Napa Post Acute

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, one of two residents sampled for tube feeding (Resident 140), who was at risk for constipation, had no bowel movement (BM) for five days and was not given bowel care medications as indicated on the care plan. This failure contributed to Resident 140 developing a fecal impaction (a severe, solid, or hard mass of stool stuck in the rectum or colon, typically resulting from chronic, untreated constipation).During an electronic medical record (eMR) review on 2/3/26 at 3:30 p.m., Resident 140's face sheet indicated an admission date of 1/9/26, age in his 70s, and medical diagnoses that include traumatic subdural hemorrhage (a type of bleeding near the brain that can happen after a head injury), broken facial bones, aphasia (language disorder resulting from brain damage that impairs speaking, writing, reading, and comprehension while leaving intelligence intact), dysphagia (difficulty swallowing), and a gastrostomy (the surgical creation of an opening (stoma) into the stomach 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 provide adequate supervision and monitoring for one out of two sampled Residents (Sampled Resident 60) when Resident 60 left the facility unnoticed by staff (eloped) on 12/27/25.This failure contributed to Resident 60 being found outside the facility by the police and had the potential to lead to injuries for Resident 60. Review of Resident 60's medical record document titled admission RECORD, indicated he was admitted [DATE], with diagnoses that included Heart Disease, Encounter for Aftercare Following Surgery on the Circulatory System, Muscle Weakness, Need for Assistance with Personal Care, and Unspecified Psychosis (A person's thoughts and perceptions are disrupted and they may have difficulty recognizing what is real and what is not.).During an observation on 2/2/26 at 9 a.m., the front doors of the facility faced north onto a busy street with consistent traffic.During an interview with Resident 60's Public Guardian I (A…

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

Based on observation, interview, and record review, the facility failed to ensure one out of one resident's sampled for ostomy care( a surgical opening in the abdomen that redirects waste outside the body into a wearable pouch system) ( Resident 110), received care according to professional standards of practice when Licensed Nurse S disregarded Resident 110's verbal and non-verbal signs of pain with old appliance removal, did not follow the correct procedure for appliance change to minimize skin exposure to feces and urine, and did not notify the supervisor of any abnormal findings. This failure caused Resident 110 to have pain, discomfort, and had the potential to contribute to further skin breakdown around his stoma(a surgically created opening in the abdomen that diverts stool flow). A review of Resident 110's admission record indicated he was admitted in 09/2024 with left sided hemiparesis (a neurological condition characterized by weakness on one side of the body affecting the arm, leg, and trunk) after a stroke, chronic pain, and had an ostomy.A review of Residents 110's…

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

Based on observations, interview, and record review the facility failed to properly maintain the residents' food refrigerator for a census of 116 when food items were not properly labeled.This failure had the potential to result in residents consuming contaminated food, increasing the risk of foodborne illness and adverse health outcomes.During a concurrent observation and interview on 2/2/26 at 9:40 a.m., with the Dietary Services Manager (DSM), the freezer unit of the resident refrigerator contained one opened 16 oz container of Dean's French Onion Dip and two (8-pack) unopened packages of El Monterey Beef and Bean Chimichangas the DSM stated, he did not see any identifying labels on the french onion dip container or either of the chimichanga packages. During an interview on 2/12/26 at 10:27 a.m., with the Director of Nursing (DON), the DON stated she expected items placed in the resident refrigerator were labeled properly with dates and who the item belonged to, otherwise resident food could be shared with another resident if not properly labeled. The DON also stated she would…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 did not securely attach the bed rails to the bedframe for one of seven residents who use bed rails, (Resident 105.) Resident 105's bed rails were loose and wobbly, easily swinging away from the bed. Resident 105 stated she did not feel safe using the bed rails for repositioning or getting in and out of bed and stated she almost fell to the floor.During an interview and concurrent observations on 02/09/2026 at 4:26 p.m., in Resident 105's room, Resident 105 reported that broken bed rails nearly caused a fall while repositioning. She stated, the rail just fell down and demonstrated how the left rail could move side to side, creating a 2 to 3-inch gap between the mattress and rail . The surveyor confirmed the rail could swing towards the middle of the room, forming a large gap which posed a fall risk. The right bed rail was also loose and could be pushed away from the bed towards the wall.During an interview and concurrent observations on 02/10/2026…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide adequate nursing services for 4 residents (Resident 2, Resident 3, Resident 4, and Resident 5) of 5 sampled residents to ensure residents achieved the highest level of physical and emotional well-being when the facility failed to make a sufficient number of nursing staff available to meet residents' needs. This failure had the potential to place residents at greater risk for dehydration, skin breakdown and placed their safety in jeopardy.A review of Resident 2's admission record indicated Resident 2 was admitted to the facility on [DATE] with