials. These deficient practices had the resulted in Resident 7 and his roommates, staffs and visitors' safety due to risk for burn from fire or smoke inhalation (damaging the airways and lungs, potentially leading 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 residents who displayed psychosocial adjustment difficulty receives appropriate treatment and services to correct the assessed problem and provided behavioral health services for one of two sampled residents (Resident 1), whose primary diagnosis was alcoholic cirrhosis (a serious liver condition caused by heavy alcohol consumption, where healthy liver tissue is replaced by scar tissue) and had a behavior of going out of the facility to the liquor store. 1. Social Services Director (SSD) 1 failed to refer Resident 1 to a psychiatrist and/or psychologist for appropriate counseling and behavioral services for alcoholism, in accordance with Resident 1 ' s written Behavioral Contract. 2. SSD 1 and the facility ' s licensed nurses failed to develop and implement person-centered care plans that included and support the behavioral health care needs, identified in Resident 1 ' s Behavioral Contract, SSD 1 ' s evaluation of Resident 1 dated 4/8/2024 and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure two of two sampled residents (Resident 3 and Resident 5) were free from physical abuse from Resident 4 by failing to: 1. Protect Resident 3, who required moderate assistance with activities of daily living (ADLs), from Resident 4. On 3/22/25, Resident 4 threw water at Resident 3 and hit Resident 3's left elbow with a metal bar which was removed from the arm rest of Resident 4 ' s wheelchair. Resident 3 experienced bruising and redness on their elbow, and stated that they felt anxious, angry, and upset after being hit by Resident 4. 2. Protect Resident 5, who was legally blind, from Resident 4, after facility staff moved Resident 4 to Resident 5 ' s room following the physical altercation between Residents 3 and 4 on 3/22/25. Five days after moving Resident 4 into Resident 5 ' s room, Resident 4 hit Resident 5 on the left side of the face with a radio. Resident 5 sustained a forehead laceration (a cut or tear in the skin resulting…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 thoroughly investigate, take appropriate corrective action/steps, by not obtaining statements from residents involved in a physical altercation, and maintain documentation of the facility's thorough investigation to prevent further abuse, for one of two sampled residents (Resident 3) in accordance with the facility's Policy and Procedure (P&P) on Abuse Prohibition Policy and Procedure. This deficient practice resulted in an incomplete investigation of physical abuse and had the potential to place other residents at risk for abuse. Cross referenced to F600 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 a diagnoses of heart failure, abnormalities of gait (walking) and mobility, and dysphagia (difficulty swallowing). During a review of Resident 3's History and Physical (H&P) dated 3/15/25, the HPE indicated Resident 3 had the capacity to understand…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 Resident 7's gastrostomy feeding tube (GT - a tube that is passed through the abdominal wall to the stomach used to provide nutrition) removal was implemented as ordered by the physician on 2/8/2025, for one of three sampled residents (Resident 7) by failing to: 1. Timely follow up following a recommendation from Physician Assistant (PA) 1 when PA1 could not remove R7's GT. PA1 referred Resident 7 to a gastrointestinal (GI) specialist (doctor who specializing in stomach issues) on 2/10/2025.Facility staff failed to refer Resident 7 to a GT specialist until 3/14/2025 (32 days after PA 1's recommendation). Resident 7's GT specialist appointment was scheduled for 4/25/2025, over two months after PA1 made the original referral. This deficient practice resulted in severe resistance of the resident's unused GT, due to the delay of Resident 1's GT removal. This deficient practice has the potential to cause further GT complications such as…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 6) who was receiving hemodialysis (HD - process of removing waste products and excess fluid from the body) treatments received care in accordance with professional standards of practice and in accordance with the facility's Policy & Procedure (P&P) on Dialysis Care, by failing to: 1. Ensure that facility staff completed Resident 6 Post Hemodialysis Treatment status, in accordance with the facility's P&P on Dialysis Care. 2. Ensure to assist Resident 6 ready for scheduled HD, three days a week, with a scheduled transportation and pick up time of 12:30 PM at the facility, every Mondays, Wednesday and Fridays. This deficient practice resulted in frequent delays in the resident's dialysis treatment sessions and had the potential to result in serious health complications. Findings: During a review of Resident 6's admission Record [AR] indicated Resident 6 was originally admitted to 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 interview and record review, the facility failed to maintain accurate documentation in accordance with accepted professional standards and practices for one of three sampled residents (Resident 6) by ensuring Residents 8's weight was accurately recorded in the resident's records on 2/8/2025 and 3/6/2025. Resident 6's weight on 2/8/2025 was recorded as 169.4 lbs. (unit of measurement) on the Hemodialysis Communication Record - Post (after) Dialysis Treatment but the Weight Vitals Summary Record indicated on 3/6/2025 Resident 6's weight was 116.4 lbs. which was a 53 lbs. difference. This deficient practice had the potential to result in inaccurate assessments and interdisciplinary team (IDT) recommendations for Resident 1's care and management of current medical condition that included diagnoses of renal failure (a condition where the kidneys lose their ability to filter waste products from the blood) and diabetes mellitus (a chronic condition where the body cannot regulate blood sugar (glucose) levels…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, interviews, and record review, the facility failed to implement an ongoing infection prevention and control program (IPCP) to prevent, control the onset and spread of scabies for two of five sampled residents (Resident 1 and Resident 2) in accordance with the facility's policy and procedure (P&P) titled, Infection Prevention and Control Program by failing to: 1. Implement Resident 1's dermatology orders to apply medication, Permethrin (medication to treat scabies) 5% topical cream, after Resident 1 was diagnosed of scabies (itchy skin rash caused by a tiny burrowing mite called Sarcoptes scabiei) on 3/6/25. 2. Place Resident 2, (Resident 1's roommate) under contact isolation (prevent transmission of infectious agents) for seven (7) days, as indicated in the physician orders. Resident 2 was transferred to another resident's room with three new roommates (Residents 3, 4, and 5) on 3/10/2025. 3. Monitor and track Resident 2 on 3/6/25, after Resident 1 was diagnosed of Scabies and perform…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 the residents by failing to ensure the resident ' s call light (a device used by residents to signal his or her needs for assistance) is accessible to the residents at all times, in accordance with their resident assessments on functional abilities and the facility ' s policy and procedure (P&P) on Answering the Call Light, for three of four sampled residents (Resident 56, 15, and 73). These deficient practices resulted in Residents 56, 15 and 73 not able to use their call light devices to call the facility staff to ask for help or assistance for basic needs of activities of daily living (ADLs). These deficient practices also had the potential for other residents to have delay in care and services, avoidable falls, and accidents. Findings: A review of the facility ' s P&P titled, Answering the Call Light, dated 10/24/2024 indicated the purpose of the policy is to ensure timely responses to the resident ' s requests…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 inform one of one sample resident (Resident 44), including 11 of 12 residents alert and oriented residents who were present during a group interview, of their rights and responsibilities. This failure had the potential for the residents to feel uninformed and unable to fully exercise their rights while residing in the facility. Findings: During a review of the Resident Council Minutes, dated 8/21/2024, the Resident Council Minutes indicated the Activity Director (AD) reminded the residents about the smoking policy and procedure (P&P). During a review of the Resident Council Minutes, dated 9/18/2024, the Resident Council Minutes indicated the AD discussed the smoking P&P with the residents. During a review of the Resident Council Minutes, dated 10/16/2024, the Resident Council Minutes indicated the AD reviewed the grievance process with the residents. During a review of the Resident Council Minutes, dated 11/21/2024, the Resident Council Minutes did not include informing the residents of their rights. 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 the most recent State and Federal survey inspection results were posted in a manner that was clear and visible for residents that included 11 of 12 residents who attended a group meeting, and their families. This failure had the potential to prevent the residents and their families from viewing the survey inspection results without having to ask the facility ' s receptionist. Findings: During an observation on 2/25/2025 at 7:46 AM in the front lobby, an empty file holder was mounted to the wall next to the facility ' s bulletin board. The bulletin board had a posted note indicating, Survey results readily accessible please see receptionist. During a group interview on 2/25/2025 at 2:45 PM in the Activity Room, 12 alert and oriented residents were present during the meeting. Eleven of the 12 residents stated the survey inspection results were not posted or readily available for the residents and families to view. During a concurrent observation and interview on 2/26/2025 at 7:04 AM in the front desk…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 inform, explain and follow up with the residents' representatives (RP) and offer to assist the residents and their RPs with formulating an Advance Directive (AD- legal documents that express a person's wishes regarding their medical care in the event they become unable to make decisions for themselves due to illness, injury, or incapacity ) upon admission for three of three sampled residents (Resident 63, 180, and 391). As a result of this deficient practice Resident 63, 180 and Resident 391 was not able to exercise their resident's rights to express their wishes to meet the care and medical treatment decisions. Findings: 1. During a review of Resident 63's admission Record (AR), the AR indicated Resident 63 was initially admitted on [DATE] and readmitted on [DATE] to the facility with diagnoses that included pneumonia, chronic obstruction pulmonary disease (COPD - a lung disease characterized by long-term poor airflow) with acute exacerbation, 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 develop and implement a comprehensive person-centered care plan for three of four sampled residents (Resident 43, Resident 128, and Resident 54) in accordance with the facility's policy and procedure on Care Plan Comprehensive by failing to: 1. Develop a care plan for Resident 43's psychotropic medications, Lithium and Risperidone (medications that affects mood and behavior) since 11/27/2024. This failure had the potential for Resident 43 not to receive monitoring and interventions related to the adverse (undesired) side effects of psychotropic medications. 2. Develop a care plan for Resident 128 after a fall, resulting in a left shoulder fracture (break in bone) on 12/23/2024. This failure had the potential for Resident 128 to experience another fall which could lead to further physical injury. 