The Springs Health And Rehabilitation Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to accurately document the Responsible Person (RP) notification of one of three residents' (Resident 3) transfer to the general acute care hospital (GACH) on January 17, 2025. This failure resulted in inaccurate documentation of events in relation to Resident 3 ' s transfer process. Findings: On January 29, 2025, at 9:37 a.m., the RP was interviewed via telephone. The RP stated in the morning of January 17, 2025, family member (FM) 1 visited Resident 3 but did not stay long since Resident 3 had a cough. The RP stated in the afternoon of January 17, 2025, the facility called and notified her that Resident 3's blood pressure (BP) was low and that they were going to start intravenous (IV- into the vein) fluid hydration, and may possibly do an X-ray, after which they were to receive another update. The RP stated neither she nor her family members (FMs) received any notification from the facility thereafter. The RP stated the following morning (Saturday,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 pain medications were administered as ordered by the physician, for one of three residents (Resident A). This failure had the potential for Resident A's pain not be managed and affect overall health condition. Findings: On January 2, 2025, at 11:30 a.m., an unannounced visit to the facility was conducted to investigate an allegation of abuse. On January 2, 2025, a review of Resident A's medical record was conducted. Resident A was admitted to the facility on [DATE], with diagnoses which included atherosclerotic (a buildup of fats, cholesterol, and other substances in and on the artery walls) heart disease and polyneuropathy (a condition where multiple peripheral nerves throughout the body become damaged or malfunction). A review of Resident A's care plan, dated June 26, 2023, indicated, .Resident is at risk for pain r/t (related to) risk factors .Interventions .Administer medications as ordered . A review of Resident A's Order Summary Report,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the resident receive the necessary care and treatment to prevent and treat allergic reactions, for one of four residents reviewed (Resident A) when: 1. Resident A's allergy to aspirin (medication to treat pain, fever, headache, and inflammation. It can also reduce the risk of heart attack) was not listed in the allergy list. Aspirin was administered to Resident A from June 3 to 17, 2024, and June 19 to 22, 2024 (total of 19 days); and 2. Resident A did not receive medication to treat signs and symptoms of allergic reaction. These failures resulted in Resident A to be transferred to the general acute hospital and acquired toxic epidermal necrolysis (a rare, life-threatening skin reaction, usually caused by a medication. It's a severe form of [NAME]-[NAME] syndrome [SJS- a rare, serious disorder of the skin and mucous membranes usually a reaction to medication that starts with flu-like symptoms, followed by a painful rash that spreads 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, record review, and facility policy review, the facility failed to ensure Minimum Data Set (MDS) assessments accurately reflected the status of 1 (Resident #91) of 3 sampled residents reviewed for nutrition and 1 (Resident #101) of 1 sampled resident reviewed for dementia care. Specifically, the MDS assessments inaccurately indicated Resident #91's weight-loss was due to a physician-prescribed weight-loss regimen and did not reflect Resident #101's use of bed and wander/elopement alarms. Findings included: A facility policy titled, Resident Assessment, revised in 03/2023, revealed, 1. The facility conducts initially and periodically a comprehensive, accurate, standardized reproducible assessment of each resident's functional capacity. 1. An admission Record revealed the facility admitted Resident #91 on 10/21/2021. According to the admission Record, the resident had a medical history that included diagnoses of liver cancer and encounter for palliative care. Resident #91's Care Plan included a…

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

Based on observation, interview, record review, and facility policy review, the facility failed to ensure staff properly donned personal protective equipment (PPE) prior to entering the room of 1 (Resident #268) of 4 residents reviewed for transmission-based precautions. Findings included: A facility policy titled, Resident Isolation-Categories of Transmission-Based Precautions, revised on 09/01/2023, revealed, III. A. Contact precautions are implemented for residents known or suspected to be infected or colonized with microorganisms that are transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident-care items in the resident's environment. i. Examples of infections requiring Contact Precautions include, but are not limited to: a. Gastrointestinal, respiratory, skin, or wound infections or colonization with multi-drug resistant organisms (e.g. [exempli gratia, for example], MRSA [Methicillin-Resistant Staphylococcus Aureus]. The policy further revealed, gloves (clean, nonsterile) are worn when entering the room, and gown is worn 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 for one three residents (Resident A) was free from verbal abuse when a Certified Nursing Assistant (CNA) was witnessed to have used explicit words towards Resident A in the hallway. This failure resulted in a verbal abuse from CNA towards Resident A and had the potential to have a negative effect on the psychological, behavioral, or psychosocial outcomes to maintain or improve resident's overall well-being. Findings: