Monterey Park Conv Hosp

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure oxygen was administered for one (1) of 1 sampled resident (Resident 44) reviewed for respiratory care in accordance with the physician's order and facility policy. This deficient practice placed Resident 44 at risk for hypoxia (a condition that occurs when the lungs cannot get enough oxygen to the blood) causing serious harm. Findings: During a review of Resident 44's admission Record, the admission Record indicated Resident 44 was admitted to the facility on [DATE] with diagnoses that included acute respiratory failure (a sudden, life threatening emergency where the lungs cannot get enough oxygen into the blood, or they cannot remove enough carbon dioxide from the body) with hypoxia and encephalopathy (a brain disease, disorder, or damage that affects brain function). During a review of Resident 44's Minimum Data Set (MDS- a resident assessment tool), dated 5/28/2026, the MDS indicated Resident 44 had severe impairment 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 maintain an accurate clinical record in accordance with the facility's policy by failing to accurately document the meal percentage on 6/29/2026 for one (1) of two (2) sampled residents (Resident 41).This deficient practice had the potential to affect Resident 41's nutritional assessment, care planning, monitoring of intake trends, and timely identification of nutritional risks or decline. Findings: During a review of Resident 41's admission Record, the admission Record indicated the resident was admitted to the facility on [DATE] with the following but not limited to diagnoses of repeated falls, dementia (a progressive state of decline in mental abilities), muscle weakness and diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 41's Minimum Data Set (MDS - a resident assessment tool), dated 5/13/2026, the MDS indicated the resident was severely impaired with cognitive…

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

Based on observation, interview, and record review, the facility failed to maintain essential laundry equipment in safe operating condition by failing to remove the lint as scheduled from the lint trap of one of two (2) dryers in accordance with Policy and Procedure (P&P) This deficient practice resulted in lint buildup within the dryer, creating a fire hazard that placed residents and staff at risk of harm.Findings:During a laundry tour on 7/1/2026 at 2:48 PM, one of the two dryers (Dryer 2) was operating without any items in it. Laundry Aid 1 (LA 1) opened the lint door located underneath the dryer and observed lint build up on the lint trap. During an interview on 7/2/2026 at 9:51 AM, the Maintenance Service Supervisor (MSS) stated the dryer lint trap should be cleaned by every 2 hours as scheduled for fire safety and prevention. During an interview on 7/2/2026 at 12:30PM, LA 2 stated she forgot to clean the lint trap of Dryer 2 on 7/1/2026 at 2 PM. LA 2 also stated the dryer should be regularly cleaned and be free from lint build up to prevent fire. During a review of the…

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

Based on observation, interview, and record review, the facility failed to maintain safe, clean, comfortable, sanitary and home-like environment for one (1) of two (2) sampled residents (Resident 17) reviewed for environment by failing to ensure Resident 17's gastrostomy tube (G-tube pump, an electronic, battery-powered medical device that delivers liquid nutrition, fluids, or medication at a controlled rate directly into a person's stomach through a surgically placed abdominal tube) was free of dried milk residue and the flooring in Resident 17's room was free of dry milk residue. These deficient practices created an unsafe and unsanitary environment for Resident 17 and had the potential to result in accidents and risk of contamination and infection. Findings: During a review of Resident 17's admission Record, the admission Record indicated the resident was initially admitted ), and facility on 8/8/2025 with diagnoses of Parkinson's disease (progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movement), diabetes mellitus (a disease…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow its Advance Directive (a legal document indicating resident preference on end-of-life treatment decisions) policy to ensure the residents receive information to formulate an advance directive for two (2) of two sampled residents (Resident 139 and 141). This deficient practice had the potential for Resident 139 and 141 to not have their wishes met regarding life-sustaining treatment (any treatment that serves to prolong life without reversing the underlying medical condition) or health care. Findings: 1. During a review of Resident 139's admission Record, the admission Record indicated the resident was admitted to the facility on [DATE] with the following diagnoses of immunodeficiency (failure of the immune system to protect the body adequately from infection) and schizoaffective disorder (a mental illness that is characterized by disturbances in thought). During a review of Resident 139's Minimum Data Set (MDS - a resident assessment tool),…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the proper use and follow the physician's order for use of bed rails (are adjustable metal or rigid plastic bars that attach to the bed) for six (6) of 6 sampled residents (Resident 1, 2, 17, 26, 56 and 69), as indicated in the facility's policy and procedure. This deficient practice had the potential to place Residents 2, 17, 26, 56 and 69 at risk for entrapment (residents becomes caught or trapped in spaces around a bed rail) which could result in injury and death. This deficient practice resulted in Resident 1 getting trapped on the bed rails on 3/25/2025, wherein Resident 1's stomach was caught on the side rail (middle section of the bed) with the resident's upper body off the bed with his head touching the floor, while his lower body was on the bed, and Resident 1 sustaining a half centimeter (cm, unit of measure) cut on the nose bridge. Findings: 1. During a review of Resident 56's admission Record, the admission Record…

