Heritage Manor

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and closed record review, the facility failed to ensure the required Notice of Proposed Transfer/Discharge (a written notification to the resident or responsible party (RP) was fully completed and sent to the Long Term Care Ombudsman (advocates for residents of nursing homes, board and care homes and assisted living facilities) for two of two sampled residents (Resident 7 and Resident 101). The required notice, which provides written information to the resident or responsible party regarding the reason for the transfer or discharge, was not completed in full before being sent to the Ombudsman. This deficient practice failed to ensure the residents' rights to have the Long Term Care Ombudsman notified and able to advocate on behalf of Resident 7 and Resident 101 regarding their proposed transfer/discharge. Findings: 1 During a review of Resident 7's admission Record (AR), the AR indicated that the facility admitted Resident 7 on 9/5/2022 and readmitted Resident 7 on 4/5/2026 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 observation, interview, and record review, the facility failed to provide care and services based on Professional Standard of Practice for two of two sampled residents (Residents 38 and 43). The facility failed to: 1.For Resident 38 with diabetes (a condition of having high blood sugar) Registered Nurse (RN) 3 transcribed in a physician order to administered IV (intravenous or administered into the vein) 5% Dextrose Normal Saline (solution with salt and glucose) to the resident without a physician order. This deficient practice had the potential to result in inaccurate treatment and inappropriate IV fluid administration and result in serious complications that included hyperglycemia (high blood glucose levels) fluid overload (the body retaining and unable to remove excess fluids) or need of hospitalization. 2. For Resident 46, who had a foley catheter (a flexible tube used to drain urine from the bladder continuously into a bag) the Treatment Nurse (TXN) reinserted the foley catheter without 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 to ensure to maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, sufficient fluid intake to maintain proper hydration and health to two of two sampled residents (Residents 6 and 65) by failing to: 1.For Resident 65, who has had weight loss, the staff failed to monitor and document the percentage of intake of nourishments/snacks to indicate if the snacks were consumed or not as ordered by the physician and recommended by the Registered Dietician. 2.For Resident 6, who required peritoneal dialysis (PD, a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) was not monitored to restrict fluid intake to 1500 milliliters (mL, unit of measure) as indicated in the Nutritional Assessment on 3/3/2026. These failures had the potential to place Resident 6 and Resident 65 to be at risk for altered…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 drugs and destruct biologicals in accordance with the facility's policy and procedure titled Medication Storage and Destruction of Unused Drugs when unknown white medication tablet was found on the floor in one of the two medication rooms. This deficient practice resulted in unsafe storage of the medication and had the potential to result in medication errors and misuse. During an observation Medication Room (MR) and concurrent interview with Licensed Vocational Nurse (LVN) 2 on [DATE] at 5:22 AM, a white round unknown medication tablet was found on the floor. LVN 2 stated she did not know what medication it was and why the tablet was on the floor. LVN 2 stated nurses should check the MRs for any loose tablets and discard medication tablet into the Medication Disposable bin to prevent medication errors. During an interview on [DATE] at 1:46 PM with the Director of Nursing (DON), the DON stated that nurses are required to check 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 that the arbitration agreement (AA, a written contract where parties agree to settle disputes privately through a neutral third party [an arbitrator] rather than in a public courtroom) was adequately explained so the resident or their responsible party (RP) could understand its terms for one of three sampled residents (Resident 65) by failing to inform Resident 65's RP that he had 30 days after signing to fully review the agreement and rescind any agreement if it was not understood at the time of admission. This deficient practice has the potential to affect Resident 65's and the resident's RP's right to make informed decisions and choices about important aspects of the resident's health, safety and welfare. Findings: During a review of Resident 65's admission Record (AR), the AR indicated that Resident 65 was admitted on [DATE], and Resident 65's RP was Family Member (FM 1). The AR indicated that Resident 65 was admitted 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.

Based on observation, interview and record review, the facility failed to ensure call light was within reach for five of five sampled residents (Resident 46, . The deficient practices had potential for Resident 46 not being able to call the facility staff to ask for help or assistance, especially during emergencies. During a review of Resident 46's admission Record (AR), the AR indicated the facility admitted Resident 46 on 3/22/2026 with diagnoses that included displaced fracture of base of neck of right femur (right hip fracture) and Parkinson's disease (a progressive condition that affects movement). During a review of Resident 46's Minimum Data Set (MDS, a standardized assessment and care planning screening tool), dated 3/26/2026, indicated Resident 46's had moderately impaired cognition (ability to understand and make decisions) and memory. The MDS indicated Resident 46 required partial/moderate assistance with eating, oral hygiene and personal hygiene, and was dependent on toileting hygiene, shower/bathe self and chair/bed-to-chair transfer. During a concurrent observation and…

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

Based on observation, interview and record review, the facility failed to ensure safe and sanitary food storage and food production practices were implemented by failing to: Dispose of one sandwich, with a use by date of 2/23/26, stored in the facility's refrigerator in the conference room. Ensure kitchen towels used to wipe food contact surfaces were stored in the sanitizer solution bucket and ensure hair nets were readily available in the conference room where food was served. Ensure temperature of Time/Temperature control for safety food (TCS foods that can support bacterial growth that can result in food borne illness unless stored, prepared and served safely) foods were not above 41 degrees Fahrenheit (F). The temperature of milk held for cold storage served during lunch service was measured at 52.5F. These deficient practices had the potential to result in harmful bacteria growth and cross contamination (transfer of harmful bacteria from one place to another) that could lead to food borne illnesses in 89 out of 93 residents who received food from the facility. Findings: 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.