diagnoses of Acute on Chronic Heart Failure ( a worsening of a clinical condition when the heart cannot pump enough blood to meet the body's needs for oxygen and nutrients), End Stage Renal Disease (kidney function has declined to 15% of normal capacity) and Diabetes Mellitus (DM-disorder characterized by difficulty in blood sugar control and poor wound healing). A review of Resident 2's care…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to initiate a baseline care plan for one resident (Resident 1) of three sampled residents when licensed nurses did not create a care plan for Resident 1's indwelling urinary catheter (a flexible tube inserted into the bladder to allow urine to drain from the bladder and into a bag which collects the urine).This failure decreased the facility's potential to prevent urinary tract infections (UTI) among residents with urinary catheters in place.Findings:A review of Resident 1's admission record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses of Fracture of Left Patella (kneecap), Intervertebral Disc Degeneration (progressive breakdown of shock absorbing discs in the spine), Muscle Weakness, Obstructive and Reflux Uropathy (two distinct conditions that interrupt the one way flow of urine from the kidneys to the outside of the body) and Need for Assistance with Personal Care.A review of Resident 1's care plans, dated 11/6/25,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, observation, and facility policy review, the facility failed to ensure the most recent survey results were readily accessible for all residents to review. This deficient practice had the potential to affect all residents who resided in the facility. Findings included: A facility policy titled, Examination of Survey Results, revised 04/2017, indicated, 2. A copy of the most recent survey report and any plans of correction are kept in a binder in the residents' dayroom. During observations on 03/05/2025 beginning at 8:15 AM of readily accessible areas to residents, the state survey results could not be found in the facility. During an interview on 03/05/2025 at 8:24 AM, the Activities Director revealed she did not know where the survey results were posted. She stated she did not know the survey results were required to be available without asking. During an interview on 03/05/2025 at 9:40 AM, the Social Services Director (SSD) stated the survey binder was on the table near the building's entrance. She said she last saw the survey binder when the state surveyors…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, observation, and facility policy review, the facility failed to protect the rights of residents and their representatives to have the ability to file grievances anonymously. This deficient practice had the potential to affect all residents who resided in the facility. Findings included: A facility policy titled, Grievances / Complaints, Filing, dated 2001, indicated, 5. Grievances and/or complaints may be submitted orally or in writing, and may be filed anonymously. An undated facility Grievance Process, indicated, Grievance forms are available for the individual and/or their family members to complete independently and/or with employee assistance. Forms can be obtained by contacting the executive director, director of nursing services, social services director and other department heads, or they can be obtained from the nurses' station. A sign posted in the facility indicated that the Grievance Officer was Social Worker (SW) #16. During an observation on 03/05/2025 at 8:15 AM, there were no grievance forms available for public use. There was no way to take 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 interview, record review, and facility policy review, the facility failed to ensure Minimum Data Set (MDS) assessments accurately reflected the status of 3 (Residents #107, #106, and #61) of 29 sampled residents reviewed for MDS accuracy. Specifically, the MDS assessments inaccurately reflected Resident #107 was discharged to a hospital; Resident #106 was discharged to home/community, and Resident #61 did not use a wander/elopement alarm. Findings included: A facility policy titled, Certifying Accuracy of the Resident Assessment, revised 11/2019, indicated, Any person completing a portion of the Minimum Data Set/MDS (Resident Assessment Instrument) must sign and certify the accuracy of that portion of the assessment. The policy also indicated, 3. The information captured on the assessment reflects the status of the resident during the observation (look-back) period for that assessment. 1. An admission Record indicated the facility originally admitted Resident #107 on 05/29/2024, readmitted the resident on 11/18/2024, and discharged the resident on 12/06/2024. According 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 interview, record review, and facility policy review, the facility failed to ensure a resident's admission Pre-admission Screening and Resident Review (PASRR) accurately captured an admission diagnosis of a serious mental illness (SMI) for 1 (Resident #64) of 2 residents reviewed for PASRR. Specifically, Resident #64's admission PASRR did not capture their admission diagnosis of unspecified psychosis. Findings included: A facility policy titled, Pre-admission Screening and Resident Review, revised 12/2016, revealed, a. The facility will participate in or complete the Level I screen for all potential admissions regardless of payer source to determine if the individual meets the criterion for mental disorder (SMI/SMD), intellectual disability (ID) or related condition. An admission Record revealed the facility admitted Resident #64 on 11/01/2024. According to the admission Record, the resident had a medical history that included a diagnosis of unspecified psychosis (onset date 11/01/2024). Resident #64's quarterly Minimum Data Set (MDS), with an Assessment Reference 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.