On April 10, 2024, at 10 a.m., an unannounced visit to the facility to investigate an incident of verbal abuse was conducted. On April 10, 2024, at 10:10 a.m., an interview was conducted with the Assistant Administrator (AADM). The AADM stated CNA 1 reported she overheard CNA 2 told Resident A, Fuck you, you are a grown woman, why are you acting like this? in the hallway. The AADM stated the facility had completed their investigation and confirmed by multiple witnesses that CNA 1 indeed verbally abused Resident A on the alleged…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 for one three residents (Resident A), an incident of verbal abuse from a Certified Nursing Assistant (CNA) towards Resident A was reported to California Department of Public Health (CDPH) within two hours. This failure resulted to a delay in the reporting and investigation of a verbal abuse and potentially placed Resident A and/or other residents at risk for further abuse. Findings: On April 10, 2024, at 10 a.m., an unannounced visit to the facility to investigate an incident of verbal abuse was conducted. On April 10, 2024, at 10:10 a.m., an interview was conducted with the Assistant Administrator (AADM). The AADM stated on March 28, 2023, at around 11:30 a.m., the Director of Staff Development (DSD) received report from CNA 1 of an alleged verbal abuse towards Resident A. The AADM stated CNA 1 reported that on March 28, 2024, between 4 a.m. to 5 a.m., she overheard CNA 2 told Resident A, Fuck you, you are a grown woman, why are you acting like…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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, facility failed to ensure for one three residents (Resident A), was free from any further abuse, when Certified Nursing Assistant (CNA) was not removed from all patient care after being witnessed by other staff to have verbally abused Resident A in the hallway. This failure had the potential to placed Resident A and/or other residents at risk for further abuse. Findings: On April 10, 2024, at 10 a.m., an unannounced visit to the facility to investigate an incident of verbal abuse was conducted. On April 10, 2024, at 10:10 a.m., an interview was conducted with the Assistant Administrator (AADM). The AADM stated the Director of Staff Development (DSD) received report from CNA 1 of an alleged verbal abuse towards Resident A on March 28, 2023, at around 11:30 a.m. The AADM stated CNA 1 reported she overheard CNA 2 told Resident A, Fuck you, you are a grown woman, why are you acting like this? in the hallway on March 28, 2024, between 4 a.m. to 5 a.m. The AADM stated after…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 home medications were destructed or disposed according to the facility's policy and procedure when: 1. Multiple Dilaudid (narcotic medication for pain) tablets were destructed together with non-narcotic medications; and 2. Multiple Zofran (medication to treat nausea) tablets and a tube of antifungal cream (medication to treat fungal skin infection) were destructed without verification of the physician orders for the medication. These failures had the potential administration error, inaccurate reconciliation, and drug diversion (illegal distribution or abuse of prescription drugs or their unintended purposes) of narcotic and non-narcotic medications. Findings: On October 20, 2023, at 9:50 a.m., an unannounced visit ws conducted at the facility to investigate a compliant on quality of care. On October 20, 2023, at 10:25 a.m., Licensed Vocational Nurse (LVN) 1 was interviewed. She stated home medications were to be given to the Registered Nurse Supervisor (RNS) for review. She stated narcotic medications…

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

Based on observation, interview, and record review, the facility failed to report a scabies (a parasitic infestation of the skin caused by an itch mite) outbreak to the California Department of Health (CDPH), within 24 hours according to the facility's policy and procedure and CDPH scabies outbreak reporting timeframe guidelines. This failure had the potential to interfere with facility operations and agencies ability to respond to outbreak as needed. Findings: On August 17, 2023, at 2 p.m., a concurrent interview and record review with the Infection Preventionist (IP) was conducted. She stated one resident was positive for scabies on July 28, 2023. She stated 10 residents were tested for scabies on August 7, 2023 due to presence of rashes, and one resident was identified positive for scabies on August 11, 2023. She stated she reported the scabies outbreak to the state agency on August 16, 2023 (19 days after onset of outbreak). On August 17, 2023, at 5:10 p.m., during an interview with the Administrator (ADM) and the Director of Nursing (DON), they both stated the scabies outbreak…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 skin condition was identified, addressed, and monitored timely, for one of two residents reviewed for skin condition (Resident A), when Resident A had a scab (a dry, rough protective crust that forms over a cut or wound during healing) on her front scalp (skin covering the head). This failure had the potential to result in a delay in the care and treatment for Resident A's scab on her front scalp, which could worsen the overall health skin condition for Resident A. Findings: On April 5, 2023, at 11:48 a.m., an unannounced visit to the facility was conducted to investigate a facility reported incident. On April 5, 2023, at 11:55 a.m., an interview was conducted with the Director of Nursing (DON). The DON stated on April 2, 2023, at around 2:43 p.m., Resident A's family member