Napa Community Health Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews, the facility did not maintain hot water temperatures within safe regulatory limits when water temperatures in multiple resident-use restrooms were measured above 120 degrees Fahrenheit (F, a unit measurement of heat) for 16 residents out of a facility census of 24. This failure decreased the facility's potential to provide a hazard-free environment and prevent thermal injury. Cross Reference F835Findings:During a concurrent interview and observation in Resident 8's room on 6/3/26 at 8:15 a.m., Resident 8 stated she was bothered by not having any cold water in her restroom. Upon entering Resident 8's restroom and turning on the cold-water tap, the surveyor observed the water was lukewarm. When the hot water tap was turned on, the water became too hot to safely hold hands under, even briefly. A calibrated thermometer was obtained, and the hot water temperature measured 128.5 degrees F.During observations on 6/3/26 between 8:15 a.m. and 8:45 a.m., hot water temperatures 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 and record review, the medical and nursing staff failed to ensure one resident (Resident 5) out of four sampled residents received a gradual dose reduction (GDR) and behavioral interventions when Resident 5 was given a psychotropic (medication that alter brain chemistry to affect mood, thoughts, behavior and perception) drug.This failure decreased the facility's potential to ensure Resident 5 was not given unnecessary psychotropic medication without evaluating its effectiveness or necessity. Cross Reference F835Findings:A review of Resident 5's admission record indicated she was admitted to the facility on [DATE] with diagnoses of Polymyositiis (a rare, chronic condition that causes swelling, heat, and pain to the skeletal muscles) and major depressive disorder (a mood disorder characterized by feelings of sadness, emptiness and a loss of interest in activities).A review of Resident 5's care plan, revised on 11/20/25, indicated Resident 5 was receiving a psychotropic medication. The plan…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the licensed nurses failed to develop a baseline care plan within 48 hours of admission and provide written copies of the baseline care plan summaries to two residents (Resident 14 and Resident 16) of three sampled residents.These failures decreased the facility's potential to effectively communicate resident needs among facility staff to promote a continuity of care and prevent adverse events from occurring right after admission.Findings:A review of Resident 14's admission record indicated admission to the facility on 5/14/26. This document also indicated Resident 14 was her own Responsible Party (RP, able to make decisions for herself).A review of Resident 14's Minimum Data Set (MDS, an assessment tool) dated 5/20/26 indicated Resident 14 had a Brief Interview for Mental Status (BIMS) score of 15 which meant she had no cognitive (mental processes like memory, learning, concentration, or decision-making) impairment. ).A review of Resident 14's baseline care plan provided…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 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 nursing staff failed to assess, prevent, and identify the occurrence of pressure injury for one resident (Resident 3) of three sampled residents, when Resident 3 obtained a facility-acquired pressure injury (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence) on her left cheek.This failure had the potential for the facility acquired Stage 2 pressure injury (a partial-thickness loss of skin, presenting as a shallow open sore or wound) to worsen and placed Resident 3 at risk of complications including infection and pain. Cross Reference F658, F835Findings:A review of Resident 3's admission record indicated she was admitted to the facility in February 2021 with the diagnosis of long-term use of anticoagulants (medication used to prevent blood clots from forming or getting larger), protein-calorie malnutrition (an inadequate intake of protein or calories), rosacea (a chronic inflammatory skin condition which…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 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 licensed nurses failed to ensure expired and discontinued prescription medication were properly stored and disposed of when:Discontinued medications were observed overflowing from a large, uncovered cardboard box in front of shelves of prescription medications and medical supplies; and,Easily accessible undestroyed medication pills were found in a pharmaceutical waste container.These failures reduced the licensed nurses' ability to safely administer medication and decreased the facility's potential to prevent prescription drug diversion (the illegal redirection of prescription or controlled medication from their intended medical use to unauthorized or illicit use). Cross Reference F835Findings:During a concurrent interview with the Assistant Director of Nursing (ADON) and observation of the medication room on [DATE] at 8:42 a.m., the following were noted:An uncovered, cardboard box measuring 15 inches high by 16 inches wide by 25 inches long was overflowing…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 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 licensed nurses failed to ensure expired medication was properly stored when expired multivitamins and pain medication were not removed from one of two medication carts.This failure reduced the facility's ability to ensure administered medications are safe and effective.Findings:During a concurrent observation of the East medication cart and interview on [DATE] at 11:16 a.m. with Licensed Nurse 3 (LN 3), LN 3 confirmed the cart contained:One bottle of calcium 600 milligram (mg) with Vitamin