Based on observation, interview and record review the facility failed to ensure a QA/QAPI (Quality Assurance/Quality Assurance and Performance improvement, a date driven proactive approach to improvement used to ensure services are meeting quality standards) plan was developed on how to monitored interventions put in place related to the inoperable elevator from and to the kitchen and food service in the conference room by failing to: 1. Safe and sanitary food storage and distribution practices in the conference room. 2. Staff received ongoing training and evaluations of their skills and knowledge to ensure safe food receipt and delivery procedure, safe and sanitary food distribution to residents and reduced risk of injury. 3.Food items were received and handled in a safe and sanitary manner from suppliers. This deficient practice had the potential for unsanitary and unsafe food storage and distribution practices that can result in food poisoning or foodborne illnesses (gastrointestinal infection due to consumption of contaminated food with toxins from bacteria, virus or parasites).…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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, facility failed to maintain safe and functional environment by ensuring the elevator from the kitchen was maintained in functioning condition to maintain sanitary and safe food service for all residents in the facility and staffs. As a result, resident food was carried by the staff from basement through the stairwell, food distribution and service is relocated to the conference room, food vendors leave food deliveries in the parking lot to be carried by kitchen staff through the stairwell. This deficient practice had the potential to result in unsafe and unsanitary food storage and distribution practice and place staff at risk of injuries.Findings: During a concurrent observation and interview with Assistant Administrator (AADM) and Maintenance Supervisor (MS) on 2/24/2026 at 10:30AM, the facility conference room was being used by the facility as a food distribution and serving area for the residents. During the same observation on 2/24/2026 at 10:30AM, 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 provide the necessary diabetic care and services for one of three sampled residents (Resident 1), who had a diagnosis of type 2 diabetes mellitus (DM, a disorder characterized by difficulty in blood sugar control), by failing to coordinate services for diabetic care and management for Resident 1 that included checking blood sugar with an accu-check machine (checking blood sugar level with the use of a machine, by pricking the finger and collecting a small blood sample on a test strip, which would be read by the machine) in accordance with Physician 1's H&P treatment plan. This deficient practice resulted in Resident 1 experiencing hyperglycemia (a condition where there's too much glucose in the blood) placing Resident 1 at risk for various serious complications, in ketoacidosis (DKA, a complication of diabetes in which acids build up in the blood to levels that can be life-threatening), dehydration (a condition occurs when the body loses more fluids…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop a comprehensive resident centered care plan (a formal process that correctly identifies existing needs and recognizes a resident's potential needs or risks to achieve healthcare outcomes) in accordance with the facility's care plan policy for one of three sampled residents (Resident 1), by failing to ensure the diabetes mellitus care plan initiated on 7/15/2025 was appropriate. This deficient practice had the potential to result in delay or lack of delivery of care and services to Resident 1, which could affect the resident's overall wellbeing. Cross Reference to F684, F726, F756 Findings: During a review of Resident 1's admission Record, the admission Record indicated the resident was originally admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including type 2 diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) with hyperglycemia (high blood sugar), encounter…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to ensure the Minimum Data Set Nurse (MDSN, a licensed nurse who specializes in the assessment and documentation of patient health data in long-term care) 1 completed the annual licensed nurse competency for 2023 and 2024. This deficient practice caused an increased risk for improper resident assessments, inadequate documentation, and could negatively impact the quality of care to the residents which could lead to hospitalization or death. Cross Referenced to F656, F684, F756 Findings: During an interview on 8/14/2025 at 10:30 AM, MDSN 1 stated she did not know the facility's policy and procedure for comprehensive care plans (a detailed, individualized document that outlines all aspects of a patient's medical, emotional, and daily living needs). During an interview on 8/14/2025 at 12:30 PM, MDSN 2 stated developing residents' comprehensive care plans is one of the tasks of the MDS nurses. MDSN 2 stated MDS nurses should know the facility's policy for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to perform a comprehensive medication regimen review (MRR, a thorough evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medication) in accordance with the facility's policies and procedures (P&P) for one of three sampled residents (Resident 1). This deficient practice resulted in Resident 1 not having medication for the diagnosis of diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control) since admission on [DATE], which lead to Resident 1's hyperglycemia (high blood sugar) on 8/9/2025. Cross Referenced to F656, F684, F726 Findings: During a review of Resident 1's admission Record, the admission Record indicated the resident was originally admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including type 2 diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 3. During a review of Resident 94 ' s AR, the AR indicated the facility admitted Resident 94 on 1/31/2025, with diagnoses including hypertension (a long-term medical condition in which the blood pressure in the arteries is persistently elevated), and dysphagia (difficulty or discomfort in swallowing). During a review of Resident 94 ' s H&P, dated 2/2/2025 indicated, Resident 94 had the mental capacity to make medical decisions. During a review of Resident 94's MDS, dated [DATE], indicated the cognitive (the ability to think and process information) skills for daily decisions making was moderately impaired, and dependent on staff for the activities of daily living. During a