notified the Licensed Vocational Nurse (LVN) of a scab observed on the resident's front scalp. The DON stated the LVN was not able to provide any information…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide necessary care and treatment when: 1. The facility failed to assess changes in skin condition for three of eight residents (Residents 70, 73, and 88) reviewed for skin conditions. The facility failed to assess Residents 70 and 88's skin discolorations and Resident 73's open skin. These failures had the potential to result in delayed treatment, which could cause worsening of Residents 70, 73, and 88's, skin conditions; and 2. The facility failed for one of five residents (Resident 66) reviewed for dialysis (the process of removing waste or fluid from the blood with the use of a machine) to obtain a physician order for monitoring, care, and treatment of Resident 66's right upper chest Quinton catheter site (a central venous catheter inserted thru a large vein into the heart). This failure had the potential for Resident 66 to develop an infection and experience complications. Findings: 1. a) On August 17, 2021, at 11:52 a.m.,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 medications were stored, according to the facility's policy and regulatory requirements when: 1. For Resident 49, one albuterol inhaler (medication to treat shortness of breath) was found unsecured on top of Resident 49's bedside table; 2. For Resident 5, one bottle of nystatin powder (medication to treat fungal infection) was found unsecured on top of Resident 5's bedside table; 3. For Resident 230, one small tub of Eucerin cream (medicated cream) was found unsecured on top of Resident 230's bedside table; 4. For Resident 88, one-unit dose of albuterol (medication to treat shortness of breath) was found unsecured on top of Resident 88's drawer; and 5. For Resident 66, two small packets of hydrocortisone cream (medication to treat a skin condition) were found unsecured on top of Resident 66's bedside table. These failures increased the possibility for Residents 5, 49, 66, 88, and 230, to receive medications unsafely. Findings: 1. On August 17, 2021, at 11:15 a.m., a concurrent observation and interview…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 infection control practices were observed, when: 1. One staff member unvaccinated for COVID-19 (a highly contagious respiratory disease spread from person to person) did not wear a respirator mask when inside of the facility; 2. Inside the bathroom of resident room [ROOM NUMBER], one unlabeled bedpan was stored between the wall and the handrail; 3. Resident 88's suction tubing with a Yankauer tip (a type of device used to remove oral secretions) and nebulizer tubing with a chamber (a container to hold a liquid medication for breathing treatments) were observed stored together inside a plastic bag and were undated; 4. One staff entered the PUI unit (Person Under Investigation - a designated unit for residents under observation for suspected or exposed to COVID-19) without wearing a respirator mask (N95 - a mask to filter airborne particles); and 5. Multiple facility staff did not observe proper hand hygiene and wearing of PPE…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 follow their infection control program to prevent the spread of COVID-19 (a highly contagious respiratory illness caused by a corona virus that can be spread from person to person) when the facility did not conduct daily COVID-19 testing for facility staff according to their policy and procedure. This failure had the potential to result in the spread of COVID-19 infection among healthcare personnel and residents, which could result in an outbreak affecting the vulnerable facility residents. Findings: On August 17, 2021, at 2:50 p.m., the Director of Nursing (DON) was interviewed. The DON stated the facility conducted daily COVID-19 testing by antigen rapid test for all facility staff who were scheduled to work. The DON stated all staff were tested before starting work. On August 19, 2021, the daily COVID-19 staff testing records and staffing records were reviewed. The records indicated the following: 1. The facility Daily Nursing Staffing Sign-In Log, dated August 16, 2021, indicated there were 71 staff members recorded…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to accommodate the need of one resident (Resident 91), when the facility did not provide batteries for the hearing aids used by Resident 91. This failure resulted in Resident 91 to not be able to hear properly and communicate effectively. Findings: On August 16, 2021, at 12:43 p.m., Resident 91 was observed inside her room, sitting in the wheelchair and watching television. Resident 91 was alert and able to answer questions. During an interview, Resident 91 pointed to her right and left hearing aids and stated, I can't hear you, no battery. Resident 91's record was reviewed. Resident 91 was admitted to the facility on [DATE], with diagnoses which included hearing loss bilateral (both) ears. The BIMS (Brief Interview for Mental Status - an assessment for cognitive status) indicated a score of 15 out of 15 - cognitively intact. The Social Services Progress Notes dated August 2, 2021, were reviewed. The notes indicated, .Social Service informed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to inform the Responsible Party (RP) when there was a change of condition (COC) in one of five residents (Resident 95) reviewed for skin condition. This failure resulted in Resident 95's RP not being notified of Resident 95's change of condition on the right and left buttocks on July 29, 2021. Findings: On August 18, 2021, Resident 95's