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

Based on observation, interviews, and record review, the facility failed to ensure Dietary Aide 1 (DA 1) wore hair restraint (worn by food handlers to avoid hair getting into the food) to cover mustache and beard while in the kitchen and food storage areas. This deficient practice had the potential to result in cross contamination (transfer of harmful bacteria [tiny, single-celled living things that are found everywhere, including in and on your body] from one place to another) and harmful bacterial growth that could lead to illness for 69 of 80 medically compromised residents who receive food from the kitchen. Findings: During a concurrent observation and interview on 5/14/2025 at 10:35 AM in the kitchen, with the Dietary Service Supervisor (DSS) and DA 1, DA 1 was observed with mustache and beard and was not wearing beard mask. DA 1 stated he forgot to wear a beard mask today. DSS and DA 1 stated hair could fall into the food and could cause food contamination. DSS and DA 1 stated it was important to wear a beard mask while in the kitchen and storage areas to prevent the spread 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, record review, the facility failed to ensure standard infection prevention control practices (a set of practices that prevent or stop the spread of infections and or diseases in the healthcare setting) were followed for five (5) of seven (7) residents sampled for infection control care areas (Resident 49, 50, 56, 69 and 141) and in accordance with the facility's policy and procedure when: 1.a Licensed Vocational Nurse (LVN) 3 failed to don (putting on) an isolation gown prior to entering Resident 49's room who was on a Transmission Based Precaution (TBP - refers to actions [precautions] implemented in addition to standard precautions that are based upon the means of transmission [airborne, contact, and droplet] to prevent or control infections). 1.b Resident 49 who was on TBP was transported and left in the dining room area for activities on 5/12/2025 by Certified Nursing Assistant 9 (CNA 9). 2.a. LVN 2 failed to change gloves and perform hand hygiene (the process of cleaning 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 the facility was safe and sanitary by failing to: 1. The kitchen ceiling was free from water leak stains, bubbling and paint that was peeling off. 2. One of four dumpsters was completely closed and not overflowing. This deficient practice resulted in an unsanitary and unhomelike environment and had the potential for residents to be placed at risk for serious illness and hospitalization. Findings: During a concurrent observation and interview on 5/12/2025 at 8:09 AM by the dumpster area, one of four dumpsters was observed overflowing with boxes and dumpster cover was not completely closed. The Maintenance Director stated the company that picks up the garbage has not arrived yet and they were scheduled to be picked up early this morning. During a concurrent observation and interview on 5/12/2025 at 8:13 AM inside the kitchen, with the Dietary Service Supervisor (DSS), the ceiling was observed with water stains, paint patches, bubbling and paint that was peeling off. The DSS stated that the water stains…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure one (1) of 1 sampled resident (Resident 139) was treated with respect and dignity in accordance with the facility policy by failing to keep the resident clean and free from food particles. This deficient practice has the potential to affect the resident's self-worth and self-esteem. Findings: During a review of Resident 139's admission Record, the admission Record indicated the resident was admitted to the facility on [DATE] with the following diagnoses of immunodeficiency (failure of the immune system to protect the body adequately from infection) and schizoaffective disorder (a mental illness that is characterized by disturbances in thought). During a review of Resident 139's Minimum Data Set (MDS - a resident assessment tool), dated 5/11/2025, the MDS indicated the resident was moderately impaired in cognitive (the ability to understand and make decisions) skills for daily decision making. The MDS also indicated the resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure one of five sampled residents (Resident 56) psychotropic medication (substance that affect the brain's activities and influence mental processes and behaviors) was appropriate to treat the resident's specific and documented condition in accordance with the facility's policy. This deficient practice placed Resident 56 at risk for unnecessary medication and delayed provision of necessary care. Finding: During a review of Resident 56's admission Record, the admission