3. Develop a care plan for Resident 54 that included interventions related to oxygen use. This failure had a potential to result in Resident 54'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 2. During a review of Resident 186 ' s admission Record, the facility admitted Resident 186 on 1/31/2025 with diagnoses that included acute respiratory failure (ARF, when the lungs have trouble getting enough oxygen [odorless gas needed for plant and animal life] into the blood) with hypoxia, muscle weakness, and peripheral vascular disease (PVD, a slow progressive narrowing of the blood flow to the arms and legs). During a review of Resident 186 ' s H&P, dated 1/31/2025, Resident 186 had the capacity to understand and make decisions. The H&P indicated Resident 186 had no skin breakdown and skin was intact. During a review of Resident 186 ' s Braden Scale for Predicting Pressure Sore Risk Original (Braden Scale, Standardized and evidence-based assessment tool to assess a resident ' s risk of developing pressure ulcers, dated 1/31/2025, the Braden Scale indicated Resident 186 was at mild risk for developing pressure ulcer. The Braden Scale indicated Resident 186 ' s skin was occasionally moist, and Resident 186…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 complete a performance review of every nurse aide at least once every 12 months and must provide regular in-service education based on the outcome of the areas concern at the facility by failing to: 1. Complete a performance/competency review for two sampled Certified Nurse Assistants (CNAs) and one Licensed Vocational Nurse (LVN). The CNAs and LVN did not have a completed Annual Core Clinical Competencies (ACCC, an assessment and training on the nursing staffs the ability to perform clinical nursing care). 2. Develop a system to keep track of the facility ' s ACCC to make sure all CNAs and LVNs to be evaluated annually. This deficient practice had the potential for the residents not to receive based on the standard of professional practice, residents care plans, physician ' s orders and the facility ' s policy and procedures and the Facility Assessment (an assessment to make decisions about direct care staff needs, as well capabilities to provide services to the residents) from the nursing staffs (CNAs and LVNs) not able 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 maintain a medication error rate of five percent or (5%) or less during medication pass for two of four observed residents (Residents 111 and 113) in which eight (8) medication errors were identified out of 29 opportunities which yielded a cumulative error rate of 27.59 %. The facility failed to ensure: 1. The Licensed Vocational Nurse (LVN) 3 did not mix Keppra (medication given to treat seizures-[sudden, uncontrolled electrical discharges in the brain that can cause changes in behavior, movement, sensation, or consciousness]), multivitamins and Phenytoin (medication given to prevent seizures) in a 5 oz cup before administering via gastrostomy tube (GT- a tube inserted into the stomach through a surgical incision use for feeding and administration of medication for a resident unable to swallow) to Resident 133. 2. LVN 4 did not mix all prescribed medications together in one cup before administration via GT from Resident 111. 3. LVN 3 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 two out of four residents (Resident 111 and 113) were free from significant medication errors as indicated in the physician's order, pharmacy recommendation and facility's policy and procedures by failing to ensure: 1. The Licensed Vocational Nurse (LVN) 3 did not mixed Keppra (medication given to treat seizures-[sudden, uncontrolled electrical discharges in the brain that can cause changes in behavior, movement, sensation, or consciousness]), multivitamins and Phenytoin (medication given to prevent seizures) in a 5 oz cup before administering via gastrostomy tube (GT- a tube inserted into the stomach through a surgical incision use for feeding and administration of medication for a resident unable to swallow) to Resident 133. 2. LVN 4 did not mixed all prescribed medications together in one cup before administration via GT for Resident 111. 3. LVN 3 and LVN 4 did not stop the tube feeding at least one hour before and after administering…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 standardized recipes for lunch menu was followed on 2/25/2025 when food items listed on the resident menu were not available and were replaced by alternative menu without the Registered Dietician (RD) approval. This deficient practice had the potential to result in meal dissatisfaction, decreased nutritional intake, weight loss in 14 residents out of 142 residents. Findings: During a review of the facility ' s P&P titled Menus, revised on 10,2022, the P&P indicated Menus will be planned in advance to meet the nutritional needs of the residents/patients in accordance with the established national guidelines. Menus will be developed to meet the criteria through the use of an approved planning guide. During a review of the facility lunch menu for 2/25/2025, the following food items would be served. Regular diet: beef soft taco with flour tortillas (2 each), garlic green beans ½ cup, green Chile rice ½ cup. During an observation of the tray line service (a system of food preparation, in which trays move…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 sanitation and safe food handling by failing to: 1. Ensure pre-made cheese sandwiches found in the facility ' s walk-in refrigerator were dated and labeled with the prepared and used by dates, as indicated in the facility ' s policy and procedure (P&P) titled, Food Storage: Cold Foods. 2. Ensure the ice scoop used for scooping ice found in the ice machine was stored in a separate container when not in use, to limit exposure to dust and moisture retention, as indicated in the facility ' s P&P titled, Ice. 3. Staff wear gloves when preparing resident apple sauce cups. These deficient practices had the potential for cross contamination and put residents at risk for foodborne illnesses (illness caused by food contaminated with bacteria, viruses, parasites, or toxins). Findings: During a review of the facility ' s P&P titled Food Storage: Cold Foods with a revision date of April 2018, the P&P indicated All foods will be stored wrapped or in covered containers, labeled and dated, and arranged in 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 During observation, interview, and record review, the facility failed to implement infection control practices as indicated in the facility ' s policy and procedure titled Infection Prevention and Control Program for four of nine residents (Residents 14, 166, 54 and 63) by failing to: 1. For Residents 14 and 166, the Treatment Nurse (TXN) 4 and TXN 5 provided wound care treatments to the residents with pressure ulcers (localized damage to the skin and/or underlying tissue usually over a bony prominence) without performing hand hygiene. 2. For Resident 54, and 63 who had a physician order for oxygen use by failing to ensure the nasal cannula (NC- a tube with small opening used to deliver oxygen to the nares) was labeled of when the NC was first used and when to be changed or discarded was on the floor. These deficient practices had the potential to result of cross contamination of disease-causing organisms that could result in infection for Resident 54 and 63 at increased risk for lung infection and for 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 three of three sampled residents (Resident 138, 110, and 166) bedframes and mattresses gaps were compatible and identified areas for possible bed entrapment (when a resident becomes trapped in a hospital bed, usually in the space between the mattress and the bedrail [the metal or plastic bars along the side of the bed]). This failure had the potential to result in Residents 138, 110, and 166 becoming entrapped between the bedframe and the mattresses gaps and may result in serious injuries such as cuts, bruises, pressure ulcers (localized damage to the skin and/or underlying tissue usually over a bony prominence) or even death. Findings. 1. During a review of Resident 138's admission Record, the facility admitted Resident 138 on 5/31/2024 and readmitted Resident 138 on 10/16/2024 with diagnoses of quadriplegia (paralysis from the neck down, including legs, and arms, usually due to a spinal cord injury), muscle weakness, and seizures…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 three of four residents sampled (Resident 126, 159 and 171) call light (device used by the resident to communicate needs) in functional and operating condition. This deficient practice had the potential for unmet resident ' s needs and calls for assistance that, may cause negative outcomes such as accidents/injury and/or anxiety (fear of the unknow) and depression (a severe feeling of hopelessness and sadness). Findings: 1. During a review of Resident 126 ' s Face Sheet (front page of the chart that contains a summary of basic information about the resident) indicated an admission to the facility on 8/08/2023 with diagnoses that included metabolic encephalopathy (a change in how your brain works due to an underlying condition), fatty liver (a condition where excessive fat accumulates in the liver) During a review of Resident 126 ' s History and Physical [H&P] dated 1/16/2025, the H&P indicated the resident has fluctuating…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 392), was provided privacy and treated with dignity when being changed on 2/25/2025 at 11:13 AM. This failure resulted in the violation of residents right for privacy and dignity that resulted in the resident feeling upset and a potential to result in Resident 392's emotional distress. Findings: During a review of Resident 392's admission Record (AR), the AR indicated the facility admitted Resident 392 on 2/19/2025 with diagnoses that included Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills, and eventually, the ability to carry out the simplest tasks), muscle weakness, and lack of coordination. During a review of Resident 392's History and Physical Examination, dated 2/19/2025, indicated Resident 392 did not have the capacity to understand and make decisions. During an observation on 2/25/2025 at 11:13 AM in Resident 392's room, Certified Nurse Assistant (CNA) 6 was assisting Resident 392 change clothing and exposed 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 notify the physician for two of two sampled residents (Resident 14 and Resident 25) of sediment (accumulation of particles or debris that settle at the bottom of the urine bag) of the indwelling catheter (flexible tube that collects urine) bag between 2/25/25-2/28/25. This failure resulted in the delay of Resident 14 and Resident 25's Change of Condition (CoC), which had the potential to result in the delay in treatment for urinary tract infection (UTI, an infection in any part of the urinary system, the kidneys, bladder, or urethra) and reoccurrence of UTIs. Crossed Reference with F690 Findings: 1. During a review of Resident 14's admission Record, the facility admitted Resident 14 on 1/19/2022 and readmitted Resident 14 on 8/22/2024 with diagnoses of Chronic Respiratory Failure (long term condition where the lungs cannot get enough oxygen), Neuromuscular Dysfunction of Bladder (damage to the nerves that control the bladder), 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 privacy during incontinent (no control bladder and bowel) care for one of one sampled resident (Resident 19). Certified Nursing Assistant (CNA) 18 did not close the privacy curtain while performing perineal care (cleaning the private areas of the body, including the genitals and the area around the buttocks) for Resident 19. This failure violated Resident 19's right to personal privacy and dignity, exposed Resident 19's private area to Resident 19's roommate (Resident 10) and caused both Residents 10 and 19 felt uncomfortable. Findings: During a review of Resident 19's admission Record (AR), the AR indicated the facility admitted Resident 19 on 4/13/2024, and readmitted on [DATE] with diagnoses including diabetes mellitus (DM: long-term metabolic disorder that is characterized by high blood sugar, insulin resistance, and relative lack of insulin), and heart failure (a condition in which the heart can't pump enough blood to meet…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 implement the facility ' s policy and procedure titled, Grievance/Concern, dated 8/25/2021, to ensure prompt receipt and resolution of Resident/Representative grievance/concern by failing to: 1. Ensure that information on how to file a grievance or complaint was made available to the resident in accordance with the facility's policy and procedure (P&P) titled Grievance/Concern by posting the information on each unit's prominent locations. 