review of Resident 14's AR, the AR indicated the facility admitted Resident 14 on 10/21/2021, with diagnoses including hypertension (a long-term medical condition in which the blood pressure in the arteries is persistently elevated), and dementia (decline in mental ability severe enough to interfere with daily life) During a review 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 the two of two dietary staff (Dietary Manager and Facility Cook) had appropriate competencies and skills sets to carry out the functions of the food and nutrition service based on resident assessments, individual plans of care of the 30 residents who were prescribed with pureed diet (diet with food that has been blended, mashed, or strained until it's smooth and free of lumps, like applesauce or mashed potatoes, often used for those with difficulty chewing or swallowing) and were served pureed food that was pasty and thick in texture by failing to: 1. Ensure the Facility [NAME] reviewed and followed the recipe to ensure adequate measurement of thickener powder (powder like starch used to thicken the texture of food) were mixed when preparing the pureed food on 3/26/2025. 2. Ensure the Dietary Manager follow the pureed recipe and oversee the Facility [NAME] when preparing puree food for the residents on 3/26/2025. The deficient practices had put the residents at risk poor nutrition to weigh loss or gain,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 in accordance with the facility ' s policy and procedures by failing to ensure: 1. The scoop used for scooping flour was not on the top of the flour container and was stored in a plastic bag when not in use to limit exposure to potential contamination. 2. The dietary staff correctly conduct the calibration (correlating the readings of an instrument with those of a standard to check the instrument's accuracy) of the food thermometer used to readily identify the proper temperatures of the food being served. These deficient practices had the potential to result in cross contamination and food-borne illnesses (food poisoning) of the residents with symptoms including upset stomach, stomach cramps, nausea, vomiting, diarrhea and fever and can lead to other serious medical complications and hospitalization. and put residents at risk for foodborne illnesses (illness caused by food contaminated with bacteria, viruses, parasites, or toxins). Findings: 1. 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.

2. On 3/26/2025 at 3:09 PM, while onsite at the facility, the California Department of Public Health (CDPH) an Immediate Jeopardy situation (IJ, a situation in which the provider ' s noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death of a resident) was identified and called regarding the facility ' s failure to notify the physician regarding significant changes in Resident 98 ' s respiratory conditions and provide the necessary respiratory care and monitoring. 3. LVN 1 who was in charge of Resident 98 on 2/12/25 to 2/13/25 did not implemented Resident 98 ' s Physician Orders for Life-Sustaining Treatment (POLST, a portable medical order that communicates a patient's wishes for end-of-life care and treatment interventions) according to the resident ' s preferences. During an interview on 3/26/2025 at 7 AM with LVN 1, LVN 1 stated, he was the charge nurse that took care of Resident 98 from 11 PM on 2/12/2025 until the resident expired on 2/13/2025 at 5:59 AM. LVN 1 stated, Resident 98 was alert,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 treat resident with dignity and respect by ensuring one of five sampled residents (Resident 78) by receive meal at the same time as other residents who were dining in the dining room during lunch time on 3/25/2025. The deficient practice resulted in Resident 78 reported feeling disrespected and frustrated when watching other residents eating and completing their meals in front of him. Findings: During a review of Resident 78's admission Record (AR), the AR indicated the facility originally admitted Resident 78 on 11/18/2024 and readmitted him on 1/2/2025 with diagnoses that included chronic obstructive pulmonary disease (a group of lung [an organ located in the chest and provide gas exchange for the body] diseases that cause ongoing damage to the airway and lungs, leading to difficulty breathing) and pulmonary edema (a condition where fluid accumulates in the lungs, making it difficult to breathe). During a review of Resident 78's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to follow its policy and procedure (P&P) titled, Notification of Changes, revised [DATE], its professional standards of practice and the physician ' s order for one of one sampled resident (Resident 98), who had a diagnosis of acute respiratory failure with hypoxia (a life-threatening condition where the lungs fail to deliver enough oxygen to the blood, leading to dangerously low oxygen levels in the body), chronic obstructive pulmonary disease exacerbation (COPD, sudden severe symptoms of a lung disease characterized by poor airflow to the lungs that results in shortness of breath, difficulty breathing and respiratory distress) and pulmonary hypertension [a condition that affects the blood vessels (the network of tubes through which blood is pumped around the body) in the lungs] by failing to ensure LVN 1 immediately notified the physician when CNA 1 reported to LVN 1 that Resident 98 was experiencing labored breathing with his oxygen saturation…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 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 27's AR, the AR indicated the facility admitted Resident 27 on 2/25/2016 and readmitted on [DATE] with diagnoses that included aphasia (a language disorder that affects a person's ability to communicate) following cerebral infarction (or ischemic stroke, occurs when the blood supply to part of the brain is blocked or reduced), and type 2 diabetes mellitus (DM2 - condition that results in too much sugar circulating in the blood). During a review of Resident 27's History and Physical, dated 11/20/2024, indicated Resident 27 did not have the capacity to understand and make decision. During a review of Resident 27's MDS, dated [DATE], indicated Resident 27's cognition (ability to think, remember, and reason with no difficulty) was severely impaired and was dependent (helper does all of the effort) in the ability to walk at least 10 feet in the room. During a concurrent observation and interview on 3/28/2025 at 9:50 AM with Certified Nurse Assistant (CNA) 6 in Resident 27's room,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 Minimum Data Set (MDS-a