record was reviewed. Resident 95 was admitted to the facility on [DATE], with diagnoses which included left breast metastatic cancer (cancer that spread to other parts of the body), status post left mastectomy (a surgical operation for breast removal)) pulmonary embolism ( a blood clot in the lungs), pneumonia (infection of the lungs) and chest wall abscess (an infection in the upper part of the chest) and chronic kidney disease (kidney failure). The nursing admission assessment dated [DATE], was reviewed. The assessment indicated the following: .Alert and oriented to person, place and situation .; .ADLs, (Activities of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to notify the Responsible Party (RP) for one of three residents (Resident 95) reviewed for closed records, when Resident 95 was transferred to the hospital due to a change of condition. This failure resulted in Resident 95's RP not being notified of Resident 95's transfer to the acute hospital on August 3, 2021. Findings: On August 18, 2021, Resident 95's record was reviewed. Resident 95 was admitted to the facility on [DATE], with diagnoses which included left breast metastatic cancer (cancer that spread to other parts of the body), status post left mastectomy (a surgical operation for breast removal)) pulmonary embolism ( a blood clot in the lungs), pneumonia (infection of the lungs) and chest wall abscess (an infection in the upper part of the chest) and chronic kidney disease (kidney failure). The laboratory blood work for Resident 95's BUN (Blood urea nitrogen - medical test that measures the amount of urea nitrogen in the blood, high level means the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to develop a baseline (an initial) care plan to address the care and treatment of an unused Quinton catheter - a central line catheter used temporarily for hemodialysis (a procedure where a dialysis machine and special filter are used to clean the blood) for one of five residents reviewed (Resident 66). This failure resulted in Resident 66 not receiving the necessary care and treatment of the unused Quinton catheter from July 2, 2021 to August 17, 2021. Findings: On August 17, 2021, at 3:05 p.m., Resident 66 was observed awake, alert and able to verbalize his needs. Resident 66 was observed with a Quinton catheter on his right upper chest area which was covered with an undated adhesive transparent dressing. In a concurrent interview with the Treatment Nurse (TN) he stated Resident 66 had not received hemodialysis treatment for a while. The TN stated the Registered Nurse (RN) was responsible for the care of the Quinton catheter. On August 18,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 resident (Resident 73) received care and services necessary to maintain the highest level of physical and psychosocial well-being when Resident 73 did not receive an oral care. This failure increased the potential for Resident 73 to develop tooth cavities, gum infections, and cause emotional distress. Findings: On August 16, 2021, at 11:17 a.m., an observation and concurrent interview were conducted with Resident 73. Resident 73 was observed sitting in a wheelchair, alert, oriented, and conversant. Resident 73's teeth were observed to be brownish in color with food residue in between his teeth. Resident 73 also had multiple missing teeth, and bad breath. Resident 73 stated the last time his teeth were brushed was two months ago. On August 16, 2021, at 1:40 p.m., Certified Nursing Assistant (CNA) 2 was interviewed. CNA 2 stated she did not provide oral care to Resident 73. On August 16, 2021, at 1:45 p.m., the Assistant Director…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow physician's orders when the facility did not administer oxygen as ordered for two of six residents (Resident 331 and 108) reviewed for oxygen therapy. These failures had the potential for Resident 331 and 108 to experience respiratory problems and a decline in their health condition due to ineffective oxygen therapy. Findings: 1. On multiple dates and times during the survey Resident 331 was observed awake, lying in bed, and conversant. Resident 331 was observed wearing a nasal cannula (plastic tubing with two prongs connected to the nose to deliver oxygen) connected to a concentrator (a machine converting room air to oxygen) at the bedside on the following dates and times: - August 16, 2021, at 1:50 p.m.; - August 17, 2021, at 10:17 a.m.; - August 18, 2021, at 12:20 p.m.; - August 19, 2021, at 3:30 p.m.; and - August 20, 2021, at 8:20 a.m. Resident 331's record was reviewed. Resident 331 was admitted to the facility on [DATE],…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide the necessary dental services for one of two residents (Resident 68) reviewed for dental service, when there was no follow up dental service provided for Resident 68 to address broken dentures. This failure had the potential to decrease Resident 68's food intake which could result in a decline in the resident's nutritional condition, weight loss, and decreased self-esteem. Findings: On August 17, 2021, at 10:45 a.m., a concurrent observation and interview was conducted with Resident 68. Resident 68 was observed not wearing dentures. Resident 68 stated, I broke my dentures, its been a while, and I want to have a denture. Resident 68's record was reviewed. Resident 68 was admitted to the facility on [DATE], with diagnoses which included dysphagia (difficulty in swallowing), anxiety disorder (feeling of worry, nervousness, or unease), and major depressive disorder (mood disorder that causes a persistent feeling of sadness and loss of…

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