Based on interview, record review, and facility policy review, the facility failed to ensure residents with limited range of motion (ROM) received care and services to prevent any further decrease in ROM for 1 (Resident #28) of 2 residents reviewed for rehabilitation and restorative services. Specifically, Resident #28 had an order for staff to ask rehabilitation services to perform passive ROM, but there was no documentation that this order had been completed. Findings included: A facility policy titled, Restorative Nursing Services, indicated, 1. Restorative nursing care consists of nursing interventions that may or may not be accompanied by formalized rehabilitative services (e.g. [exempli gratia, for example], physical, occupational or speech therapies). 2. Residents may be started on a restorative nursing program upon admission, during the course of stay or when discharged from rehabilitative care. An admission Record revealed the facility admitted Resident #28 on 03/04/2017. According to the admission Record, the resident had a medical history that included diagnoses of morbid…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, and facility policy review, the facility failed to ensure a resident was safe from eloping from the facility for 1 (Resident #61) of 2 residents reviewed for elopements. Specifically, Resident #61 eloped from the facility on 02/25/2025 and was found in a parking lot approximately one block away from the facility. At the time of the elopement Resident #61 was utilizing a WanderGuard device (departure alert system); however, the WanderGuard device was not applied in accordance with manufacturer's instructions. Additionally, the facility failed to ensure 1 of 1 supply closet observed containing medical supplies was locked and inaccessible to residents. Findings included: 1. A facility policy titled, Wandering and Elopements, revised 03/2019, specified, 2. If a resident is missing, initiated the elopement/missing resident emergency procedure: which included, c. if the resident is not located, notify the administrator and the director of nursing services, the resident's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and facility policy review, the facility failed to ensure medication carts were locked when unattended by staff for 1 of 6 medication carts observed. Findings included: A facility policy titled, Storage of Medications, revised 04/2019, indicated, The facility stores all drugs and biologicals in a safe, secure, and orderly manner. The policy revealed the section titled, Policy Interpretation and Implementation, included, 9. Unlocked medication carts are not left unattended. During an observation on 03/07/2025 at 10:35 AM, an unattended and unlocked medication cart was observed outside room [ROOM NUMBER]. The staff were not around or within eyesight of the cart. There were no residents nearby. During an interview on 03/07/2025 at 10:39 AM, Registered Nurse (RN) #19 confirmed she was in a resident's room and out of eyesight from the medication cart. She stated she should have locked the medication cart. During an interview on 03/07/2025 at 11:31 AM, the Director of Nursing (DON)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, record review, and facility policy review, the facility failed to ensure an order to discontinue a medication was transcribed into the clinical record for 1 (Resident #84) of 28 sampled residents for whom orders were reviewed. Findings included: A facility policy titled, Discontinued Medications, revised in 04/2007, indicated, 1. A practitioner's order to discontinue a resident's medication must be documented in the resident's clinical record and on the medication administration record (MAR). An admission Record indicated the facility admitted Resident #84 on 09/15/2024. According to the admission Record, the resident had a medical history that included a diagnosis of type two diabetes mellitus. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/23/2024, revealed Resident #84 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. A physician note, dated 01/27/2025, revealed Resident #84 had a follow-up appointment with an outside provider, Physician #22, on 01/27/2025 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 assistance with Activities of Daily Living (ADL) for three residents (Resident 1, Resident 2 & Resident 3) of four sampled residents when Resident 1, Resident 2, and Resident 3 developed a gray-white residue inside their oral cavities and malodorous breath. This finding had the potential to result in tooth decay, gum disease, discomfort, and tooth loss among residents. Findings: Record review of Resident 1's admission record indicated admission to the facility on 9/5/17 with medical diagnoses including Hemiplegia (Paralysis or weakness on one side of the body) & Hemiparesis (One-sided muscle weakness) following a Cerebral Infarction (A medical condition where blood flow to the brain is interrupted, leading to damage or death of brain tissue). Record review of Resident 1's Minimum Data Set (MDS-An assessment tool) dated 8/06/24 indicated he needed set-up or clean-up assistance with oral care. Record review of a Palliative Care…