federally mandated resident assessment tool) entries were accurate and reflects resident's status for one of three sampled residents (Resident 99) who was discharged home with home health services. The MDS was incorrectly coded as a transfer to a hospital, which does not reflect the actual discharge disposition of the resident who was discharged to home. This failure resulted in inaccurate documentation in the resident's medical record could impact continuity of care, facility reporting accuracy, and regulatory compliance. Incorrect discharge coding may also affect quality measures, reimbursement, and tracking of resident outcomes. Findings: During a review of Resident 99's admission Record indicated the facility admitted Resident 99 on 1/27/2025 with diagnoses that included hypertension (a long-term medical condition in which the blood pressure in the arteries is persistently elevated) and hyperlipidemia (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 develop and implement a comprehensive person-centered care plan for one of four sampled residents (Resident 10) who had an impaired vision and needed eyeglasses to improve his vision and to meet the residents ' needs, resident ' s goals, and preferences. The deficient practices have the potential to delay necessary care and services to assist with the Resident 10 ' s vision that and affect resident ' s quality of life. Findings: During an observation on 3/25/25 at 12:11pm, Resident 10 was awake watching Television in the room with a pair of eyeglasses was on the table. Resident 10 stated he ' s waiting for the new pair of eyeglasses to be sent to him because the old pair doesn ' t work well for him anymore, which he held for about a year. Resident 10 stated the optometrist (a healthcare professional for routine eye and vision care) came to facility about a month ago and checked his vision. Resident 10 stated everything has become blurry,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 resident (Resident 11) was provided care and services to prevent skin pressure injury (PI-pressure injury skin damage due to unrelieved pressure or sheer or friction to the skin). Resident 11 developed Stage 2 PI (partial-thickness loss of skin, presenting as a shallow open sore or wound) on left first metatarsal (big toe) that developed in the facility and on 12/31/24 that progressed to Stage 3 P1 (Full-thickness loss of skin. Dead and black tissue may be visible) on 3/4/25. Resident 11 ' s new footwear was not assessed and evaluated to determine if the shoes was effective to prevent worsening or development of new or old pressure injury. This deficiency had the potential for Resident 11's left first metatarsal pressure injury to worsen and experience pain and infection. Findings: During a review of Resident 11's admission record (AR) indicated that Resident 11 was originally admitted on [DATE] and readmitted…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 one of four observed residents (Residents 52) in which three (3) medication errors were identified out of 29 opportunities that yielded a cumulative error rate of 10.34 %. The facility failed to ensure: 1. Licensed Vocational Nurse 2 (LVN 2) checked the heart rate of Resident 52 prior to the administration of Metoprolol tartrate (medication that lowers blood sugar level) and Amlodipine (medication ordered to manage hypertension [HTN - elevated blood pressure]). 2. Licensed Vocational Nurse 2 (LVN 2) provided food during medication administration of Metoprolol and Metformin HCL (medication given to lower blood sugar level) ordered by the physician. These deficient practices had the potential to result in ineffective managed hypertension and diabetes and may cause a harmful significant drop in the heart rate, blood pressure, hypoglycemia (low blood…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 out of four residents (Resident 52) was free from significant medication errors as indicated in the physician ' s order, pharmacy recommendation and facility's policy and procedures by failing to ensure Licensed Vocational Nurse (LVN) 2 failed to check the heart rate of Resident 52 prior to the administration of Metoprolol tartrate (medication given to lower the blood pressure) and Amlodipine (medication ordered to manage Resident 52's hypertension [HTN - elevated blood pressure]). This failure places the resident at risk for adverse effects, including bradycardia (low heart rate), hypotension (low blood pressure), dizziness, increasing the risk of falls, and cause the heart to stop that could lead to hospitalization or death. Findings: During a review of Resident 52's admission Record (Face Sheet), indicated the facility admitted the resident on 9/5/2022 and readmitted on [DATE] with diagnoses including diabetes mellitus (DM: long-term…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 food prepared in a form designed to meet individual needs for one of two sampled residents (Resident 47) who had difficulty swallowing was served pureed diet (a food item that has been blended, mixed, or processed into a smooth and uniform texture) that was too thick in texture. This deficient practice resulted in Resident 47 and other residents with difficulty swallowing to be at increased risk for choking (happens when something blocks the airway, preventing a person from breathing properly, often due to food or other objects getting stuck in the throat) and aspiration (accidentally inhaling food, liquid, or other material into the lungs instead of the stomach, which can lead to complications like pneumonia [a severe lung infection]) that could lead to death. Finings: During a review of Resident 47's admission Record (AR), the AR indicated the facility admitted Resident 47 on 10/3/2019 and readmitted on [DATE] with diagnoses…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 clean and sanitary environment for six out of 20 sampled residents(Residents in room [ROOM NUMBER] and 5) when a rusty and dirty commode was found in shared bathroom of room [ROOM NUMBER] and 5. This failure resulted in unsanitary environment and potential to lower the residents' quality of life. Findings: During an observation on 3/25/2025 at 9:52 AM in the shared the restroom between room [ROOM NUMBER] and 5, a dirty and rusty commode was observed. During an interview on 3/25/2025 at 10 AM with Housekeeper (HK) 1, HK 1 stated, she was not aware and did not receive any report that the commode was dirty and rusty. HK 1 stated, HK 1 supposed to check all equipment and report to the Maintenance Supervisor (MS) to replace dirty and rusty commode. HK 1 stated, she could not recall if she checked shared restrooms between room [ROOM NUMBER] and 5 to make sure all equipment was clean and functional. During a concurrent observation 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 prompt efforts were made to resolve grievances verbalized by one of two sampled residents' (Resident 1) responsible party (RP) apprised of progress towards resolution. In addition, the facility failed to issue a written grievance decision to the resident and RP, in accordance with the facility's policy on Grievance/Concern. This deficient practice increased the risk for 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) indicated the resident was admitted to the facility on [DATE] with diagnoses that included Metabolic encephalopathy (a condition in which the brain does not function properly due to an underlying metabolic imbalance),acute respiratory failure with hypoxia(a condition when the body doesn't get enough oxygen). During a review of Resident 1's History and Physical [H&P] dated…