Record indicated the resident was originally admitted to the facility on [DATE] and was readmitted on [DATE] with the following diagnoses of dementia (a progressive state of decline in mental abilities), Alzheimer's disease (a disease characterized by a progressive decline in mental abilities), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), schizophrenia (a mental illness that is characterized by disturbances in thought) 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 an individualized resident-centered care plan (a care plan that prioritizes the unique health needs and desired outcomes of the resident) with measurable objectives, timeframe, and interventions to meet the resident's oxygen needs for one (1) of 19 sampled residents (Resident 141). This deficient practice has the potential to delay in the necessary care and services for Resident 141's oxygen therapy resulting to shortness of breath or other respiratory complications. Findings: During a review of Resident 141's admission Record, the admission Record indicated the resident was admitted to the facility on [DATE] with the following diagnoses of sepsis (a life-threatening blood infection), acute respiratory failure (condition making it difficult to breathe on your own) and immunodeficiency. During a review of Resident 141's History and Physical (H&P), dated 5/9/2025, the H&P indicated the resident does not have the capacity to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement interventions to prevent injuries for two (2) of five (5) residents sampled by failing to: 1. Ensure Resident 55's feet were on a footrest while resident was seated on a wheelchair during transport. This deficient practice had the potential to cause Resident 55's feet to drag which could result in serious injuries. 2. Provide padded siderails (a barrier attached to the side of a bed) for Resident 190 who had history of seizures (burst of uncontrolled electrical activity between brain cells that causes temporary abnormalities in muscle tone or movements like stiffness, twitching or limpness). This deficient practice had the potential for Resident 190 to sustain injuries during a seizure disorder activity. Findings: 1. During a review of Resident 55's admission Record, the admission Record indicated the resident was initially admitted to the facility on [DATE] and was readmitted on [DATE] with a diagnosis that included displaced…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide the necessary respiratory care services to one (1) of one sampled resident (Resident 141) by failing to ensure the Resident 1's nasal cannula (NC - a small plastic tube, which fits into the person's nostrils [nasal prongs] for providing supplemental oxygen) for oxygen was placed correctly while the resident is receiving oxygen. This deficient practices have the potential for Resident 141 to develop complications associated with oxygen therapy. Findings: During a review of Resident 141's admission Record, the admission Record indicated the resident was admitted to the facility on [DATE] with the following diagnoses of sepsis (a life-threatening blood infection), acute respiratory failure (condition making it difficult to breathe on your own) and immunodeficiency. During a review of Resident 141's History and Physical (H&P), dated 5/9/2025, the H&P indicated the resident does not have the capacity to understand and make decisions.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 hemodialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney[s] have failed) care was provided for one (1) of two (2) sampled residents (Resident 190) when: 1. A pitcher full of water and a 64 ounce (oz- unit of measurement) bottled watermelon cucumber juice was left at Resident 190's bedside table. 2. A 1000 cubic centimeters (cc - units of volume on liquids) per 24 hours fluid restriction sign was not posted inside Resident 190's room. 3. A precaution sign not to use left arm with the arteriovenous shunt (AV- a surgical connection between an artery and a vein used for hemodialysis) for blood pressure [BP] reading, intravenous (IV- within the vein) access and laboratory sticks were not posted inside the room. These deficient practices had the potential to place Resident 190 at risk for fluid overload (a condition where the body has too much fluid) and complications from…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 during toileting and failed to ensure the sensor alarm (helps to alert caregivers when a resident gets out of bed in order to ensure resident safety) was functioning for one (1) of two (2) sampled residents (Resident 34), who was at high risk for falls. This deficient practice resulted to Resident 34 had fall on 2/13/2024 and was sent to General Acute Care Hospital (GACH 1) and another fall on 3/23/2024. Findings: A review of Resident 34's admission record indicated the facility admitted Resident 34 on 5/9/2022 with diagnoses which includes muscle weakness, repeated falls, and lack of coordination. A review of Resident 34's H&P dated 5/26/2024 indicated Resident 34 does not have the capacity to understand make decisions. A review of Resident 34's Minimum Data Set (MDS, standardized care and screening tool), dated 3/15/2024, indicated Resident 34 was severely impaired with cognitive (processes of thinking and reasoning)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to follow its Medication Storage policy by failing to: 1. Remove an expired Humulin R insulin (Insulin Regular Human - a medication used to treat high blood sugar) vial in the refrigerator. 2. Store five (5) unopened Insulin Glargine Flex Pen (a medication used to control high blood sugar) in the refrigerator. This deficient practice increased the risk for Residents on insulin to receive medication that had become ineffective or toxic due to improper storage possibly leading to health complications, which may result to harm and hospitalization. Findings: 1. During a concurrent observation and interview with the Director of Nursing (DON) on [DATE] at 6:33 PM in the Medication Storage room located in Nursing Station 1 (NS 1), a Humulin R insulin vial was observed to be labeled with an open date of [DATE] and discard date of [DATE] in the medication refrigerator. The DON stated the Humulin R vial should be used or discarded within 28 days 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 follow proper food handling practices in accordance with its policy and procedure by failing to ensure: 1. A container of [NAME] was not broken. 2. A container of cookies was sealed properly. 3. A can opener was clean and free of gunk and rust. 4. Trash can lid was closing properly. Trash can was observed to be full beyond capacity. These deficient practices had the potential to result in pathogen (germ) exposure to residents, which could place the residents at risk for developing foodborne illness ([food poisoning] with symptoms including upset stomach, stomach cramps, nausea, vomiting, diarrhea, and fever) and can lead to other serious medical complications and hospitalization. Findings: During an observation in the facility's kitchen on 5/24/2024 at 1:55PM, the following were observed: 1. The yellow container of [NAME] rice storage was broken. The corner of the hard plastic lid was missing. 2. One container of cookies was not sealed. 3. A can opener was dirty with dried food residue, gunk (unpleasantly…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 dispose garbage and refuse (disposable material, which includes both recyclable and non-recyclable material) from the kitchen properly when two bags of kitchen trash were observed on the ground right outside at the back of the facility kitchen. This failure had the potential to result in the attraction and spread of vermin (animals that are believed to be harmful, or that carry diseases, e.g., rodent's parasitic worms or insects) that could potentially infiltrate the facility, affect the resident care areas and pose a disease threat to residents of the facility. Findings: During a concurrent observation and interview on 5/25/2024 at 8:38 AM with the maintenance supervisor (MS), observed two bags of kitchen trash on the ground near outside the back of the facility kitchen. MS stated the trash was not and should be inside the dumpster (a movable waste container designed to be brought and taken away by a special collection vehicle). MS stated the kitchen staff left the trash on the ground instead of dumping it…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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, dignity, and respect for one of four sampled residents (Resident 70) when Licensed Vocational Nurse 2 (LVN 2) did not close Resident 70's door and/or pull the resident's privacy curtain during administration of resident's medication via G-tube (a tube inserted through the belly that brings nutrition directly to the stomach This deficient practice had the potential to affect Resident 70's emotional and mental well-being. Findings: A review of Resident 70 's admission Record, indicated the resident was admitted to the facility on [DATE] with diagnoses that included gastrostomy (an opening into the stomach from the abdominal wall, made surgically for the introduction of food) and hypertension (elevated blood pressure). A review of the History and Physical Examination (H&P), dated 2/13/2024, indicated Resident 70 does not have the capacity to understand and make decisions. A review of the 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.