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

Based on observation, interview and record review, the facility failed to ensure expired medications were discarded from the only treatment cart (cart containing supplies and treatments for resident wounds) the facility had. This finding decreased the facility's potential to prevent residents from receiving outdated medications/supplies. Findings: During an interview with Licensed Staff E on 2/04/25 at 11:30 a.m., she confirmed she was a treatment nurse at the facility. Licensed Staff E stated the charge treatment nurse regularly checked the cart to ensure there were no expired medications or supplies but was on leave of absence. During a concurrent observation and interview on 2/04/25 at 12:03 p.m., with Licensed Staff E, the treatment cart was checked for expired medications. The following expired medications and supplies were found in the treatment cart, stored with other active medications/supplies, and not labeled for destruction or disposal: 1. Silver nitrate (A topical antiseptic agent used to treat certain types of wounds) applicators (approximately 10), with an expiration…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 Social Services Department resolved the resident concerns grievances for brought up by one resident (Resident 2) of three sampled residents (Resident 2) when Resident 2 reported his bed frame was broken and a staff member broke his electronic tablet (a portable computer with a touchscreen designed for easy use on the go). This resulted in Resident 2's boredom and frustration when the electronic tablet had not been replaced and the inability to sleep comfortably in bed. Findings: Record review or Resident 2's admission record indicated admission to the facility on 3/29/21 with medical diagnoses including Hemiplegia (Paralysis or weakness on one side of the body) & Hemiparesis (One-sided muscle weakness) following a Cerebral Infarction (A medical condition where blood flow to the brain is interrupted, leading to damage or death of brain tissue), and insomnia (sleep disorder characterized by difficulty falling or staying asleep). Record review of a facility document titled, THEFT AND LOSS 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 observation, interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) was able to receive private telephone calls during her stay at the facility. This triggered a family member (Family Member AA) to call the police to perform a wellness check on Resident 1 since she was unable to contact Resident 1 by phone after multiple attempts. This failure had the potential to result in inability for Resident 1 and other residents of the facility to socialize and interact with the outside world, which could affect their emotional and mental health. This finding also had the potential to result in inability for friends and family members to advocate for the residents' health, request updates on their medical status, and ensure they were safe and comfortable at the facility. Findings: Record review of Resident 1's Face Sheet (Facility demographic) indicated Resident 1 was admitted to the facility on [DATE] with medical diagnoses including Fracture of One Rib. During a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of three residents (Resident 1) received medications as ordered by the physician, when one routine medication (a prescription that is followed until another order cancels it), Chlordiazepoxide (a medication used to treat symptoms of anxiety and symptoms of alcohol withdrawal) was unavailable for five scheduled doses. This failure had the potential to cause Resident 1 to experience anxiety and symptoms of alcohol withdrawal. Findings: A review of Resident 1's admission Record (patient demographics and admission diagnoses), indicated Resident 1 was admitted on [DATE] with diagnoses of anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities) and alcohol dependence with withdrawal (symptoms that occur when someone stops using alcohol after a period of heavy drinking and may include headaches, nausea, tremors, and anxiety). A review of Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and facility document review, the facility's Quality Assurance and Performance Improvement Committee (QAPI, a data driven and proactive approach to quality improvement; process used to ensure services are meeting quality standards and assuring care reaches a certain level) failed to identify quality deficiencies and subsequently investigate and act upon the deficiencies once identified, as evidenced by: 1 of 3 sampled Residents (Resident 1) experienced a 30.8 (31) pound weight loss during his first 18 days at the facility. Facility staff did not notify Resident 1's physician or nurse practitioner (NP) of the severe weight loss; interventions to address the severe weight loss were not implemented; and Resident 1's family took him from the facility AMA (Against Medical Advice - in an effort to get him help) and transported him directly to Hospital 1's Emergency Department (ED), where he was admitted into the ICU (Intensive Care Unit). Resident 1's weight loss at