D, expired on 6/26;One bottle of Daily Vite(R) multivitamin, expired on 5/26; and,Four acetaminophen 650 mg suppositories, expired on [DATE].LN 3 confirmed the medications were expired and removed them from the medication cart.During an interview with the Assistant Director of Nursing (ADON) on [DATE] at 4:38 p.m., the ADON stated licensed nurses were expected to check the expiration dates of medication prior their administration. The ADON stated licensed nurses should…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 store food in a safe and sanitary manner in the resident refrigerator for a census of 24 when food was found unlabeled and undated. This failure decreased the facility's potential to prevent foodborne illnesses in a vulnerable resident population.Findings:In an observation of the resident refrigerator with the Dietary Manger (DM) on 6/3/26 at 4:07 p.m., a bowl with a half-eaten burrito in it and bottles of drinks and supplements were found unlabeled with a resident name to identify whose food it was and undated to identify when it was placed in the refrigerator and when it was expected to be discarded. The DM stated the items were likely a resident's who treated the resident refrigerator as her own personal refrigerator. The DM stated it was not good to have the items in the resident refrigerator unlabeled and undated.A review of the facility's policy titled, Food Brought in by an Outside Source Policy, dated 4/11/23, indicated, All food or beverages brought in from the outside will be labeled with the…

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

Based on interview and record review, the facility failed to treat one of three sampled residents (Resident 1) with kindness, respect, and dignity, when the Director of Nursing (DON) was witnessed bullying Resident 1. This failure resulted in Resident 1 crying.During an interview on 3/24/26 at 2:19 p.m., Confidential Witness (CW) stated that back in January 2026 something happened during activities that caused Resident 1 to get mad at someone. CW stated that while CW was at the nurses station that afternoon, Resident 1 was in the lobby when DON came at the nurses station very emotional and aggressive and said Resident 1 was out of control and we need to do something about her, we need to send her out. CW stated DON was very physically and verbally aggressive about the way she approached the nurses at the desk, all within earshot of Resident 1, who was only a few feet away. CW stated that when Resident 1 heard DON talking about her in this way, she began sobbing. CW stated it felt immediately like DON was bullying Resident 1. CW stated Resident 1 was sent later that day to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to inform the family member of one of three sampled residents (Resident 1) of changes to Resident 1's treatment plan for her behaviors and her pain. This failure resulted in Resident 1's family member (FM) finding out after the changes to the treatment plan had already been implemented, feeling that Resident 1 was being over-medicated with sedating drugs, and having to request further changes to Resident 1's medication regimen.During an interview on 3/11/26 at 1:28 p.m., Family Member (FM) stated he got a call in February 2026 that Resident 1 was in respiratory distress due to an increase in her fentanyl patch (a powerful synthetic opioid, 50 to 100 times more potent than morphine, that is absorbed through the skin for consistent pain relief) dose. FM stated that if facility staff had asked him he would not have agreed to the 50 mcg/hr (micrograms per hour, the rate the drug is released from the patch) fentanyl patch because Resident 1 was already 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 protect one of three sampled residents (Resident 1) from chemical restraint when Resident 1 had a physician order for an antipsychotic drug (mood altering drugs- used to treat symptoms like hallucinations, delusions, and paranoia) to be given as needed (PRN) for longer than 14 days without a re-evaluation for continued need. This failure resulted in Resident 1 having the potential to receive a dose of the antipsychotic when the drug continued to remain an active order for seven weeks.During an observation on 3/12/26 at 11:50 a.m., a musician in the common room adjacent to the lobby sang into a microphone and played an electric guitar. Resident 1 was in the lobby in her wheelchair with her eyes closed and her chin resting on her chest.During an observation on 3/12/26 at 12:22 p.m., Resident 1 was in the lobby in her wheelchair with her eyes closed and her tongue hanging out of her mouth, her chin resting on her chest.During a medical 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, interview and record review, the facility failed to follow its abuse prevention policy and procedures when one of one sampled resident (Resident 1) reported an incident of alleged physical abuse by staff, but the facility had no evidence it conducted an investigation nor reported the results of the investigation to the State Department of Health (the Department) within 5 working days. This failure had the potential to delay the Department ' s independent investigation of the incident. Findings: Review of Resident 1 ' s nurse's progress note, dated 10/29/2024 at 10:15 p.m., indicated, Resident [1] stated to the LN [licensed nurse] the CNA [certified nursing assistant] from last time [10/28/24] pulled on her arms and gave her a 2.5cm x 2 cm discoloration to her left hand near thumb . During a concurrent interview and record review on 2/12/25 at 3:20 p.m., with Medical Record Staff (Staff D), Resident 1's electronic medical record was reviewed. Staff D stated Resident 1's medical record contained a nurse's note dated 10/29/24 at 10:15 p.m. documenting 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.