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

Based on interview and record review the facility failed to report an injury of unknown source, immediately, but not later than two (2) hours after the allegation was made at 8:30 AM and reported the allegation to the Department of Public Health (DPH) at 1:23 PM (five [5] hours after the allegation), when Resident 2 was found having ecchymosis (a bruise) to both arms and a skin tear to the left forearm, for one (1) of five (5) sampled residents (Resident 2), in accordance with the facility's policy and procedure [P&P] titled Abuse, Neglect, and Exploitation. This deficient practice had the potential to result in placing the resident at risk for undetected elder neglect or abuse. Findings: During a review of Resident 2 ' s admission Record indicated the facility admitted the resident on 10/8/2024 with diagnoses including dementia (a progressive state of decline in mental abilities), anemia (a condition where the body did not have enough healthy red blood cells), and lack of coordination. During a review of Resident 2 ' s History and Physical (H&P) dated 10/10/2024, 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 implement the facility ' s policy and procedure titled Clean Dressing Change to prevent infection during wound care of the pressure ulcer (a skin injury resulting from prolonged unrelieve pressure in the body). Licensed Vocational Nurse (LVN 1) failed to change gloves and wash hands after touching a soiled wound dressing during wound care for one of three sample residents (Resident 2) who had Stage 4 pressure ulcer (skin injury that involves full-thickness tissue loss that exposes bone, tendon, or muscle). This deficient practice had the potential for Resident 2 to develop severe wound infection, pain and could lead to delayed healing process and a decline in the resident ' s wellbeing. Findings: During a review of the admission record indicated Resident 2 was originally admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses that included diabetes (a disease in which your blood glucose, or blood sugar, levels are too…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 surveillance tracking and heighten the facility ' s surveillance activities for coronavirus illness during periods of transmission to prevent and control the spread of Covid-19 (Coronavirus, a severe respiratory illness caused by a virus and spread from person to person) in accordance with current standards and the facility ' s policies and procedures. The facility failed to develop an effective line listing (a table/list that summarizes information about cases [possible, probable or confirmed] associated with an outbreak) for 20 out of a facility census of 98 who tested positive for Covid 19. As a result, Resident 1 residing in Room A with a positive Covid 19 result was mistakenly moved to Room B to share a room with Residents 3 and 5 who were negative with Covid-19 during the facility ' s testing on 6/30/2024. These deficient practices had the potential to spread the Covid 19 to other residents,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 sufficient monitoring and supervision to one of two sampled residents (Resident 1) who eloped (the act of leaving a facility premises or a safe area without notifying anyone) from the facility. The facility found out that Resident 1 was missing on 4/20/24 at around 8 PM when a family member (FAM 1) called the facility to inform a staff that the resident went home. This deficient practice had the potential for Resident 1 and other residents who are at risk for elopement to be exposed to danger or harm that could lead to injury or death. Findings: A review of Resident 1 ' s admission Record indicated the facility initially admitted the resident on 3/27/24 with diagnoses that included metabolic encephalopathy (a problem in the brain caused by a chemical imbalance in the blood, not because of a head injury) and chronic obstructive pulmonary disease (COPD, a group of diseases that cause airflow blockage and breathing-related problems). A review of Resident 1 ' s History and Physical assessment, dated 3/28/24, 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 Certified Nurse Assistant (CNA) 3 was seated during meals times while assisting feeding for three of three sampled residents (Residents 25, 33, and 388). This failure had the potential for Residents 25, 33 and 388 to experience loss of dignity, self-esteem and respect. Findings: 1. During a meal observation on 4/9/2024 at 12:42 pm at Resident 25's bedside, Resident 25 was observed sitting in bed while CNA 3 was observed standing on the left side of the bed (right side of the resident), feeding lunch to Resident 25. A review of Resident 25's admission Record indicated Resident 25 was readmitted to the facility on [DATE], with diagnoses that include dementia (a condition characterized by progressive or persistent loss of intellectual functioning), dysphagia (difficulty swallowing), aphasia (an impairment of language affecting the ability to express or understand speech), hemiplegia (paralysis of one side of the body) and hemiparesis…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 comprehensive care plans (a document that outlines the facility's plan to provide personalized care to a resident based on the resident's needs) for three of three sampled residents (Resident 12, 2, and 31). 1. Resident 12 who had oxygen therapy in accordance with the facility's protocol for Oxygen Administration. 2. Resident 2 who was admitted with diagnoses of sepsis (a potentially life-threatening condition that arises when the body's response to infection causes injury to its own tissues and organs) and pneumonia (a severe infection in your lungs). 