2. Provide prompt efforts to resolve the grievances and provide a written copy of the grievance resolutions (10/3/2024, 10/11/2024, 10/16/2024, 10/21/2024 and 10/22/2024) for one of five sampled residents (Resident 44) reviewed for grievances during the Resident Council Meeting. These deficient practices had the potential to result in the violation of the residents' rights to have his or her grievance addressed due to lack of information in how to file a grievance and had resulted in Resident 44's grievance not being acted upon and not communicated as to what actions were taken to resolve…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 he facility failed to complete a significant change Minimum Data Set ([MDS] a resident assessment tool) assessment after Resident 128's fall on 12/23/2024 which resulted in a left shoulder fracture (break in bone). This failure resulted in the facility's failure to develop and implement interventions to Resident 128's care plan to prevent another fall. Cross reference F656 and F689. Findings: During a review of Resident 128's admission Record, the facility admitted Resident 128 on 10/19/2023 with diagnoses including Type 2 Diabetes Mellitus ([DM] disorder characterized by difficulty in blood sugar control and poor wound healing), chronic (long-standing) kidney disease, presence of a right artificial shoulder joint, muscle weakness, and history of falling. During a review of Resident 128's MDS, dated [DATE], the MDS indicated Resident 128 had clear speech, expressed ideas and wants, understood verbal content, and had intact cognition (ability to think, understand, learn, and remember). The MDS indicated 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 interview and record review, the facility failed to revise a care plan for one of one sampled resident (Resident 491) who was identified as at risk for fall since admitted to the facility on [DATE]. This failure resulted in Resident 491 sustaining three recurrent falls from his bed within two weeks and has the potential to place Resident 491 for recurrent falls. Crossed reference with F689 Findings: During a review of Resident 491's admission Record, the facility admitted Resident 491 on 2/14/2025 with diagnoses which included acute respiratory failure (ARF, when the lungs have trouble getting enough oxygen [odorless gas needed for plant and animal life] into the blood) with hypoxia (condition where the body's tissues doesn't have enough oxygen), unspecified atrial fibrillation (a heart condition that caused an irregular heart beat), and other abnormalities of gait (the pattern a person walks) and mobility. During a review of Resident 491's History and Physical (H&P, a comprehensive physician's note…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 one of three sampled residents (Resident 130) with care and services to residents unable to carry out Activities of Daily Living ([ADLs] tasks related to personal care including bathing, dressing, hygiene, eating, and mobility) independently in accordance with the care plan. This deficient practice resulted to Resident 130 verbalizing feelings of helplessness and had the potential to result in skin redness and irritation to Resident 130 ' s skin due to the facility ' s inability to attend timely to the resident ' s perineal care needs. Findings: During a review of the facility ' s policy and procedure (P&P) titled, Activities of Daily Living ([ADLs] tasks related to personal care including bathing, dressing, hygiene, eating, and mobility), supporting, revised on 3/2018, the P&P indicated resident will be provided with care, treatment, and services to residents unable to carry out ADLs independently in accordance with the care plan. During a review of the facility ' s P&P titled, Answering the Call…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 store prescription medications in a safe place for one of 8 sampled residents (Resident 391), who was found with prescription medications on top of the bedside drawer on 2/25/2025 in accordance with the facility's policy and procedure (P&P) titled, Medication Storage in the Facility, dated 2008, This failure had a potential to result in accidental consumptions and result in adverse reactions (undesired effects) from medication and harms for any residents and visitors who walked into Resident 391 ' s room and take the prescription medications. Findings: During a review of Resident 391 ' s admission Record, indicated Resident 391 was admitted to the facility on [DATE] with diagnosis that included bilateral primary osteoarthritis (a common joint disease that causes the breakdown of cartilage, the protective tissue that cushions the ends of bones) of knee, hypertension (high blood pressure), and dementia [the loss of cognitive functioning…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 no delay in informing the physician about critical lab results for one of three sampled residents (Resident 180), who had critical lab values of white blood cell (WBC, a type of blood cell that helps fight infection and disease) count and low blood glucose (BG, the main sugar found in the blood), which were reported on 2/23/2025 at 11:48 PM as evidenced by the critical lab results were not followed up with Resident 180 ' s covering physician [Nurse Practitioner (NP) 1] until 2/24/2025 at 2:36 PM (approximately 14.5 hours when the critical lab results were reported). This deficient practice had a potential to result in a delay in care, interventions and treatment. Cross reference to F690, F842 Findings: During a review of Resident 180's admission Record (AR), the AR indicated the facility admitted Resident 180 on 1/29/2025 with diagnoses that included pneumonia (a severe an infection of the lungs that may be caused by bacteria, viruses, or fungi), sepsis (a life threatening infection in the blood which could lead 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.

Based on observation, interview, and record review, the facility failed to develop specific policies regarding freezer storage and implement the facility ' s current policy of storing foods brought in by residents and family members, that included one of two sampled residents (Resident 96) who use the residents ' refrigerator for food storage. This deficient practice had the potential to promote miscommunication among facility staff, residents, and families about frozen food storage and prevent frozen food from safe and sanitary storage, handling, and consumption. Findings: During a review of the facility ' s policy and procedure (P&P) titled, Food Brought by Family/Visitors, revised 3/28/2024, the P&P indicated the responsible staff member will ensure foods are in a sealed container to prevent cross contamination and will label foods with the resident ' s name, current date, and ' use by date. ' The P&P indicated items not opened can follow the manufacturer use by date and the refrigerator/freezer for storage of foods will be cleaned daily. During a review of Resident 96 ' 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 2. During a review of Resident 180's admission Record (AR), the AR indicated the facility admitted Resident 180 on 1/29/2025 with diagnoses that included pneumonia (a severe an infection of the lungs that may be caused by bacteria, viruses, or fungi), sepsis (a life threatening infection in the blood which could lead to decreased in blood pressure (BP), increased heart rate (HR), shortness of breath and altered level of consciousness, that can damage the body organs). During a review of Resident 180 ' s Minimal Data Set (MDS-a federally mandated resident assessment), dated 2/4/2025, indicated Resident 180 ' s cognition (ability to think, remember, and reason with no difficulty) was intact and needed partial assistance (helper does less than half the effort) in eating and personal hygiene. During a review of Resident 180 ' s Laboratory Results Report, dated 2/23/2025 timed at 11:48 PM, indicated Resident 180 had critical lab values for blood glucose (BG, the amount of sugar in the blood) level of 60 milligrams…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 ' s Quality Assessment and Assurance (QAA) committee failed to develop a Quality Assurance Performance Improvement (QAPI-a systematic, interdisciplinary, comprehensive, and data-driven approach to maintain and improve quality in nursing homes) to maintain an effective system to identify, monitor and evaluate implement the facility ' s plan to address care areas of concern that were substantiated during the previous year recertification survey, complaint and facility reported incident (FRI) during the period from 3/2024 to 3/2025 in accordance with the professional standards of practice, physician's orders and facility ' s policy and procedures. The deficient practices previously substantiated were under quality of care for the following Federal tags- F686 (prevention of pressure ulcer), F684 (quality of care), F689 (accidents and supervision) and F755 (pharmacy services- medication administration) The facility failed to: 1. Develop a QAPI plan on how ensure residents with significant change in condition were assessed, monitored,…

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

Based on interview and record review the facility failed to maintain complete and accurate medical records in accordance with accepted professional standards and the facility's policy and procedure (P&P) on Documentation of Medication Administration for one (1) of two (2) sampled residents (Resident 2) by failing to document the reason for the refusal of four (4) medications and two (2) nutritional supplements on 1/3/2025 and 1/14/2025 for the 5 PM dose. This deficient practice placed Resident 2 at risk for not receiving the necessary care and services and develop a comprehensive plan of care due to licensed nurses not accurately documenting the reasons for resident's refusals of medications and nutritional supplements. Findings: During a review of the facility's policy and procedure (P&P) titled Administering Medications revised April 2019, the P&P indicated if a drug was withheld, refused, or given at a time other than scheduled, document the refusal. During a review of the facility's P&P titled Documentation of Medication Administration revised November 2022, the P&P indicated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement the facility's an infection control program and the Department of Public Health recommendation ensure a safe, sanitary, and comfortable environment and to help prevent transmission of disease for 3 of 21 sampled residents (Resident 1, 3 and 7) by failing to: 1. Ensure Resident 1, who had an indwelling catheter (a tube inserted into the bladder used to drain urine), a stage 3 pressure ulcer (a full-thickness skin loss where the underlying fat tissue is visible within the wound due to prolonged unrelieved pressure), and moisture-associated skin damage (MASD, when skin irritation and damage occur caused by prolonged exposure to moisture like urine, sweat, stool, wound fluid) was placed on enhanced barrier precautions (an infection control practice that involves the use of gown and glove use during high-contact of resident care activities known to be high risk or infected with a MDRO [multidrug-resistant organism resistant to many…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, interviews, and record reviews, the facility failed to maintain and implement an ongoing and effective infection prevention and control program (IPCP) during an influenza outbreak (when there are [NAME] disease cases of influenza than what is usually expected), for 13 of 164 sampled residents and one facility staff, from 12/19/2024 to 12/30/2024 (10 days) by failing to: 1. Ensure signage of outbreak notification at the entrance to inform visitors and family members of the influenza outbreak and masking requirements was posted. 2. Ensure compliance with mask-wearing for residents who tested positive for influenza (Residents 4, 5, 6, 7, 8, 9, 10, 11, 12, and 13) or those at risk of exposure (Residents 1, 2, and 3), in accordance with professional standard of practice for respiratory virus in nursing homes. 3. Communicate effectively with residents, families, and staff regarding the outbreak and infection control measures. 