Based on observation, interview and record review, the facility failed to ensure the sanitization, safety, and functional environment in the kitchen when the temperature of the final rinse of the dishwasher was not maintained to adequately sanitize dinnerware and cooking utensils. This failure can potentially result to food contamination and outbreak of foodborne illness among residents of the facility. Findings: During a concurrent observation and interview on 4/23/24, at 10:02 AM, the final rinse of the high temperature dishwasher was 150 degrees Fahrenheit. Dietary Aide E stated the dishwasher is not holding the final rinse temperature of 180 degrees Fahrenheit. During an interview on 4/24/24, at 5:19 PM, Dietary Aide F when asked about the final rinse temperature of the high temperature dishwasher stated, the dishwasher does not always go up to 180 degrees Fahrenheit at final rinse. Dietary Aide F stated he runs the dishwasher several times to reach 180 degrees Fahrenheit before he continues dishwashig. During an interview on 4/25/24, at 10:45 AM, Dietary Aide E confirmed she…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 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 records review, the facility failed to: 1) ensure hand hygiene was practiced by six (6) of 15 sampled residents (Resident 3, Resident 16, Resident 9, Resident 22, Resident 1, Resident 24) before meals. This failure had the potential to cause the spread of infections to other residents and worsen their already compromised health or cause an outbreak; 2) conduct ongoing analysis of infection surveillance. This failure had the potential to result in the facility missing to identify trends in infection types and occurrence and not being able to detect where an infection came from or the presence of an increasing number of infection or an outbreak; 3) ensure physician's orders were being followed when one of 15 sampled residents (Resident 34), who was on oxygen, nasal cannula (a device that delivers extra oxygen through a tube and into your nose) and oxygen humidifier (plastic bottle filled with distilled water that adds moisture to the oxygen being delivered to prevent dryness 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 interview and records review, the facility failed to consistently perform antibiotic stewardship. This failure had the potential to result to inappropriate or unnecessary antibiotic treatment, increase the risk of adverse events, development of antibiotic resistance, and worsen the already frail health condition of residents. Findings: During a concurrent interview and records review on 4/25/24, at 02:16 PM, the facility Infection Preventionist (IP) stated she had started working in the facility 3 weeks ago and had not seen the previous IP's folders except for the folder on Antibiotic Stewardship. A review of the contents of the folder indicated there were documentation on an antibiotic surveillance tracking form with residents' names who were treated with antibiotics for the months of 1/24 to 4/24 but none for the past months. During an interview on 4/26/24, at 9:40 AM, when asked where the IP documents were, the Director of Nursing (DON) stated Infection control, surveillance and monitoring, and antibiotic stewardship documents could not be located or may have been…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based upon observation, interview, and record review the facility failed to appropriately diagnose and treat a growth on the left side of Resident 29's nose for one out of one sample residents (Resident 29). This failure had the potential to cause an infection and create discomfort for ongoing growth on Resident 29's face. Findings: During a review of Resident 29's, admission Record dated, 6/20/2022, indicated Resident 29's had a history of dementia (a general term for the impaired ability to remember, think or make decisions that interferes with doing everyday activities) and dry eye syndrome of bilateral lacrimal glands (lacrimal gland doesn't make enough tears, causing the eyes to become dry, sometimes caused by age). During an observation on 4/22/24 at 12:25 p.m., Resident 29 was observed lying in bed, asleep with a large growth on the left side of her nose with three streaks of dried blood on her cheek. During an interview on 4/22/24 at 3:29 pm. with Unlicensed Staff A, Unlicensed Staff A indicated Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the RNA (restorative nursing assistant) program (assist the patient in performing tasks that restore or maintain physical function as directed by the established care plan) was being received per physician orders for one of 15 sample residents (Resident 33). This failure resulted in a disruption in treatment and had the potential for Resident 33 to have a decline in range of motion, strength and endurance, an increase in joint pain and depression, and an overall decrease in ADLs (Activities of Daily Living: activities related to personal care, which includes bathing or showering, dressing, getting in and out of bed or a chair, walking, using the toilet, and eating). Findings: A review of Resident 33's admission Record, indicated Resident 33 was admitted to the facility on [DATE], with a diagnosis including cerebral infarction (stroke), major depression disorder, hemiplegia (paralysis on one side of the body), hearing loss, amongst…