the facility was documented on a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) was emergently transferred to a General Acute Care Hospital (GACH) in a safe manner, when physician orders and facility policies were not followed. This had the potential to result in harm, and even death to Resident 1. Findings: Record review indicated Resident 1 was admitted to the facility on [DATE] with medical diagnoses including Cirrhosis of the Liver (Permanent scarring that damages the liver and interferes with its functioning), and Hepatic Encephalopathy (An often-temporary neurological (nervous system) disorder due to chronic, severe liver disease) according to the facility Face Sheet (Facility demographic). Record review of Resident 1's MDS (Minimum Data Sheet-An assessment tool) dated 5/03/23 indicated his BIMS (Brief Interview of Mental Status-A cognition [ the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses] assessment) score…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 laundry staff observed proper PPE (Personal Protective Equipment) use when handling used laundry. This failure increased the potential of spread of pathogens and communicable diseases among residents and staff at the facility. Findings: During an observation of the laundry room on 11/17/22 at 4:04 p.m., a single yellow gown was observed hanging on a peg by the washers. During a concurrent interview, Housekeeping Supervisor stated the staff would put on gloves and the yellow gown, handle the dirty laundry, then remove the gloves and gown after. Housekeeping Supervisor stated the gloves get discarded, but the gown would be re-hung on the peg for re-use. Housekeeping Supervisor stated the laundry staff would use one gown to process an approximated 10 loads of laundry during an eight-hour shift. Housekeeping Supervisor confirmed the laundry staff moves between the dirty (area for receiving and handling the soiled laundry) and clean (area for processing the washed items) areas frequently throughout 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 interviews and records review, the facility failed to ensure the Minimum Data Set (MDS - provides a comprehensive assessment of each resident's functional capabilities) for three of three sampled residents (Resident 53, 90 and 7) were accurately assessed of their current health and functional status when: 1) Resident 53's MDS indicated he had stage four pressure ulcer (wound is very deep, reaching into muscle and bone and causing extensive damage); however, Resident 53's physician documented Resident 53 had an arterial ulcer (damage to the arteries due to lack of blood flow to tissue). 2) Resident 90's MDS indicated she had septicemia (bacteria enter the bloodstream, and cause blood poisoning which triggers sepsis [an overwhelming and life-threatening response to infection]); however, Resident 90's record did not indicate she was monitored or treated for infection. 3) Resident 7 spoke Cantonese and used hand gestures to communicate with facility staff, however, Resident 7's MDS, dated [DATE], indicated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and records review, the facility failed to develop and implement person-centered Care Plan for three of 24 sampled residents (Resident 27, 80 and 7) when, 1. Facility staff were aware of Resident 27's repeated refusal of showers, however, no care plan interventions were put in place to ensure Resident 27's personal hygiene needs were maintained. (Reference F677) 2. Facility did not develop a communication care plan and activity care plan for Resident 80 to ensure Resident 80's needs were met. 3. Facility did not develop communication care plan and activity care plan for Resident 7 to ensure Resident 7's needs were met. These failures had the potential for facility staff to provide inadequate care to vulnerable residents when their individual needs and interests were not addressed appropriately. Findings: RESIDENT 27 1. During an observation and concurrent interview with Resident 27 on 11/14/22 at 11:19 AM, Resident 27 was in her bed watching television. When Resident 27 was asked about her…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 the facility failed to provide scheduled showers to three (Resident 27, 80 and 35) out of five sampled residents. This failure resulted in residents verbalizing feelings of not feeling clean or good about themselves. Findings: RESIDENT 27 During a record review for Resident 27, the Face sheet (A one-page summary of important information about a resident) indicated Resident 27 was admitted on [DATE] with diagnoses including Left Hip Fracture (a break in the thigh bone); Depression (a mental disorder characterized by a persistently depressed mood and long-term loss of pleasure or interest in life) and Anxiety (intense, excessive, and persistent worry and fear about everyday situations). During an observation and concurrent interview with Resident 27 on 11/14/22 at 11:19 AM, Resident 27 was in her bed watching television. When Resident 27 was asked about her shower schedule, Resident 27 stated she had not received shower since admission; however, she stated she received…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and records review, the facility failed to provide activities to meet the needs and preferences for three of 24 sampled residents (Residents 27, 80, and 7) when: 1. Resident 7 was not provided with activity that he could understand. Resident 7 spoke Chinese and used hand gestures to communicate with facility staff. 