4. Provide appropriate personal protective equipment (PPE), such as…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 prompt efforts were made to resolve a grievance for one of two sampled residents (Resident 1) and keep Resident 1 apprised of progress towards resolution and a written resolution within 72 hours in accordance with the facility's policy on Grievance/Concern. This deficient practice violated the resident's rights to be updated of the resolution of his/her grievance that was filed by the resident and may have a negative psychosocial impact on Resident 1's quality of life. Findings: During a review of Resident 1's Face Sheet (front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated the resident was admitted to the facility on [DATE], with diagnoses that included Acute kidney failure (when the kidneys suddenly can't filter waist products from the blood), Type 2 Diabetes Mellitus (Type 2 diabetes is a condition that happens because of a problem in the way the body regulates and uses sugar as 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 needed care and services to perform wound treatment and administer Mupirocin External Ointment 2 % [antibiotic ointment] every day and evening shifts, for one of three sampled residents (Resident 1), in accordance with the physician's order for wound treatment, wound care plan, and the facility's policy & procedure [P&P] on Administering Medications. This deficit practice had a potential to result in Resident 1's worsening of the cellulitis (a skin infection that causes swelling and redness) in the left lower extremity. Findings: During a review of Resident 1's Face Sheet (FS - admission record), the FS indicated Resident 1 was admitted to the facility on [DATE], with diagnoses that included cellulitis (a skin infection that causes swelling and redness) of left lower limb, abnormalities of gait and mobility, and protein calorie malnutrition. During a review of Resident 1's History and Physical (H&P) dated 7/12/2024, the H & P indicated 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 observations, interview and record review, the facility failed to develop resident centered care plans (means to focus on the resident and support the resident in making their own choices and having control over their daily lives) that includes measurable objectives and timeframes to meet the needs and preferences for three of three sampled residents (Residents 2, 5 and 6) by failing to: 1. Ensure the facility developed a care plan for Resident 2, who had requested facility staff and preferred a different time scheduled for morning blood sugar checks (measures the amount of sugar in blood). 2. Ensure the facility developed a care plan for Resident 6's activities of daily living that indicated the resident's need for two facility staff assistance during bed mobility. 3. Ensure the facility developed a care plan or hold an IDT care plan meeting (a discussion between the resident, their family and the staff providing care for the resident to review and update resident's care plan to ensure the resident'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 accurately account, provide and obtain pharmaceutical services, including the provision of routine medications, for three of three sampled residents (Resident 1, 5 and 2) by failing to: 1. Reorder simvastatin (a medication used to treat high cholesterol) on a consistent basis by ordering 56 tablets to cover an 81-day period between 8/6/24 to 10/29/24 totaling 25 missed doses for Resident 1. The facility was not able to account for the discrepancy of the medications [simvastatin] not delivered by the pharmacy, contrary to the licensed nurses' documentation of administration in the MAR. 2. Ensure Resident 5 received antibiotic Intravenous [IV] therapy when Resident 5, who had an infected right neck mass, did not receive his Ceftolozane-Tazobactam [an IV antibiotic [medication to treat an infection]), that was scheduled to be administered on 10/25/2024 at 10 PM, during the 3 PM to 11 PM shift. The facility did not have an available…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 there was a clear indication for the simultaneous use of levothyroxine (a medication used to treat low thyroid levels) and methimazole (a medication used to treat high thyroid levels) in one of eight sampled residents (Resident 1). The deficient practice of failing to document an adequate indication for the simultaneous use of two medications [levothyroxine and methimazole] whose actions oppose each other, increased the risk that Resident 1 would experience adverse effects related to the use of unnecessary medications or an unmanaged thyroid (a hormone that regulates metabolism and other bodily functions) condition possibly leading to a decline in quality of life. Findings: A review of Resident 1 ' s admission Record (a document containing resident demographic and diagnostic information), dated 10/29/24, indicated the resident was admitted to the facility originally on 8/6/24 and readmitted on [DATE] with diagnoses including hyperlipidemia (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 interview and record review, the facility failed to implement the facility ' s policy and procedure (P&P) titled, Abuse Prohibition, for one of six sampled residents (Resident 1) and failed to followed its P&P titled, Background Screening Investigations, for four of four sampled employee (Certified Nurse Assistants [CNAs] 1, 2, 3 and 4) by failing to: 1. Prevent Resident 1 from verbal and mental abuse by Certified Nursing Assistant (CNA) 1, when CNA 1 raised his voice over Resident 1. CNA 1 also used obscene [something that is morally offensive in a sexual way] language while talking to Resident 1 and threatened to record and report Resident 1 on [DATE]. 2. Conduct employment background screening checks and license/certifications from the State Registry on all applicants for positions with required direct access to the residents. - CNA 1, who was employed at the facility since [DATE], did not have proof of CNA certificate verification from the State Registry [California Department of Public Health…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 sufficient nursing staff to provide routine Activities of Daily Living [ADL] to meet the residents needs for five of seven sampled residents (Resident 9, 10, 11, 12, 13) assigned to a certified nurse assistant [CNA 2] on 10/18/2024 from the 11 PM to 7 AM shift. On 10/18/2024, CNA 2, who was on suspension, was assigned to care for residents [Residents 9, 10, 11, 12, 13] during the 11 PM to 7 AM shift. There was no evidence of another CNA assigned to care for Residents 9, 10, 11, 12, and 13 the night of 10/18/2024. This deficient practice resulted to Residents 9, 10, 11, 12, 13 potentially not receiving routine ADL care and services during the night shift on 10/18/2024 and had the potential to result in unmet resident ' s needs, which can result to a decline in physical and emotional well-being. Cross referenced to F607 Findings: During a review of the facility ' s Nursing Staffing Assignment and Sign-in Sheet dated 10/18/2024 for 11 PM to 7 AM…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 prompt efforts were made to resolve grievances verbalized by one of two sampled residents (Resident 7) to appropriately apprised (inform) of progress regarding Resident 7 ' s missing food items on 10/14/2024. In addition, the facility failed to inform Resident 7 verbally and in writing of the findings of the investigation and the actions taken by the facility to correct any identified problems from the grievance, in accordance with the facility ' s policy & procedures [P&P] titled Grievance/Complaints, Filing. This deficient practice violated Resident 7 ' s rights to voice grievances and ensure facility process the grievance and made prompt efforts to resolve the grievance according to established facility P&P. This had the potential to cause psychological distress to Resident 7 and affect the resident ' s quality of life. Findings: A review of Resident 7 ' s admission Record [AR] indicated the facility admitted the resident on 11/23/2022, with diagnoses that included paraplegia (the loss of the ability to move 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.

Based on interview and record review, the facility failed to implement pre-employment procedures and ensure not to employ individuals who have been found guilty by a court of law with convictions that included theft [robbery], for one of four sampled employees (Certified Nursing Assistants [CNA]) in accordance with the facility ' s policy and procedures titled Background Screening Investigations. CNA 1 was identified with a background history of a convicted felon [a person who was guilty of a serious crime] on 4/30/2002 and was hired and employed at the facility from 1/25/2024 to 10/22/2024. This deficient practice increased the risk of applicants and employees with possible criminal convictions had direct access to all residents in the facility and the potential for occurrences of misappropriation of property for the residents by CNA 1. Cross referenced to F607. Findings: A review of CNA 1 ' s employee file, dated 1/25/2024 indicated CNA 1 was offered for employment by the facility on 1/25/2024. A review of CNA 1 ' s background check record dated 1/25/2024, indicated CNA 1 had a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to administer medications as ordered by the physician for one (1) of three (3) sampled residents (Resident 6), by failing to: 1. Notify the physician when Resident 6's Carbamazepine (Tegretol, used to treat certain types of seizures), Levetiracetam (a drug used to treat seizures [a sudden, uncontrolled burst of electrical activity in the brain] medicine), Clopidogrel Bisulfate (Plavix, used to treat blood clots, a mass of blood that stick together) and Atorvastatin Calcium (drug used to lower the amount of cholesterol in the blood) were unavailable and unable to administer the resident's medications as ordered on 10/4/24 and 10/5/24. 2. Ensure medications were readily available by following up with the Pharmacy on delivery of medications prior to the next scheduled dose for Carbamazepine, Clopidogrel Bisulfate, Atorvastatin Calcium and Levetiracetam on 10/4/24 and 10/5/24. 3. Administer Resident 6's Levetiracetam, Carbamazepine, Clopidogrel Bisulfate 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 follow its policy and procedure [P&P] titled Change in Condition: Notification of and Care Planning-Interdisciplinary Team for one of three sampled residents (Resident 1) by failing to: 1. Notify Resident 1 ' s primary physician [Physician 1] of the resident ' s ongoing rashes and unrelieved itchiness, and coordinate with Physician 1 that the treatment ordered by the Dermatologist (a physician who specializes in wounds and skin diseases) was ineffective and had not resolved Resident 1 ' s ongoing rashes and itchiness from March 2024 to October 2024 [6 months]. 2. Ensure Resident 1 ' s family and representatives participated in the development and revisions of the resident ' s comprehensive care plan with regards to ongoing rashes and unrelieved itchiness from March 2024 to October 2024 [6 months]. These deficient practices resulted to Resident 1 and the resident ' s representative not able to exercise their rights to make informed decision for 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 interview, observation, and record review the facility failed to ensure, Resident 1 was provided with comfortable and homelike environment, in accordance with the facility's policy and procedure [P&P] titled Homelike environment by failing to ensure Resident 1 had extra linens/blankets and pillows after the facility performed deep cleaning of Resident 1's bedroom on 10/03/2024. This deficient practice led to Resident 1 who was bed bound (someone who is unable to move around safely or comfortably and is confined to their bed) to repeatedly ask facility staff for linens/blankets and pillows from facility staff to cover herself on 10/03/2024 from 12 noon to 4:45 PM, because she was cold. Findings: During a review of Resident 1's facility records titled admission Record indicated a facility readmission on [DATE], with diagnoses that included Parkinson's Disease (a disorder of the central nervous system that affects movement, often including tremors) without dyskinesia (uncontrolled, involuntary muscle…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 medically related social services by the Social Services Director [SSD] is provided to one of two (Resident 2) sampled residents, in accordance with the facility's policy and procedure titled Social Services, by failing to: 1. Provide medically related social services that included coordination in discharge planning when Resident 2 was accepted to a residential care facility (a licensed community care facility that provides non-medical care and supervision for people who need assistance) on 9/3/2024 and 9/25/2024. 