Based on observation, interview, and record review the facility failed to provide a clean comfortable, sanitary, and home like environment for three (3) of five (5) sampled rooms by failing to ensure: 1. Rooms A and B's bathroom toilet was free of fecal matter. 2. Room D's bathroom light bulb and wire were covered. This deficient practice caused an unsanitary and unsafe environment and had a potential for residents to be placed at risk for infection and injury. Findings: 1. During an observation in Rooms B and Room C 's bathroom on 5/24/2024 at 4:37 PM, Rooms B and Room C's bathroom toilet seat was observed to have a dry dark brown to blackish in color stool. During a concurrent observation, interview, and record review on 5/26/2024 at 7:55 PM with Licensed Vocational Nurse (LVN 3), LVN 3 stated Rooms B and Room C's bathroom toilet seat was observed to have a dry dark brown to blackish in color stool. LVN 3 stated the toilet needs to be sanitary to prevent infection. LVN 3 stated the staff should have cleaned it after for the next resident to use. LVN 3 also stated the 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 interview, and record review, the facility failed to develop an individualized baseline care plan with 48 hours of admission for one of 19 sampled residents (Resident 182) who was receiving hemodialysis (process of removing waste products and excess fluid from the body). This deficient practice had the potential not to meet the needs of Resident 182 that included interventions for hemodialysis, safety, and wellbeing, which could lead to harm and hospitalization. Findings: A review of Resident 182's admission Record indicated Resident 182 was admitted to the facility on [DATE] with diagnoses that included end stage renal disease (kidneys suddenly become unable to filter waste products from your blood that can develop rapidly over a few hours or a few days), dependence on renal (kidney) dialysis, and hypertension (high blood pressure). A review of Resident 182's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 5/25/2024, indicated Resident 182's cognitive (ability to think…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 care plan for one of five sampled residents (Resident 285) was developed to address non-compliance with medications, as indicated on the facility's care plan policy. This failure had the potential for licensed staff not to utilize interventions for resident to comply with timely administration of medications, which could place Resident 285 at risk for adverse effects from not taking medications as ordered. Findings: A review of Resident 285's admission Records indicated the resident was originally admitted to the facility on [DATE] with diagnoses that included diabetes mellitus (a chronic disease that result in high blood sugar levels in the blood) and cerebral infarction (stroke, a loss of blood flow to part of the brain, causing damage). A review of Resident 285's History and Physical (H&P), dated 5/17/2024, indicated the resident has the capacity to understand and make decisions. A review of Resident 285's Minimum Data Set…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 meet professional standards of quality (care and services are provided according to accepted standards of clinical practice) for one (1) of four sample residents (Resident 18) when Licensed Vocation Nurse 2 (LVN 2) failed to apply gentle pressure to the lacrimal (tear) duct to prevent systemic absorption of the medication of Artificial Tear ophthalmic Solution (a medication used to treat dry eye) during medication administration, as indicated on the facility's Administration of Eye Drop or Ointment policy. This deficient practice had the potential for Resident 18 to have an adverse reaction. Findings: A review of Resident 18's admission Record indicated Resident 18 was admitted to the facility on [DATE], with diagnoses that included Alzheimer's disease (brain disorder that disables a resident from performing everyday activities) and hyperlipidemia (a condition in which there are high levels of fat particles [lipids] in the blood). A review of…