3. Resident 31's preference to receieve prescribed medication at different times from the usual medication scheduled times at the facility. These deficient practices had a potential for Resident 12 not to receive or receive delayed necessary interventions during oxygen therapy, Resident 2 to have inadequate and incomplete provision of care and treatment which would put her at risk…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 residents (Resident 81) was assessed, monitored, and evaluated for skin breakdown related to MASD (Moisture-associated skin damage caused by prolonged exposure to various sources of moisture, including urine or stool, perspiration, mucus, saliva, and their contents. MASD is characterized by inflammation of the skin, occurring with or without erosion [gradual destruction of tissue] or skin infection) and fungal infection (irritation or swelling of the skin cause by overgrowth of fungus) in accordance with the facility's policy and procedure and resident's plan of care. The facility failed to ensure: 1. Resident 81's plan of care was implemented to assess and document status of wound perimeter; wound bed and healing progress and report improvements and declines to medical doctor and resident. 2. The Treatment Nurse (TN) assessed, monitored and evaluated Resident 81 ' s skin weekly for as needed for size, appearance,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of one sampled resident (Resident 81), was assessed, provided pain management and interventions to relieve severe pain in the perianal (body area near the anus), perineal (body area between the anus and vaginal area) area due to severe MASD (Moisture Associated Skin Damage characterized by skin inflammation and damage of the outer layer of the skin resulting from prolong exposure moisture from to feces, urines and perspiration) and fungal dermatitis (irritation or swelling of the skin due to overgrowth of fungus) during wound care, hygiene care or when sitting on the chair for a long period of time as indicated in the facility's policy and procedure and as ordered by the physician. This failure resulted in Resident 81's having unrelieved severe pain and verbalized feeling sad that the facility allowed her to suffer from pain, which prevented her from moving around and attending activities and potentially caused a decline 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.

Based on interview, and record review, the facility failed to complete a performance review for eight of nine (9) Certified Nurse Assistants (CNAs) based on the outcome of the review for each of the CNAs. The CNAs did not have a completed Annual Core Clinical Competencies (ACCC, an assessment and training on the CNAs the ability to perform clinical nursing care). This failure had a potential to result in the facility ' s CNAs not able to provide quality care to the resident ' s population based on the Facility Assessment (an assessment to make decisions about direct care staff needs, as well capabilities to provide services to the residents). Findings: During an interview on 4/11/24 at 9:19 am with the Director of Staff Development (DSD), the DSD stated, all CNAs were supposed to have yearly clinical skills competency check to assess for their competency and to refresh their knowledge on how to provide appropriate care to the residents. The DSD stated, she just started the DSD position three months ago and the previous DSD did not use CNA Core Clinical Competencies checklist 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.

Based on observation and interview and record review the facility failed to implement the facility's policy and procedure on food storage and in accordance with professional standards of practice for food service safety by failing to: 1. Label and date of when it was opened or used by a brown powder in a clear plastic container, the chicken bouillon (ingredients used for seasoning). 2. Label a clear plastic container containing rice found in the refrigerator, with the use-by-date (the date the food product could be safely consumed). 3. Label a clear plastic container containing sliced peaches found in the refrigerator with the use-by date. 4. Label a clear plastic container containing tofu found in the refrigerator with the use-by-date. 5. Label a clear plastic container containing green peas found in the refrigerator with the use-by date. These deficient practices had the potential to result in food contamination or growth of microorganisms (disease causing organism) that could cause foodborne illness (food poisoning or food illness due to pathogens (organism that cause illness…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to: 1. Complete the facility's Surveillance Data Collection Form (SDC - a form used by the facility to indicate if the resident met the criteria for the use of antibiotic [medication used to treat infection]), a part of the facility's Antibiotic Stewardship Program (protocols and a system in the facility to monitor antibiotic use) prior to the administration of antibiotic for one of three sampled residents (Resident 30). 2. Implement the facility's Antibiotic Stewardship Program (a facility policy that uses protocols and a monitoring system for antibiotic [medication used to kill bacteria and to treat infections]) use by not conducting a surveillance (close observation) and monitoring prior to antibiotic use. for one of three sampled residents (Resident 2). These deficient practices had the potential for Residents 30 and Resident 2 to receive unneccessary or inappropriate antibiotics, incomplete monitoring during antibiotic therapy, and to develop…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 reasonable accommodation of needs for two of two residents (Resident 30 and 81). 1. Provide reasonable accommodation of needs for one of two sampled residents (Resident 30) by failing to ensure to place resident's call light within reach. 