2. Schedule and coordinate the Interdisciplinary Team (IDT- a group of professionals with different areas of expertise who work together to achieve a common goal in an individual's healthcare needs) care plan meeting when Resident 2's family requested to meet with the facility's IDT on 9/11/2024, to discuss discharge planning. These deficient practices led to a delay in Resident 2's discharge planning to the Residential…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 supervision for one of two sampled residents (Resident 4), who was assessed at risk for elopement (a form of unsupervised wandering [to move/walk aimlessly without a purpose or definite destination] that leads to resident leaving the facility) dated 7/10/2024, due to a history of elopement and resident ' s wandering behavior. As a result, Resident 4 eloped from the facility on 9/24/2024, and was missing until 9/26/2024 [2 days]. Resident 4 was found at a location, 8.4 miles away from the facility. Resident 4 did not receive routine medications as ordered for Diabetes Mellitus Type 2 (long-term condition in which the body has trouble controlling blood sugar and using it for energy), Parkinson ' s disease [(clinical syndrome characterized by tremor (involuntary shaking)], depression (mental health condition that causes persistent feeling of sadness and changes in how you think, sleep, eat and act), schizophrenia (serious 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 provide one of three sampled residents (Resident 1) with meals that accommodated the resident's food preferences. As aresult of this deficient practice, Resident 1 ' s psychosocial wellbeing was affected and had the potential to alter the residents' health status. Findings: During a review of Resident 1 ' s admission Record indicated the facility admitted Resident 1 on 11/23/22 and readmitted her on 8/14/24 with diagnoses that include paraplegia (a form of paralysis that mostly affects the movement of the lower body) and major depressive disorder (a mental disorder that causes a persistent low mood and loss of interest in activities that are normally enjoyable). During a review of a Minimum Data Set (MDS, a standardized assessment and care planning screening tool), dated 5/9/24, indicated Resident 1 had intact cognitive (ability to understand and make decisions) skills for daily decision making. The MDS indicated Resident 1 was independent…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to ensure three licensed nurses had sufficient competency and skill sets in proper Fentanyl Transdermal patch (a pain medication administered on the skin via patch) administration, removal, rotation of site placement and disposal as indicated in the facility's policy and procedure titled, Controlled Medication Disposal, dated 01/2013, for one of two sampled residents (Resident 2). This failure resulted in Resident 2's skin irritation around the application site (chest area), and had a potential for the facility's residents, staffs and visitors to exposed toFentanylpatches that were not disposed correctly according to the facility's protocol. Findings: During a review of Resident 2's admission Record, indicated the resident was admitted to the facility on [DATE] with diagnoses that included quadriplegia (a form of paralysis that affects all four limbs), chronic (long-term) pain syndrome, respiratory failure (difficulty breathing on your own) with hypoxia…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 2), fentanyl (narcotic/controlled substance with a high risk for addiction and dependence used to treat severe pain) Transdermal (supplying a medication in a form for absorption through the skin into the bloodstream) patch placement was rotated, routinely monitored, and application, removal and disposal was accurately documented. This failure resulted in Resident 2 ' s fentanyl patch being removed by Resident 2 and placed on objects at Resident 2's bedside, such as bedside table and water bottles. The facility failing to document removal and disposal of fentanyl patch increased the potential for Resident 2 to not be administered medication as prescribed to reduce or relieve severe pain, increased risk for adverse reactions, medication errors, drug (medication) diversion, and exposed residents, staff, and visitors to access to unsecured fentanyl, potential for overdose, hospitalization, 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 the observation, interview, and record review, the facility failed to ensure the call light (used in healthcare facilities as an alerting device for nurses or other nursing personnel to assist a resident when in need) was within reach as indicated in the facility's policy and procedure for one out of two sampled residents (Resident 1) who needed to request for assistance to be cleaned after urinating and bowel movement on 8/2/2024. This deficient practice resulted in Resident 1 feeling upset because he was not able to use the call light while having a soaking wet diaper which could lead to skin breakdown, accident and injury, and/or not able to receive needed care timely in an event of an emergency. 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 diagnosis that included cellulitis (an infection of the deeper layers of skin and the underlying tissue), type 2 diabetes (condition that results in too much…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 1), who was dependent with the staff with hygiene care and was incontinent (no control of bladder and bowel) was not assisted with care timely. Resident 1 stated he felt upset and discomfort lying on a soaking wet diaper with his urine and stool and waited for at least thirty minutes, to be cleaned on 8/2/2024. This failure resulted in Resident 1 feeling frustrated and upset. This failure also had a potential to result in Resident1 1 and other potentially affected resident to be at risk for urinary infection (a condition in which bacteria invade and grow in the urinary tract), and skin breakdown (tissue damage caused by friction, shear, moisture, or pressure and is limited to the top layer of skin). 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 diagnosis that included cellulitis (an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to act upon the consultant pharmacist ' s recommendations from 6/1/2024 and 6/20/2024 to ensure accountability of fentanyl (narcotic/controlled substance with a high risk for addiction and dependence used to treat severe pain) Transdermal (supplying a medication in a form for absorption through the skin into the bloodstream) Patch, removal, and disposal for one of two Resident (Resident 2). (Cross Reference F755) This deficient practice of failing to act upon special handling of controlled medication irregularities (potential issues with a resident's medication regimen) identified by the consultant pharmacist during the Medication Regimen Review (MRR - a monthly report from the consultant pharmacist identifying any medication irregularities in a resident's current medication regimen) increased the potential for exposure of fentanyl by residents, staff, and visitors and could have experienced adverse effects (unwanted, uncomfortable, or dangerous effects…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement the facility ' s policy and procedure by failing to provide clean and sanitary environment and ensure the oxygen nasal cannula (NC, a flexible tube that provides oxygen through the nose) was not reused after it was observed on the floor for one of two sampled residents (Resident 1). This failure had a potential to result in Resident 1 ' s respiratory 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 diagnosis that included cellulitis (an infection of the deeper layers of skin and the underlying tissue), type 2 diabetes (condition that results in too much sugar circulating in the blood), and malnutrition (inadequate intake of food as a source of protein, calories, and other essential nutrients). During a review of Resident 1 ' s History and Physical, dated 6/5/2024, indicatedResident 1 had capacity to understand 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 implement with policy and procedure for abuse prevention when Certified Nursing Assistant (CNA) 2, was allowed to work and take care of residents without a completed background screening (a step in the employment process used to screen individuals for criminal records) for one of two sampled CNA records reviewed. This deficient practice placed the facility ' s residents at risk of harm or abuse from CNA 2. Findings: A review of Resident 4 ' s admission Record indicated the resident was admitted on [DATE] with diagnoses that included pneumonia (infection of the lungs) and diabetes mellitus (a chronic disease that result in high blood sugar levels in the blood). A review of Resident 4 ' s History and Physical (H&P), dated 7/15/2024, indicated the resident has the capacity to understand and make decisions. A review of Resident 4 ' s Minimum Data Set (a comprehensive standardized assessment and screening tool), dated 7/16/2024, indicated the resident has…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop resident specific comprehensive care plan for one of two sampled residents (Resident 2) to address resident safety and behavior management after Resident 2 allegedly hit Resident 3 to address specific interventions and goals to prevent further incidents of altercation. As a result of the deficient practice, Resident 2 and other residents safety were at risk for an altercation. Findings: A review of Resident 2 ' s admission Record indicated Resident 2 was admitted to the facility on [DATE] with diagnoses that included encephalopathy (damage or disease that affects the brain), psychosis (a severe mental condition in which thought and emotions are so affected that contact is lost with external reality), and dementia (a disorder of the brain, causing gradual decline in mental ability) A review of Resident 2 ' s History and Physical (H&P), dated 6/11/2024, indicated Resident 2 has the capacity to understand and make decisions. A review of Resident 2…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to monitor the behavior of one of two sampled residents (Resident 2) who suffered extreme paranoia (unrealistic distrust of others or a feeling of being persecute [punishment from a crime]) leading anger to determine the effectiveness of Quetiapine Fumarate (a psychotropic medications or type of medication that affects brain activities associated with mental processes and behavior). This failure had the potential for Resident 2 to receive inappropriate treatment and place other residents at risk of altercations with Resident 2 or unnecessary use of medication. Findings: A review of Resident 2 ' s admission Record indicated Resident 2 was admitted to the facility on [DATE] with diagnoses that included encephalopathy (damage or disease that affects the brain), psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with external reality), and dementia (a disorder of the brain, causing gradual 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 adhere to facility ' s policy and procedure for Enhanced Standard/Barrier Precaution (ESP- the use of gown and glove during high-contact resident care activities for residents known to be colonized or infected with disease causing organisms such as MDRO (multi-dose resistant organisms) that are resistant to antibiotics ( medications used to treat infection). Certified Nursing Assistant (CNA) 1 was observed providing patient care to one of one sampled residents (Resident 1), who had a wound and urinary catheter (tube inserted through the urinary tract to drain urine into a bag) without wearing an isolation gown (a type or personal protective equipment [PPE], a disposable gown made of paper-like material or plastic that helps in protecting the user ' s clothes). This deficient practice had the potential to result in a wide spread infection to the residents, staffs and visitors in the facility. Findings: A review of Resident 1 ' s admission…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 were adequate licensed nurses to provide wound care for three of four sampled residents (Resident 1, Resident 2, and Resident 3) with treatment orders for wound care. The deficient practices had placed the residents at risk for skin breakdown, poor wound healing, and deterioration of current pressure ulcers. Findings: 1.During a review of Resident 1 ' s admission Record indicated the facility originally admitted Resident 1 on 11/8/2015 and readmitted on [DATE] with diagnoses that included diabetes mellitus (a disease that affect how the body uses blood sugar and results in high blood sugar) and Parkinson ' s disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination). During a review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 4/4/24, indicated Resident 1 had severely 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 necessary treatment and services were documented for one of three sampled residents (Resident 1). This deficient practice had the potential for the resident to not receive medications and treatments as prescribed, which could cause a decline in health status. Findings: A review of Resident 1's Face Sheet indicated the facility readmitted Resident 1 on 4/5/2024 with diagnoses that included sepsis (life threatening body ' s response to an infection) and seizures (sudden, uncontrolled body movements and changes in behavior). A review of Resident 1's History and Physical dated 3/26/2024, indicated Resident 1 had the capacity to understand and make decision. A review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 3/26/2024 , indicated Resident 1 ' s cognition (ability to think and reasonably) was intact. A review of Resident 1 ' s Order Summary Report dated July 2024, indicated a treatment order to the resident ' s right ischium pressure ulcer. The order indicated to apply…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 implement its infection control policy to wear approproiate Personal Protective Equipment (PPE) to help prevent the spread and transmission of infections to residents, staff members, visitors in accordance with the facility ' s policy and procedure on infection control by failing to: 1. Ensure Certified Nursing Assistant (CNA1) wore the N95 respirator mask (a respiratory protective device designed to achieve a very close facial fit and very efficient filtration of air particles) that covered the nose and mouth while in the facility during an active Coronavirus (COVID-19, an infectious disease caused by the severe acute respiratory syndrome corona virus 2 (SARS-CoV-2 virus)) outbreak. This deficient practices had the potential to increase the number of infected residents and spread the infection to the residents, staff, and other visitors in the facility. Findings: During an observation on 6/25/2024 at 11:12 AM, CNA 1 was observed pushing a linen cart in the hallway near COVID-19 resident rooms, wearing the N95…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 residents were free from neglect (the failure to provide good and services to a patient that are necessary to avoid physical harm, pain, mental anguish, or emotional distress) for three of three sampled residents. 