2. Resident 27 and 80 were left in their rooms without activities. This failure had the potential for self-isolation and decreased stimulation resulting in a diminished quality of life. Findings: Resident 7 A review of Resident 7's admission record indicated he was admitted on [DATE] with diagnoses of heart conditions, lung conditions, unspecified dementia (a group of thinking and social symptoms that interferes with daily functioning) without behavioral distrubance, who spoke and read Chinese only. During observation on 11/14/22 at 11:18 a.m., in Resident 7's room, the facility's activity calendar, posted on his wall, was written in English. During an observation 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 follow physician orders, and provide adequate care after dialysis (A procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly) for two of three sampled residents (Resident 29 and Resident 60) when the pressure dressings to prevent bleeding, applied at the dialysis clinic right after dialysis treatments were not removed timely, and the Arteriovenous (AV) Shunts (An arteriovenous fistula or shunt is an abnormal connection or passageway between an artery and a vein surgically created to remove and return blood during dialysis) were not assessed for bruit and thrill (Normal vibrations and sounds that indicate the fistula is working. Any changes may indicate problems with the fistula). These findings could have caused Resident 29's right upper arm Arteriovenous (AV) Shunt to stop working, and had the potential to cause malfunction of Resident 29 and Resident 60's current fistulas, inability 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, interviews and records review, the facility failed to ensure sufficient nursing staff to provide care to three of sampled residents (Resident 27, 80 and 35) and two unsampled residents (Residents 320 and 325) when: 1. Scheduled showers for Resident 27, 80 and 35 were not provided. This failure to maintain Residents' personal grooming and hygiene needs had the potential to raise the risk of unidentified skin issues, bacterial and fungal infections. 2. Call lights for Resident 27, 320 and 325 were not answered timely. This failure kept the residents needs uncommunicated to the staff, potentially placing them at risk for neglect and harm. Findings: RESIDENT 27 During an observation and concurrent interview with Resident 27 on 11/14/22 at 11:19 AM, Resident 27 was in her bed watching television. When Resident 27 was asked about her shower schedule, Resident 27 stated she had not received shower since admission. During a record review for Resident 27, the document titled ADL - Bathing/ shower…

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

Based on interviews and records review, the facility failed to ensure staffing requirements where met when the facility's daily occupancy was more than 110 and did not use the services of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week to oversee the care provided to the residents. This failure had the potential risk to endanger the health and safety for all the residents. Findings: During an interview with Staffer X (person responsible to ensure staffing requirements for each shift are filled) on 11/18/22 at 10:29 AM, Staffer X was asked about her process when staff called in (could not come to work). Staffer X stated she would either call the regular staff, ask staff from prior shift, or call the registry agency to fill up the shift. Staffer X stated the facility used 4 registry agency for both CNAs and Licensed Nurses. Staffer X verified no registry staff used from 11/1/22 to 11/16/22. During a review of the document titled Daily Staffing and concurrent interview with Staffer X on 11/18/22 at 10:44 AM, Staffer X verified from 11/1/22 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 and interview, the facility did not store food items under sanitary conditions when foods was kept past the use-by dates and frozen items were found with ice crystals clinging to them. This had to the potential to cause food-borne illness in a vulnerable population. Findings: During a concurrent observation and interview on 11/14/22 at 10:12 a.m., with Dietary Manager (DM) and Registered Dietician (RD), the freezer was observed for sanitation of the food inside. The first freezer was observed to have a box labeled hot dogs which was opened with many loose hot dogs observed inside of an open plastic bag. The box was labeled with an open date of 1/8/22 and an expired date of 8/27/22. DM stated the facility does not have hot dogs on the menu any longer and did not know why the box of hot dogs remained in the freezer. RD observed the labeling of the box and agreed the hot dogs had expired and should not be prepared for residents to consume. DM observed the ice