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

Based on observation, interview, and record review, the facility failed to ensure the Low Air Loss mattress (LAL mattress, designed to prevent and treat pressure ulcer [localized damage to the skin and underlying soft tissue caused by prolonged pressure]) for one (1) of three (3) sampled residents (Resident 234) was functioning properly. This deficient practice had the potential for Resident 234's pressure ulcer to worsen and for the resident to develop new pressure injury. Findings: A review of Resident 234's admission Record indicated the facility admitted Resident 234 on 5/16/2024. Resident 234's diagnoses included abnormalities of gait and mobility, repeated fall, pressure ulcer of sacral region (are wounds that form as a direct result of pressure over a bony prominence). A review of Resident 234's Minimum Data Set (MDS, standardized care and screening tool), dated 5/21/2024, indicated Resident 234's cognitive (processes of thinking and reasoning) skills for daily decision making was intact. The MDS indicated Resident 234 was dependent (helper does all the effort) on toileting,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 resident (Resident 182), who was receiving hemodialysis (process of removing waste products and excess fluid from the body) treatment was provided dialysis care and services by failing to assess the resident's right upper chest dialysis access site on 5/20/2024, 5/22/2024, 5/24/2024, in accordance with the facility policy. This deficient practice had the potential for Resident 182 to suffer from complications such as bleeding or infection from the central venous catheter (a catheter [thin tube] that is placed under the skin in a vein, allowing long-term access to the vein. Findings: A review of Resident 182's admission Record indicated Resident 182 was admitted to the facility on [DATE] with diagnoses that included end stage renal disease (kidneys suddenly become unable to filter waste products from your blood that can develop rapidly over a few hours or a few days), dependence on renal (kidney) dialysis, and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide pharmaceutical services to meet the needs of one of four sampled residents (Resident 11) by failing to administer resident's Calcitonin Solution (a medication used to treat bone loss) nasal spray, as indicated on the physician order. This deficient practice had the potential for Resident 11's bone to become more fragile or low in bone mass which could put the resident at a greater risk for fracture (break in the bone). Findings: A review of Resident 11's admission Record indicated the resident was admitted to the facility on [DATE] with diagnosis including Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movement, chiefly affecting middle-aged and elderly people). A review of the History and Physical Examination (H&P), dated 8/29/2023, indicated Resident 11 does not have the capacity to understand and make decisions. A review of the Minimum Data Set (MDS, 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 ensure resident who required adaptive feeding equipment (modified utensils, accessories, glasses, and plates to help improve residents' comfort and independence), utilize a plate guard (unique spill guard which prevents food from accidentally being pushed off the plate) during meal, as indicated on the physician's order, for one of 19 sampled resident (Resident 24). This deficient practice placed Resident 24 at risk for further decline in physical functioning and decline to perform self-feeding skills. Findings: A review of Resident 24's admission Record indicated the resident admitted to the facility on [DATE] and got readmitted on [DATE], with diagnoses including but not limited to bilateral nuclear cataract (a type of cataract [a cloudy area in the lens of your eye] that affects the center of the eye's lens, causing cloudy vision), dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure staff followed the facility's infection control policy for one of 19 sampled residents (Resident 70) when staff was observed not using a gown while providing high-contact resident care activities to Resident 70. This deficient practice had the potential to result in Resident 70 developing an infection and spread of infection among staff and residents. Findings: A review of Resident 70's admission Records indicated the resident was originally admitted to the facility on [DATE] with diagnoses that included sepsis (a serious condition in which the body responds improperly to an infection) and urinary tract infection (infection of the urinary tract). A review of Resident 70's History and Physical (H&P), dated 2/13/2024, indicated the resident does not have the capacity to understand and make decisions. The H&P also indicated Resident 70 has a Gastrostomy Tube (g-tube, tube inserted through the belly to the stomach used to give…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 failed to ensure a string was attached to the call light in the bathroom for one of 19 sampled residents (Resident 39). This deficient practice resulted in the call light not being easily accessible to Resident 39 which had the potential to result in a delay in the provision of care and assistance leading to falls, accidents, and injuries. Findings: A review of Resident 39's admission Record indicated she was admitted to the facility on [DATE] with diagnosis including Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movement, chiefly affecting middle-aged and elderly residents). A review of the Minimum Data Set (MDS, a standardized assessment and care-screening tool), dated 4/8/2024, indicated Resident 39 cognitive skill (mental action or process of acquiring knowledge and understanding for daily decision-making) was moderately impaired. The MDS also indicated Resident 39 required…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to notify the physician for one of two sampled residents (Resident 1) when the resident had a change in condition (COC) for a fever (elevated temperature) and episodes of nausea as indicated in the facility's policy and procedure. This deficient practice had the potential to delay medical interventions and treatment for a possible wound infection. Findings: A review of Resident 1's admission Record indicated Resident 1 was admitted to the facility on [DATE], with diagnosis of Type 2 Diabetes Mellitus (a disorder in which the body does not produce enough or respond normally to insulin [a hormone released from the pancreas that controls the amount of glucose in the blood], causing blood sugar [glucose] levels to be abnormally high), chronic obstructive pulmonary disease (COPD- disease that causes obstructed airflow from the lungs), and wedge compression fraction (small breaks in the vertebrae [bones in your spine] of the T11 to T12 (the last members of the…

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