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

Based on observation and interview, the facility failed to follow a process of ensuring resident meals were served with the appropriate dietary consistency when one of two staff (Licensed Staff L) was observed reviewing the meal tray cards but not reviewing the covered food for accuracy prior to the meal being served to residents. Findings: During an observation on 4/22/24 at 12:34 p.m., with Licensed Staff L who was reviewing the resident meal tray cards and then reviewing the dietary order in the electronic medical record. Licensed Staff L was observed instructing the Certified Nursing Assistant (CNA) the appropriate texture for the tray, for example regular, pureed (food served with a pudding like texture, which is smooth and blended). Licensed Staff L was observed repeatedly checking the electronic medical record, waiting for the CNA staff to return and serve another tray. At one point, a CNA called out the resident's name and Licensed Staff L indicated the texture of the tray and CNA then delivered the tray to the resident. Licensed Staff L did not open the covered meals to…

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

Based on observation, interview and record review, the facility failed to ensure the safety, and functional environment in the kitchen when cracks and missing tiles on the kitchen floor were not repaired. This failure can cause trips and falls among the kitchen staff and cause dirt to build up on the floor attracting cockroaches and rodents. Findings: During initial tour of the kitchen on 4/22/24, at 9:20 AM, cracked tiled were noted on the floor in front of the entrance to the dry good storage. On continued observation on 4/22/24, at 10:06 AM, more cracks on the tiled floor and missing tiles were noted by the washing sinks, by the exit door to the back of the building, and by the entrance way to another dry good storage. During an interview on 4/23/24, at 10:09 AM, Certified Dietary Manager (DM) nodded in acknowledgement when told the cracks on the kitchen floor and missing tiles were findings of non-compliance to regulations. Review of the Food Code 2017 indicated: It is the standard of practice to ensure materials for indoor floor, wall, and ceiling surfaces under conditions 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 interview and record review the facility failed to perform annual performance reviews on two out of three sampled Certified Nursing Assistants (CNA). These failures had the potential for unlicensed nursing staff to not have their skills assessed under the performance review and not have necessary training addressed in the performance review. Findings: During a concurrent interview on 4/26/24 at 10:54 a.m., with Director of Nursing (DON) and Director of Staff Development (DSD) (by telephone), DSD was asked about the process for completing annual reviews for certified nursing assistants. DSD indicated the annual performance reviews were behind and agreed that Unlicensed Staff P and Unlicensed Staff Q had outstanding annual performance reviews. DSD indicated that on a three day a week schedule, there were things which were behind for the facility. DSD indicated the process would be to complete them within the month of the employee's hire date and the facility was working on the current year of 2024 and indicated 2023 was not complete with performance reviews for all unlicensed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 send in their investigative report for one of one alleged abuse incident to the department, within 5 days from the incident. This failure to not finish the investigation and sending the report, could result in missed chance to improve the care and services provided by the facility and potentially avoid other instances of abuse and neglect. Findings: During a review of records on 9/12/23, the facilities Report of Suspected Dependent Adult/Elder Abuse dated 8/12/23 was reviewed. The report indicated an allegation of abuse by staff against a resident, occurring on 8/12/23. The 5-day investigation report was not available. The report had not been sent to the department. On 9/12/23 at 10 a.m., an on-site visit was conducted at the facility to investigate the allegation of abuse. During an interview on 9/12/23 at 10:15 a.m., Administrator stated he had investigated the incident, but indicated he had not formalized the report for the facilities records. Administrator stated he did not know he was required to send in an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on Observation Interview and Record Review: 1. The facility failed to ensure a comfortable environment when the facility did not maintain comfortable room temperature (standard room temperatures are to be from 68-81 degrees Fahrenheit) in 19 out of 24 rooms (Rm): (Rm 101, 102, 105, 106, 108, 109, 110, 112, 114, 115, 116, 117, 118, 120, 121, 123, 124, 125, and 126) when temperatures measured were from 60 to 67 degrees and multiple residents (Resident 14, Resident 17, Resident 23, Resident 26, Resident 40, and Resident 244) complained of being cold inside of their rooms. 