1. Resident 1 verbalized that on 6/11/24, at around 6 PM during the evening shift (3 PM to 11 PM) when Resident 1 asked Certified Nursing Assistant (CNA) 1 for assistance with toileting. Resident 1 sat on soiled urine on 6/11/24 from 6:20 PM to 11 PM (evening shift - 4 hours and 40 minutes). This deficient practice resulted in Resident 1 verbalizing feeling upset, disrespected, and inhumane having to experienced neglect from CNA 1 on 6/11/24. 2. Resident 3 verbalized how CNA 1 was rude on 3/11/24 during the evening shift. Resident 3 stated that prior to that week (unable to state the exact date) CNA 1 refused to assist her request for transfer from bed to the wheelchair. Resident 3 verbalized being upset with CNA 1. 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 interview and record review, the facility failed to: 1. Investigate Resident 2 ' s complaint of Certified Nursing Assistant 1 (CNA 1) being rude on 5/9/24 during the 3 PM to 11 PM shift. 2. Provide Resident 2 a written grievance decision within 5 working days, in accordance with the facility ' s policy titled Grievances/Complaints, Recording and Investigating and dated 8/25/21. This deficient practice violated the residents' right to be provided with a written resolution. As a result, another resident, Resident 1, complained about CNA 1 on 6/11/24, and experienced being upset and disrespected. These deficient practices have the potential to negatively affect the resident ' s psychosocial impact. Findings: A review of Resident 2 ' s admission records, indicated Resident 2 was admitted to the facility on [DATE] with diagnoses that included difficulty in walking, generalized muscle weakness, type 2 diabetes mellitus (disease in which there is a high level of sugar in the blood, and obstructive and reflux…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 provide care that meets the professional standards of quality for one of four sampled Residents (Resident 4) by not documenting a psychotropic (a drug or other substance that affects how the brain works and causes changes in mood, awareness, thoughts, feelings, or behavior) medication administered to Resident 4 on his Medication Administration Record (MAR) in accordance with the facility ' s policy and procedure titled, Administering Medications. This deficient practice had the potential to result in medication errors and can lead to adverse reactions (any unexpected or dangerous reaction to a drug) for Resident 4. Findings: During a review of Resident 4 ' s Face Sheet indicated the facility admitted Resident 4 on 7/19/22 with diagnoses that included end stage renal disease (ESRD, 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 [a type of treatment that helps your body remove extra fluid and waste products from 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.

Based on interview and record review, the facility failed to provide supervision for one of four sampled residents (Resident 4) when Resident 4 had exited the facility ' s premise without the facility's knowledge on 6/8/24. As a result, Resident 4 was found outside of the facility at a liquor store and was brought back to the facility. This deficient practice had placed Resident 4 at risk for cold exposure, dehydration (a dangerous loss of body fluid caused by illness, sweating, or inadequate intake) and other medical complications, and being struck by a motor vehicle. Findings: During a review of Resident 4 ' s Face Sheet indicated the facility admitted Resident 4 on 7/19/22 with diagnoses that included end stage renal disease (ESRD, 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 to maintain life), bipolar disorder (a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration), and metabolic encephalopathy (a condition in which brain…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 food brought by resident at bedside for one of two sampled residents (Resident 1) in accordance with the facility's policy and procedure titled Safe Handling of foods from Visitor. This deficient practice had the potential to result in food-borne illnesses (food poisoning) for Resident 1, with symptoms including upset stomach, stomach cramps, nausea, vomiting, diarrhea, and fever and can lead to other serious medical complications (a medical problem that occurred during a disease) and hospitalization. Findings: A review of the admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE], with the diagnoses including but not limited to paraplegia (a condition in which you were unable to move all or part of your body because of illness or injury), muscle weakness, and hypertension (high blood pressure was when the force of the blood pushing on the blood vessel walls was too high). 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 post accurate Nurse Staffing Information of actual hours worked by the licensed and unlicensed nursing staff directly responsible for resident care per shift/daily. In addition, the Nurse Staffing Information was not posted in a prominent location readily accessible to residents and visitors for viewing, in accordance with the facility ' s policy and procedure titled Nursing Department – Staffing, Scheduling and Posting. This deficient practice of posting inaccurate Nurse Staffing Information could mislead the residents and visitors that may affect the quality of nursing care provided to the residents. Findings: A review of the Facility ' s Daily Nursing Staffing Posting, dated (Thursday) 4/18/2024, indicated the facility census, projected PPD (per patient day) for three shifts (day shift, evening shift, night shift) for RNs (registered nurse), LVNs (licensed vocational nurse), CNAs (certified nursing assistant) and RNAs (restorative nursing assistant). During an observation, on 4/18/2024 at 8:55 AM, the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide medically-related social services to attain or maintain the highest practicable physical, mental and psychosocial well-being for one of one sampled residents (Resident 1). This deficient practice had the potential to result in Resident 1 ' s unmet care needs. Findings: A review of Resident 1 ' s admission Record indicated a readmission to the facility on [DATE], with diagnoses that included seizure (a sudden, uncontrolled burst of electrical activity in the brain that can cause changes in behavior, movements, feelings, and levels of consciousness), paraplegia (the inability to voluntarily move the lower parts of the body), major depressive disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). A review of Resident 1 ' s History and Physical Examination dated 9/10/2023 indicated Resident 1 had the capacity to understand and make decisions. A…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of one sampled resident (Resident 63)'s rights to accept visitors in the facility. Resident 63 was denied the visitation rights to be visited by family member (FM) 1. The deficient practice violated Resident 63's right to accept visitors and resulted Resident 63's verbalizing emotional distress and stated he had felt very sad because he could not see FAM 1 who was very important to him. Findings: During a review of Resident 63's admission Record indicated the facility originally admitted Resident 63 on 11/23/19 and readmitted on [DATE] with diagnoses that included seizure (a sudden, uncontrolled burst of electrical activity in the brain that can cause changes in behavior, movements, feelings, and levels of consciousness) and paraplegia (the inability to voluntarily move the lower parts of the body). During a review of Resident 63's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 12/29/2023, indicated 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 a resident was free from abuse for one of two sampled residents (Residents 1) when Certified Nursing Assistant (CNA) 1, a CNA from Hospice (care focuses on the care, comfort, and quality of life of a person with a serious illness who is approaching the end of life) 1, continued providing sponge bath in bed to Resident 1 in a rough manner while Resident 1 cried, on 3/6/2024, as witnessed by CNA 2 (Facility CNA) and Resident 2 (Resident 1 ' s roommate). This deficient practice had a potential for Resident 1 to suffer negative psychosocial outcome such as anger, fear, anxiety, or loss of self-esteem Findings: A review of Resident 1 ' s admission Record indicated the facility initially admitted Resident 1 on 5/29/2019 and then readmitted on [DATE], with diagnoses that included hypertensive heart disease ( problems with the heart that can develop due to high blood pressure) with heart failure, Type 2 diabetes mellitus 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 observation, interview, and record review, the facility failed to ensure a resident was free from abuse according to the facility ' s policy and procedure (P&P) for one of two sampled residents (Residents 1) when Certified Nursing Assistant (CNA) 1, a CNA from Hospice (care focuses on the care, comfort, and quality of life of a person with a serious illness who is approaching the end of life) 1, continued providing sponge bath in bed to Resident 1 in a rough manner while Resident 1 cried, on 3/6/2024, as witnessed by CNA 1 (Facility CNA) and Resident 2 (Resident 1 ' s roommate) stood by Resident 1 ' s roommate's (Resident 2) bedside, outside Resident 1 ' s privacy curtain while hearing roughness and crying and did not intervene while Resident 1 was being cared for by Hospice CNA 2. This deficient practice had a potential for Resident 1 to suffer negative psychosocial outcome such as anger, fear, anxiety, or loss of self-esteem. Findings: A review of Resident 1 ' s admission Record 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 implement its infection control policy and procedure for six of 16 sampled residents (Residents 1, 2, 3, 4, 5, 6) identified with rashes at the facility by failing to: 1. Establish a surveillance system (an ongoing systematic collection, analysis, and interpretation of data, that allows the facility to track, analyze and interpret the data), and identify a concern that there was an unusual increasing number of residents with new and ongoing rashes every month from 1/2024 to 3/2024 (a total of 3 months). 