2. Use a communication board, tool or ask assistance from a translator when communicating to one of one sampled resident (Resident 81), who speaks a foreign language. These deficient practices had the potential for Resident 30 not to receive or have a delay in provision of care and necessary services for the resident's well-being, and resulted in Resident 81's verbalized feeling confused and frustrated when the staff communicated in a language that she did not understand. These deficient practices also had the potential for Resiednt 81 not to receive immediate or appropriate care and necessary interventions for her well-being. Findings: 1. A review of Resident 30's admission Record (Face Sheet)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure the physician and responsible party was notified for one of one resident (Resident 81) with significant change of condition (COC) related to severe MASD (damage of the skin caused by prolonged exposure to various sources of moisture) and fungal skin infection (skin disease irritation, swellingness caused by an overgrowth of a fungus) in the perineal (the area extending from the anus to the vulva in the female and to the scrotum in the male) and perianal (the tissues surrounding the anus) area. This deficient practice Resident 81 developed worsened skin breakdown, fungal infection that led to more pain, discomfort and recurrent sepsis (a life threatning infection of the blood). Crossed reference with F684 and F697. Findings: A review of Resident 81's admission Record, indicated Resident 81 was admitted to the facility on [DATE] with diagnoses that included Type 2 Diabetes Mellitus (a disease when blood sugar is too high) with hyperglycemia (high…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 76) receives appropriate care and services to prevent urine in the Foley catheter (a flexible tube used to empty the bladder and collect urine in a drainage bag) from entering back into the bladder and cause urinary tract infections (an infection due to a disease causing organisms that enters the bladder and the kidney). Resident 76 was observed with Foley catheter tubing kinked (sharp twist or bent) on the bedrail and causing the urine to flow back to the bladder and not flow freely into the drainage bag as indicated in the facility's policy and procedure and Resident 76's plan of care. This deficient practice had the potential for Resident 76 to experience recurrent urinary tract infection and negatively affect Resident 76s quality of life. Findings: During a review of Resident 76's admission Record (AR), dated 4/11/2024, indicated Resident 76 was admitted on [DATE], and readmitted on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement the facility's policy and procedure on Care and Treatment of Feeding Tubes, for one of one sampled resident (Resident 72). The facility failed to ensure: 1. Resident 72's gastrostomy tube (tube inserted through the belly that brings nutrition directly to the stomach) was labeled with the date when the tubing will be changed and/or the last time it was changed. This failure had the potential to cause complications to Resident 72's gastrostomy tube. Findings: During a review of Resident 72's admission Record (AR), dated 4/11/2024, indicated Resident 72 was admitted on [DATE], and readmitted on [DATE], with diagnoses including gastrostomy ( (an opening into the stomach from the abdominal wall, made surgically for the introduction of food) infection, other complication of gastrostomy, sepsis (potentially life-threatening condition that arises when the body's response to infection causes injury to its own tissues and organs), 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: 1. Ensure one of three sampled residents (Resident 12) had nasal canula and humidifier bottle dated and changed weekly in accordance with the facility's protocol for Oxygen Administration. 2. Ensure one of three residents (Resident 59) had a plastic storage bag for oxygen equipment changed weekly per facility's standard of practice. This failure had a potential to result in Resident 12 and Resident 59 using contaminated (the presence of an infectious agents- bacteria, viruses, microbes) oxygen equipment leading to a possible respiratory infection (an infection of parts of the body involved in breathing, such as the sinuses, throat, airways or lungs), sepsis (severe infection in the blood) including pneumonia (an infection that affects one or both lungs). Findings: 1. A review of Resident 12's admission Record, dated 4/11/24, indicated Resident 12 was admitted to the facility on [DATE] with diagnoses that included acute respiratory…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 attending physician failed to take an active role in supervising the total program of care, including medications and treatments, and a decision about the continued appropriateness of the resident's current medical regimen for one of one sample resident (Resident 81), in accordance with the facility policy and procedure on Physician Visits and Physician Delegation. The facility failed to ensure Resident 81's attending physician: 1. Physically assess, evaluate and document the resident's skin condition during admission and during other physician ' s visits for Resident 81 with severe MASD (damage of the skin caused by prolonged exposure to various sources of moisture), fungal infection (skin disease caused by an overgrowth of a fungus) and dermatitis (irritation or swelling of the skin). 2. Assess and evaluate Resident 81 ' s skin condition before ordering a skin treatment to ensure the accurate diagnosis. 3. Assess and provide a medication regimen for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure that two of two sampled residents (Residents 2 and 50), who were at risk for bleeding and bruising were free of unnecessary medication while receiving blood thinners by failing to ensure: 1. Resident 2 had adequate monitoring for bleeding and bruising while receiving Plavix (a medication that prevents platelets [a type of blood cell] in your blood from clumping together to form unwanted blood clots). 2. Resident 50 had routine laboratory test ordered to monitor the resident for complications of Aspirin (used to prevent blood cells called platelets from clumping together to form unwanted blood clots) and Eliquis (medication that decreases the clotting ability of the blood and helps to prevent harmful clots from forming) such as bleeding. These failures had the potential for Resident 2 and Resident 50 to experience side effects or adverse effects (undesired harmful effects) related to anticoagulant such as bleeding and/or bruising that were…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation, and record review, the facility failed to ensure that medication error rate was less than five percent (%). During the medication administration observation, four medications out of 30 total medications administered and opportunities contributed to an overall medication error rate of 13.33 % affecting three of eight residents observed for medication administration (Resident 37, 28, and 69). The medication errors noted were as follows: 1. The medication nurse attempted to administer Calcitriol (medication to treats low calcium level) and Folic Acid (medication is used to treat low blood level) without checking the expiration date on the bottle for Resident 37. 