2. The facility did not maintain comfortable resident room temperatures safely by using three space heaters in the west hallway, two space heaters in the east hallway, and a space heater in resident rooms: (Rm 101, 112, 114, 115, and 123), which had the potential of causing a fire resulting in injury or death. On 1/12/23 at 2:26 p.m., the Administrator was notified of substandard quality of care identified and the facility was on extended…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 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 safe water temperatures when the water temperatures in eight of 14 residents' bathroom sinks were too hot, one over 130 degrees Fahrenheit (° F). This failure could potentially result in vulnerable residents getting scalded or burned from hot water. Findings: During an observation on 1/9/23 at 10:27 a.m., the water from the faucet in the bathroom between rooms [ROOM NUMBERS] felt very hot to the touch. During an observation on 1/9/23 at 11:11 a.m., the water from the faucet in the bathroom between rooms [ROOM NUMBERS] felt very hot to the touch. During an interview on 1/9/23 at 11:41 a.m., Resident 17 stated that one of the two showers had fluctuating water temperatures that were so uncomfortable she refused to use that shower. During an observation on 1/9/23 at 3 p.m., the water from the faucet in one of the front public restrooms was scalding hot. During an observation on 1/9/23 at 3:41 p.m., Maintenance Supervisor checked 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 and interview, the facility failed to install call lights that could be accessed by a resident lying on the floor in the bathroom or shower room. This could potentially result in a resident falling to the floor and unable to signal to staff that they need immediate assistance. Finding: During observations on 1/9/23 between 3:41 p.m. and 4:30 p.m., all resident bathrooms and showers were noted to have call lights with a red button and no cord or other device to activate the call system from the floor. During an observation on 1/9/23 at 4:45 p.m., room [ROOM NUMBER]'s bathroom call light was located on the wall right of the sink. If a resident fell to the floor while in the bathroom, the resident would not be able to reach the call light to call for assistance. During a concurrent observation and interview on 1/12/23 at 10:15 a.m., the large shower room had shower equipment and other equipment that prevented one from being able to reach the shower call light without moving the equipment. 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 send a copy of Notice of Discharge or Transfer to the representative of the Office of the State Long-Term Care (LTC) Ombudsman [a public advocate is an official who is charged with representing the interests of the public by investigating and addressing complaints of maladministration or a violation of rights] for four out of six residents: Resident 13, who was transferred to an acute care facility and Resident 43, 247, and 249, who were discharged to home. This failure had the potential for Resident 43, 247, and 249 being inappropriately discharged and Resident 13, 43, 247, and 249 not being provided an advocate who could inform them of their rights and options before being discharge to home or transferred to the acute care facility. Findings: A review of Resident 13's Nurse's Progress Notes, dated 1/7/23, indicated Resident 13 was transferred to the Emergency Department (ED) because Resident 13 had started spiking a temperature (99.8 degrees), CBC…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 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 keep residents' pneumonia vaccines up to date when residents were not offered the 23-valent pneumonia vaccine, as recommended by the Centers for Disease and Prevention (CDC). This failure could potentially leave vulnerable residents unprotected from preventable lung infections that can lead to hospitalization or death. Finding: During an interview on 1/13/23 at 2:33 p.m., the Director of Nursing (DON) stated the immunization program was usually overseen by the Infection Preventionist (IP), Director of Staff Development (DSD), and nursing. DON stated the program was a work in progress since they had not had stable IP coverage. DON stated she had been doing her best to keep up. DON stated IP and DSD were presently going through resident records and creating a spreadsheet of resident vaccinations. DON stated the system for tracking resident vaccinations to ensure they were current was overseen by MDS Nurse. When asked which guidance the facility policy…

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