2. Identify an outbreak (an increase of disease among a specific population in a geographic area during a specific period) when Resident 1 was diagnosed with scabies (an infestation of the skin by the human itch mite. The microscopic scabies mite burrows into the upper layer of the skin where it lives and lays its eggs and cause severe itchiness) on 2/9/2024 and 4 clinically suspected cases (Residents 2, 3, 4, and 5) were treated 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 protect a resident ' s right to be free from abuse, but not limited to mental abuse (the use of verbal or nonverbal conduct which causes or has the potential to cause the resident to experience humiliation, intimidation, fear, shame, agitation, or degradation) and corporal punishment (physical punishment; and used as a means to correct or control behavior) for one of three sampled residents (Resident 2). On 2/12/2024, during the night shift (11 PM to 7 AM), Certified Nurse Assistant (CNA) 1 tilted Resident 2 ' s shower chair forward and pushed Resident 2 ' s head down to make Resident 2 pick up a diaper on the ground. CNA 1 yelled at Resident 2 to pick up the diaper from the floor because CNA 1 would not pick it up for Resident 2. On the same night, CNA 1 assisted Resident 2 back to bed and threw Resident 2 ' s feet back to bed. According to the Resident 2, CNA 1 informed her that if Resident 2 needed something else to let CNA 1 know…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 report an injury of unknown source to the Department and other officials immediately, but not later than two hours for one of three sampled residents (Resident 1) in accordance with the mandated Federal and State regulatory guidelines. On 2/13/2024, a report was received indicating Resident 1 had a discoloration on right side of forehead from an unknown source. This deficient practice had the potential for the facility to under report allegations of abuse, neglect, exploitation, or mistreatment, including injuries of unknown source, which could lead to failure to investigate in a timely manner. Findings: A review of Resident 1 ' s admission Record indicated an admission date on 12/21/2023 with diagnoses including cerebral infarction (ischemic stroke, occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it), hemiplegia (one-sided paralysis (loss of the ability to move)) affecting right dominant side, epilepsy (disorder of the brain characterized by repeated seizures),…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 assess the use of side rails for two of three sampled residents (Resident 1 and 6) to prevent accident and injury. This deficient practice had the potential for Resident 1 and 6 to sustain serious injuries. Findings: A review of Resident 1 ' s admission Record indicated an admission date on 12/21/2023 with diagnoses including cerebral infarction (ischemic stroke, occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it), hemiplegia (one-sided paralysis (loss of the ability to move)) affecting right dominant side, epilepsy (disorder of the brain characterized by repeated seizures), and dermatitis (skin inflammation characterized by itchiness, redness, and a rash). A review of Resident 1 ' s Minimum Data Set (MDS, an assessment and screen tool) dated 2/11/2024 indicated Resident 1 had moderately impaired (decisions poor/supervision required) cognition skills for daily decision making…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 three sampled residents (Resident 1) was free from significant medication error by: 1. Failing to administer lacosamide (a medication used to treat seizure [a burst of uncontrolled electrical activity between brain cells, causing changes in behavior, movements, feelings and levels of consciousness]), and is a federally controlled substance) 200 milligram (mg, a unit measurement) oral one tablet at 9 PM on 1/1/24 and 1/4/24. 2. Failing to administer Keppra (a medication used to treat seizure) 750mg oral one tablet at 9 PM on 1/1/24 and 1/4/24. 3. Failing to administer fish oil supplement (derived from the tissues of oily fish, to improve inflammation and lower blood pressure and fats in the blood) at 500mg oral one capsule at 10 PM on 1/1/24 and 1/4/24. 4. Failing to administer Prednisolone acetate 1% ophthalmic suspension (a medication to treat eye conditions due to inflammation or injury) one drop to each affected eye at 9PM on 1/1/24. 5.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 answer the call light and assist the resident in turning and repositioning timely, in accordance with the facility ' s policy and procedure (P&P) titled, Skin Integrity Management, for one of three sampled residents (Resident 1), who had paraplegia (the inability to voluntarily move the lower parts of the body) and a stage four pressure ulcer (most serious bed sore that caused by something putting pressure on or rubbing the skin) to the right ischium (a bone forms the lower and back part of the hip bone). These deficient practices had place Resident 1 ' at risk for poor wound healing and deterioration of current pressure ulcer. Findings: During a review of Resident 1 ' s admission Record indicated the facility originally admitted Resident 1 on 11/23/19 and readmitted on [DATE] with diagnoses that included paraplegia and a stage four pressure ulcer at right buttock. During a review of Resident 1's Minimum Data Set (MDS, a standardized…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow up on the physician's order for ophthalmology (a medical specialty within medicine that deals with the diagnosis and treatment of eye disorders) consultation and otolaryngology (ENT, a medical specialty which is focused on the ears, nose, and throat) follow up upon readmission for one of three sampled residents (Resident 1). These deficient practices had the potential for a delay in the delivery of care and services for Resident 1. Findings: During a review of Resident 1 ' s admission Record indicated the facility originally admitted Resident 1 on 11/23/19 and readmitted on [DATE] with diagnoses that included left eye conjunctivitis (inflammation or infection of the eye) and rhinitis (irritation and swelling of the inside of the nose). During a review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 12/29/23, indicated Resident 1 had intact memory and cognitive (ability to think and reasonably)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 one of three sampled residents (Resident 1), who had a diagnosis of seizure (a burst of uncontrolled electrical activity between brain cells, causing changes in behavior, movements, feelings, and levels of consciousness) and was on anticonvulsant (medications used to treat seizure) medications with laboratory (lab) services as ordered by the physician. This deficient practice had placed Resident 1 at risk for receiving anticonvulsants in the dosage that were not within the therapeutic range and had the potential to result in recurrent seizure. Findings: During a review of Resident 1 ' s admission Record indicated the facility originally admitted Resident 1 on 11/23/19 and readmitted on [DATE] with diagnoses that included seizure and paraplegia (the inability to voluntarily move the lower parts of the body). During a review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 12/29/23, indicated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 7) received treatment for bowel movements (process of expelling waste, including stool) by failing to: 1. Administer a rectal suppository [medication in a solid, cone-shaped form that is inserted into the rectum (last part of the large intestine where waste material is stored before elimination from the body through the anus) where is dissolves or melts to release the medication] to Resident 7 on 12/10/2023 upon Resident 7 ' s request and in accordance with the physician ' s order; and 2. Accurately document administered suppositories to Resident 7 for the months of 10/2023, 11/2023, and 12/2023, including 12/21/23. These failures had the potential for Resident 7 to experience pain, constipation (condition in which a person has uncomfortable or infrequent bowel movements), and fecal impaction (occurs when hard mass of stool gets stuck in the rectum making it difficult to have a bowel…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to: 1. Maintain accountability of 25 doses of Norco (a medication used to treat pain) 10/325 milligrams (mg – a unit of measurement for mass) between 12/17/23 and 12/21/23 for one of three sampled residents (Resident 1.) 2. Ensure licensed staff do not prepare medications for more than one resident at a time during the evening medication administration on 12/17/23 affecting one of three sampled residents (Resident 1.) 3. Ensure licensed staff signed the Ongoing Inventory of Controlled Drugs (a document transferring accountability of controlled medications [medications with a high potential for abuse] between nurses during shift change) a total of six times between 12/9/23 and 12/20/23. 4. Order Norco 5/325 mg from the pharmacy pursuant to an active physician order dated 11/10/23 for one of three sampled residents (Resident 3.) These deficient practices increased the risk that controlled medications could have been diverted (used for any…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to develop and implement a communication care plan for one of three sampled residents (Resident 6). This failure had the potential to prevent Resident 6 from receiving services, including the recommendation on 6/21/2018 for additional Speech Therapy (ST, profession aimed in the prevention, assessment, and treatment of speech, language, communicative, and swallowing disorders) intervention, to improve and maximize Resident 6 ' s ability to communicate. Findings: A review of Resident 6 ' s admission Record indicated the facility initially admitted Resident 6 on 4/22/2008, with diagnoses including muscle weakness, hemiplegia and hemiparesis (weakness or paralysis of one side of the body) following cerebral infarction (brain damage due to a loss of oxygen to the area) affecting the right dominant side, and dysphagia (difficulty swallowing). A review of Resident 6 ' s ST Discharge summary, dated [DATE], indicated Resident 6 had aphasia (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 interviews and record reviews, the facility failed to ensure one of three sampled residents (Resident 1) care plan was revised based on the resident ' s current condition. This deficient practice had the potential to result in the decline of Resident 1 ' s psychosocial status which included self-esteem and self-worth. Findings: A review of Resident 1 ' s Face Sheet indicated the resident was admitted to the facility on [DATE], with diagnoses that included opioid (a class of drugs used to reduce pain; can cause addiction) abuse, stimulant abuse and long-term use of opiate analgesics (a class of medication used in the management and treatment of pain). A review of Resident 1 ' s History and Physical Examination dated 9/5/23, indicated that Resident 1 had the capacity to understand and make decisions. A review of Resident 1 ' s Interdisciplinary Team (IDT) Notes dated 11/1/23, indicated the IDT Notes indicated no evidence of a follow up IDT meeting to address a resident to resident altercation of 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 one of two laundry staff wore a face covering, including an N95 respirator (nationally approved face mask that filters at least 95% of airborne particles), in the facility's clean linen room while the facility had an open outbreak (sudden rise of disease) of Coronavirus-19 (COVID-19, a highly contagious viral disease that can cause respiratory illness). This failure had the potential to spread disease throughout the facility. Findings: During a concurrent observation and interview on 12/21/2023 at 9:45 AM in the facility ' s hallway just outside the laundry room, Laundry Aide 1 (Laundry 1) sat on a chair against the far wall of the room. Laundry 1 stated the Laundry Room contained clean linen. Laundry 1 was not wearing any face covering while folding clean sheets. Laundry 1 walked out of the Laundry Room and returned to the room wearing a surgical face mask (loose-fitting, disposable mask that creates a physical barrier on the mouth and nose of the wearer). During an interview on 12/22/2023 at 10:46 AM…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 administer medications as ordered by the physician and document the reason on the resident's Medication Administration Record (MAR) for one of five sampled residents (Resident 1). The facility was unable to find out who the specific assigned licensed nurse to follow up on for appropriate reeducation because the resident assignments were not kept and filed for each shift. This deficient practice can prevent the resident from benefiting from the optimal effects of the medications and the facility not able to provide reeducation and follow through with the specific licensed nurses involved. Findings: A review of Resident 1's admission Record indicated the facility admitted Resident 1 on 1/24/23 with the diagnoses that included cerebral infarction (damage to tissues in the brain due to a loss of oxygen to the area, also known as stroke), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest and can interfere with your daily), and hypertension [HTN, high blood pressure, a 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 follow nursing professional standards of care (Essentials of nursing, its activities, and its accountabilities. Establishes the scope, status, and prospect of nursing) for two of four sampled residents (Resident 1 and Resident 2) failing to ensure