crystals on the hot dogs inside 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 the facility failed to have the appropriate compliment of Quality Assessment and Assurance (QAA) committee members when the Medical Director attended one out of three quarters sampled for 2022. This failure had the potential to result in the medical director not providing oversight and input into the overall clinical facility management as provided in the QAA meetings. Findings: During a concurrent interview and record review on 11/18/22 with Administrator, QAPI (Quality Assessment Performance Improvement) Meeting Minutes were reviewed with Administrator who stated the committee would meet every month and the Medical Director would attend the meetings at least quarterly. The QAPI meeting minutes sign-in attendance forms were reviewed for 1/26/22 where the Medical Director signature was observed. The QAPI committee meeting sign-in sheets for the following meetings dated: 2/23/22, 3/23/22, 4/27/22, 5/2022 (copy of requested meeting was not provided to surveyor), 6/29/22, 7/27/22, 8/31/22, 9/2022 (copy of requested meeting minutes were not provided to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop and implement effective policies and procedures to ensure COVID-19 vaccinations were offered accordingly for three of five sampled residents (Residents 102, 108 and 109) who were clinically eligible. This failure increased the susceptibility of these clinically eligible individuals to contract and transmit the COVID-19 virus among the residents and staff. Findings: During Entrance Conference on 11/14/22 at 11:12 a.m., the facility provided an undated log indicating a list of residents and their COVID-19 vaccination status. Further record review on 11/17/22 at 9:03 a.m., indicated, UKNOWN under VACCINE BRAND for Residents 102, 108 and 109. There were no entries under tabs 1st DOSE, 2nd DOSE, 1ST BOOSTER, 2ND BOOSTER, and 3RD BOOSTER, for said three residents either. During a concurrent interview DSD stated Resident 102 was admitted to the facility on [DATE], and both Residents 108 and 109 were admitted to the facility on [DATE]. During an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to complete a comprehensive assessment for one of three sampled residents (Resident 76) when an annual assessment for Resident 76 was not completed for more than 92 days. This failure had the potential to cause inadequate care based on delayed assessments and care planning. Findings: During a record review for Resident 76, the Minimum Data Set (MDS-health status screening and assessment tool used for all residents) dated 7/04/22, indicated Resident 76 was admitted on [DATE] with diagnoses including Coronary Artery Disease (CAD - caused by plaque buildup in the wall of the arteries that supply blood to the heart); Hypertension (High Blood Pressure); Diabetes (disease that result in too much sugar in the blood); and Cerebrovascular Accident (CVA - also known as Stroke). During a record review for Resident 76 and with MDS Consultant A on 11/17/22 at 3:10 PM, the electronic MDS tracking log for Resident 76 indicated the most recent MDS Quarterly assessment…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 one resident (Resident 35) out of two sampled residents safe while smoking. This failure resulted in Resident 35 suffering burns on his fingers from smoking. Findings: During a review of Resident 35's, admission Record, dated 4/4/22 indicated Resident 35 was admitted to the facility on [DATE] with a history of chronic pulmonary edema (a condition caused by excess fluid in the lungs), primary osteoarthritis of both hips (a condition that starts with the breakdown of cartilage in the joints and as the cartilage wears down the bone ends may thicken and form bony growths also known as spurs), insulin dependent diabetes (a chronic condition that affects the way the body process blood sugar or glucose) and difficulty walking. During a record review for Resident 35, the Minimum Data Set (MDS- health status screening and assessment tool used for all residents) dated 9/16/22 indicated Resident 35 had a BIMs (Brief Interview for Mental Status) score of 15…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure one of three sampled residents (Resident 29) was kept safe, when medications were left by Resident 29's bedside, unattended, when she did not have an order for self-administration of medications. This failure could have resulted in omission and/or overdoses of medications, and deterioration of medications by leaving them unattended and exposed for a prolonged period of time, which ultimately could have caused serious harm to Resident 29 and other residents if they had ingested them. Findings: Record review indicated Resident 29 was admitted to the facility on [DATE] with medical diagnoses including End Stage Renal Disease (A medical condition in which a person's kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis or a kidney transplant to maintain life), Dependence on Renal Dialysis, and Diabetes Mellitus (A chronic disease characterized by high levels of blood sugar),…

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