2. The medication nurse administered Metoprolol Tartrate (medication used to lower blood pressure) without offering food as ordered by the physician for Resident 28. 3. The medication nurse administered Metoprolol Succinate (medication to lower the blood pressure) without offering food as order by the physician 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 and record review, the facility failed provide documented evidence that two of three sampled residents (Residents 53 and 390) were offered or declined (refused) the influenza (flu- results in severe infection of the lungs) vaccine (a substance used to stimulate immunity to a particular infectious disease administered via injection) annually (every year). This deficient practice placed Residents 53 and 390 at a higher risk of acquiring and transmitting the flu to other residents and staffs that could result in a widespread infection in the facility. Findings: A review of the facility's Resident Immunization Record dated 2/6/2024, indicated Resident 53 and Resident 390 declined the flu vaccine for the flu season of 2023-2024 (October to March). 1. A review of Resident 53's admission Record indicated Resident 53 was admitted to the facility on [DATE] with diagnoses of hyperthyroidism (when the thyroid gland makes too much thyroid hormone, resulting in a rapid heartbeat and an increased rate 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: 1. Ensure that employee's personal item was not stored in the one of two medication rooms (Med room [ROOM NUMBER]) at Nursing Station 2. 2. Ensure one of three sampled residents (Resident 6), was maintained with sanitary environment by failing to timely clean up Resident 6's bedside commode with feces and urine. These deficient practices had the potential for cross contamination leading to infection and had a potential to result in a negative effect on Resident 6's overall well-being. Findings: 1. During the inspection of the medication room in Nursing Station 2 with a Registered Nurse 1 (RN 1), on 4/10/24 at 12:23 PM, a black colored jacket was observed hanging on the back of door of the medication room. RN 1 stated the jacket should not be there. RN 1 further stated that employees have a lounge to store their personal belongings. During an interview with the Director of Nursing (DON) on 4/10/24 at 3:28 pm, the DON stated that personal…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 policy and procedure for infection control by failing to ensure the facility staffs performs hand hygiene (hand washing or use sanitizing agent to eliminate disease causing organisms) for five of 5 sampled residents (Residents 5, 6,7,8 and 9). 1. After contact and caring for Resident 5 and Resident 8. 2. Before and after dispensing the fresh and old water in a water pitcher between Resident 6, 7 ,8, and 9. These deficient practices had the potential to result in the wide spread of infection (a process when a microorganism, such as bacteria, fungi, or a virus, enters a person's body and causes harm) in the facility. Findings: During a review of Resident 5 ' s admission Record indicated the facility admitted Resident 5 on 2/26/2024 with diagnoses that included immunodeficiency (the body fail to protect itself adequately from infection, due to the absence or insufficiency of some component process or substance) and…

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

Based on interview and record review, the facility failed to maintain an infection control surveillance tracking log to ensure that facility staff members who were possible close contacts (one who has shared the same indoor airspace with someone with COVID-19 for a total of 15 minutes or more over a 24-hour period) while they were infectious to 13 of 13 sampled residents with confirmed Coronavirus 2019 (COVID-19; an infectious disease) infection for the facility's current COVID 19 outbreak that started with the first positive resident on 11/8/2023. This failure had the potential to result in the further spread of COVID-19 amongst the facility's residents and staff. allows for the facility to become quickly and efficiently aware of other positive residents and staff. Findings: During a concurrent initial observation of the facility and interview with the Infection Preventionist (IPN), on 11/21/2023 at 9:42 AM, the IP stated the facility currently had a total of 92 residents in-house with 11 total positive residents for COVID-19. The IP stated the first resident residing 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 that one of five sampled residents (Resident 6) out of the 92 residents residing at the facility, was educated, and offered a Coronavirus 2019 (COVID-19; an infectious disease) vaccine, in accordance with the facility's policy and procedure. This failure resulted in the resident contracting COVID-19 during his stay at the facility. Findings: During a concurrent initial observation of the facility and interview with the Infection Preventionist (IPN), on 11/21/2023 at 9:42 AM, the IP stated the facility currently had a total of 92 residents in-house with 11 total positive residents for COVID-19. The IP stated the first resident residing in the facility that was confirmed as COVID 19 positive was on 11/8/2023. A review of Resident 6's Facesheet indicated the resident was initially admitted to the facility on [DATE] with diagnoses of interstitial pulmonary disease (a large group of disorders which cause scarring of lung tissue) and pneumonia (lung…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 and implement the resident ' s fall risk care plan that indicated to follow facility fall protocol (system of rules or accepted behavior that staff should follow in certain situations) to prevent further accidents and injury for one of three sampled residents (Resident 1), who had a recent fall in 10/22/2023, when facility staff failed to: 1. Report, investigate, and review any accidents or incidents that occur or allegedly occur, on facility property and may involve or allegedly involve a resident, in accordance with the facility ' s policy and procedures titled Incidents and Accidents. There was no report endorsed from the previous night shift to the morning shift licensed nurse on 10/22/2023, when Resident 1 was found with a swollen right eyelid with bluish discoloration and swollen cheek. The facility ' s Registered Nurse (RN 2) and interdisciplinary team did not investigate immediately by interviewing the resident, assigned facility staff,…

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