Resident 1 and 2 was administered medication timely in accordance with the residents physician's orders. These deficient practices had the potential to negatively affect the delivery of care and services related to the Resident 1 and 2's health condition and place the residents at risk for serious illness and/ or death. Findings: 1. A review of Resident 1's admission Record indicated the resident was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of, but not limited to, end stage renal disease (the last stage of chronic kidney disease. It marks the point when kidney function drops to very low levels), atherosclerotic heart disease (when a sticky substance called plaque builds up…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 4), was assessed, provided interventions for pain relief and comfort, and reevaluated for pain relief as indicated in the resident ' s care plan. This failure had a potential to result in Resident 4 ' s inability to maintain his highest practicable level of well-being and to prevent pain. Findings: A review of Resident 4 ' s admission record indicated the resident was admitted to the facility on [DATE], with diagnoses that included, Type 2 Diabetes Mellitus (a condition that results in too much sugar circulating in the blood), left knee neuropathy, contracture (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints), muscle weakness, and chronic pain syndrome. A review of Resident 4 ' s History and Physical (H&P), dated 9/22/21, indicated, Resident 4 had hemiplegia (paralysis of one side of the body) on the left side…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed treat one of 7 sampled residents (Resident 1) with respect and dignity by honoring the resident's right to not to be disturbed during sleep, and to keep his meal tray at the bedside according to his preference, without interference (invading or interfering) or reprisal (act of retaliation) as indicated in the facility's policy and procedure titled Dignity. Resident 1 stated while he was asleep when Certified Nursing Assistant (CNA1) woke up him to eat his meal so that he could collect the meal tray. Resident 1 stated he told CNA3 to leave him alone and told him to leave his food tray at the bedside because he fell asleep during lunch, and he preferred his meal tray remain in the room. When CNA 3 was leaving his room, Resident 1 was heard CNA 3 say in a foreign language, You're lucky you can't walk, mother fucker, and told CNA 1 He is f .king with me, why does he not go and f .his mother . I hate the lies .the liars. These deficient practices resulted 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, interviews, and record reviews, the facility failed to ensure one of two sampled residents (Resident 1) who is receiving antiseizure medications (medications that lowers electrical activity in the brain that causes seizures [uncontrolled body movements]) was given the medications (Keppra or Levetiracetam) to control and manage seizure activity and a medication reconciliation (The process of identifying the most accurate list of all medications that the patient is taking, including name, dosage, frequency, and route, by comparing the medical record to an external list of medications obtained from a patient, hospital, or other provider) is performed to prevent omission of medications. Resident 1 ' s antiseizure medication, Levetiracetam (Keppra) was discontinued on 3/19/23 and 3/20/23. This deficient practice resulted to Resident 1 not receiving Levetiracetam (Keppra) 1500 milligrams (unit of measurement) two times a day, as ordered by the physician as an additional antiseizure medication 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 administer 47 doses of anti-seizure medications (Lacosamide, Keppra, Phenytoin) at the correct/scheduled times indicated on the physician's orders between 9/1/2023 and 9/26/2023 for one of two sampled residents (Resident 1) receiving anti-seizure medications. The failure of the facility to administer anti-seizure medications at the correct times increased the risk that Resident 1 could have experienced seizures resulting in hospitalization, coma (definition), or death. Findings: A review of Resident 1's Facility admission Record indicated the facility initially admitted the resident on 11/23/2019, with a current readmission date of 9/9/2023 with diagnoses that included acute kidney failure (a condition in which one or both kidneys no longer work on their own), seizures (abnormal electrical activity in the brain) and functional quadriplegia (refers to complete immobility due to severe physical disability). A review of the facility'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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide adequate supervision for two of nine sampled residents (Residents 6 and 7) while in facility's Smoking Patio. This deficient practice resulted in Resident 6 rammed the wheelchair into Resident 7. This had the potential for skin injury and preventable accident. Findings: A review of Resident 6's admission Record indicated the facility admitted the resident on 8/10/23 with diagnoses that included anxiety disorder (mental health disorder characterized by feelings of worry or fear that are strong enough to interfere with one's daily activities), depression (a common and serious medical illness that negatively affects how you feel, the way you think and how you act), and malnutrition (occurs when the body doesn't get enough nutrients. Causes include a poor diet, digestive conditions, or another disease.) A review of Resident 6's Minimum Data Set (MDS, a standardized resident assessment and care screening tool), dated 8/17/23, indicated Resident 6…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 residents received treatment and care in accordance with professional standards of practice and the facility ' s policy for one of two sampled residents (Resident 1) with a diagnosis of diabetes mellitus (a disease in which the blood sugar levels are too high), when it failed to ensure all appropriate discharge orders from General Acute Care Hospital (GACH) 1 were verified with the attending physician (Physician 1) upon readmission to Skilled Nursing Facility (SNF) 1 on 7/14/2023. This deficient practice resulted to Resident 1 not receiving the care and services to continue diabetic management and medications for the resident ' s diagnosis while in the facility from 7/14/2023 to 7/28/2023 (14 days) and upon transfer to another Skilled Nursing Facility (SNF 2) on 7/28/2023. As a result, Resident 1 was transferred to GACH 2 for hyperglycemia (high blood sugar) via 9-1-1 emergency services on 8/28/2023. In the GACH 2, Resident 1 had a diagnosis of diabetic ketoacidosis (DKA- a serious complication of diabetes that can…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 comprehensive, resident specific care plan for one of two sampled residents (Resident 1) upon readmission back to the facility on 7/14/2023. Resident 1 did not have a care plan developed on 7/14/2023 to 7/28/2023 for the management of Type 2 Diabetes Mellitus and hyperglycemia. This deficient practice resulted in the resident 1 ' s diagnosis Type 2 Diabetes / blood glucose levels not properly monitored for the changes in condition and a potential to develop complications from the disease. Findings: A review of Resident 1 ' s admission Record from SNF 1 indicated Resident 1 was initially admitted on [DATE] and readmitted on [DATE], with diagnoses that included metabolic encephalopathy (brain dysfunctions due to problems with your metabolism), Type 2 diabetes mellitus with hyperglycemia (high blood sugar), schizophrenia (a mental disorder characterized by disruptions in thought processes, perceptions, emotional responsiveness, 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 there is always sufficient qualified nursing staff available to provide nursing and related services to meet the residents' needs safely and in a manner that promotes each resident's rights, physical, mental, and psychosocial well-being, in accordance with the resident's assessment, resident's plan of care, and facility assessment. The facility's failure included: 1. Ensure to employ sufficient certified nursing assistants (CNA) to provide care and services in assisting residents on 8/4/23, 8/5/23, 8/6/23, 8/12/23, 8/13/23, 8/14/23, 8/15/23, 8/20/23, and 8/25/23. 2. Not ensuring licensed staff were consistently assigned to each of the facility's three Nursing Station across the shifts. Two Registered Nurses (RN 1 and 2) were consistently assigned to work double shifts with Staffing Assignments reviewed dated 8/5, 8/7, 8/12, 8/14, 8/16, 8/18, 8/19, 8/25 and 8/26) which indicated inadequacy of licensed nurses scheduled for these dates. 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.

Based on interview and record review, the facility ' s Quality Assurance and Performance Improvement (QAPI) committee failed to develop and implement policies and procedures which included how the facility ensures that data were collected, monitored, and appropriate action plans were implemented to identify quality of care issues regarding abuse. As a result of this deficient practice, the facility had no distinct performance improvement for abuse prevention Findings: A review of the facility ' s printed Risk Management System incident report (RMS) with an initiation date 7/20/2023 indicated the facility had over 200 identified RMS remaining to be unlocked. During a concurrent interview and record review on 9/9/23 at 6:30 PM of the facilities RMS form for 7/20/2023 at 6:30 PM with Administrator (ADM) and Director of Nursing (DON). The DON stated she has not had time review RMS identified issues and implement into facilities QAPI. The ADM confirmed current facilities current QAPI plan did not indicate current quality of care issues such as abuse. ADM stated the facility has not had a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews and record review, the facility failed to report allegations of sexual abuse from another resident to the Department and other officials immediately, but not later than two hours for two of three sampled residents (Residents 2 and 3). Resident 2 and 6 reported to facility staff that Resident 1 was observed lying on top of Resident 2 while in bed, with pants and underwear down on 8/24/2023 around 2 AM. This deficient practice had the potential for the facility to under report allegations of abuse, neglect, exploitation or mistreatment which could lead to failure to investigate all types of abuse in a timely manner and protect residents from abuse. Findings: 1. A review of Resident 1 ' s admission Record indicated the facility admitted the resident on 8/8/2019 and readmitted on [DATE], with diagnoses that included Alzheimer ' s disease (a brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks), dementia and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure two of two sampled residents (Resident 9 and 10), received restorative nursing services (to maintain a person ' s physical abilities to perform activities of daily living (ADLs) that promote independent living) as ordered by the physician. This failure had the potential to cause further decline in Resident 9 and Resident 10 ' s physical abilities and contractures (the shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints). Findings: During a review of Resident 9 ' s admission record, dated 9/7/23, the admission record indicated Resident 9 was admitted to the facility on [DATE] with the following diagnoses, vitamin D deficiency, paraplegia (the inability to voluntarily move the lower parts of the body), hemiplegia (the inability to voluntarily move one side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction (also known as a stroke;…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 clinical records in accordance with accepted professional standards and practices for 1 out of 2 sample residents (Resident 7) by failing to document the administration of intravenous accurately and completely (IV - within the vein) antibiotics (medication to fight infection) in the Resident 7 Infusion Medication Administration Record (IMAR). 1.Resident 7 ' s IV treatment administration record did not indicate all staff who administered IV medications. 2. Resident 7 ' s IV medications fluid volume was not documented. 3. Resident 7 ' s IV medication rate of infusion was not documented. This failure had the potential to negatively impact the delivery of care and services. Findings: A review of Resident 7 ' s admission Record indicated an initial admission to the facility on 1/17/2018 and readmission on [DATE] with diagnoses diabetes (high blood sugar), hypertension (high blood pressure), and heart disease. 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.