National City Post Acute

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure the physician was notified of a resident's change of condition (COC) in a timely manner for one of two residents (Resident 95) reviewed for nutrition.As a result, Resident 95's severe weight loss was not reported to the physician in a timely manner which had the potential to delay the resident's care and treatment.Findings:A review of Resident 95's admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses to include chronic kidney disease and stroke.A review of Resident 95's Monthly Weight Report dated 12/19/25, indicated the following weights:October 2025, the resident weighed 154 lbs. (pounds).November 2025, the resident weighed 153.6 lbs.December 2025, the resident weighed 140.6 lbs. (the weight was taken/recorded on 12/6/25).A review of Resident 95's Nutritional assessment dated [DATE], indicated, .-13 lbs (8%) x 30d [in a month].According to the State Operations Manual (SOM) revised 7/23/25, a 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.

Based on interview and record review, the facility failed to ensure that one out of five sampled residents (Resident 6) was free from unnecessary psychotropic (affecting brain activities associated with mental processes and behavior) medication when Resident 6 was prescribed a psychotropic medication as needed for more than 14 days. This failure had the potential for Resident 6 to receive an unnecessary psychotropic medication which can lead to side effects, such as sedation and falls, and a decline in psychosocial (how a person feels about themselves and their environment) well-being.Findings: A review of Resident 6's medical records indicated she had an active order for lorazepam (a medication for anxiety, a condition characterized by excessive worrying) 0.5 milligrams (mg, unit of measure) by mouth every six hours prn (as needed) anxiety aeb (as evidenced by) restlessness for 30 days, dated 12/2/25.During an interview with the Director of Nursing (DON) on 12/19/25 at 2:08 P.M., the DON confirmed she was aware that orders for prn psychotropics exceeding a 14-day treatment duration…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide a written notice of transfer to a resident's responsible party (RP) and the Long-Term Care Ombudsman for one of three residents (Resident 97) reviewed for closed records.This deficient practice had the potential for the Resident 97's RP to not be aware of the resident's rights pertaining to transfers. FindingsOn 12/18/25 a review of Resident 97's clinical record was conducted. Resident 97 was admitted to the facility on [DATE] per the facility's admission Record. A review of Resident 97 Alert Charting dated 9/17/25 indicated the resident was assessed to have an acute change in level of consciousness (a crucial neurological indicator of a patient's arousal and awareness) and was transferred to the hospital for evaluation. On 12/19/25 at 2:12 P.M., a record review and interview was conducted with the Social Services Director (SSD). SSD stated Resident 97 was discharged from the facility to the hospital on 9/17/25. SSD stated the written notice of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure it completed a pre-admission screening and resident review (PASARR) and appropriately referred one of two residents (Resident 8), reviewed for PASARR, after the resident was newly diagnosed with schizophrenia (a mental disorder characterized by paranoia and psychosis) while residing in the facility.As a result of this deficient practice, there was the potential Resident 8 required specialized services that he did not have access to.Findings: A review of Resident 8's admission Record indicated the resident was admitted to the facility on [DATE]. The admission Record did not indicate Resident 8 had been admitted with schizophrenia.A review of Resident 8's PASARR I level screening, completed while at the hospital prior to admission to the facility on [DATE], indicated, .9. Diagnosed Serious Mental Illness. Does the individual have a serious mental disorder such as.Schizophrenia.? The question was marked, No.A review of Resident 8's Psychiatry…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement the use of a heel protector (pressure ulcer prevention device) as ordered by the physician and identified on the care plan for one of two residents (Resident 5).This deficient practice had the potential for the resident to be at risk for pressure injury and skin breakdown.Findings:A review of Resident 5's admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses to include hemiplegia and hemiparesis (paralysis and weakness) affecting the left side, contracture (shortening of the muscle) of left ankle, and muscle wasting and atrophy.A review of Resident 5's written care plan for higher risk/ potential for pressure ulcer development related to impaired mobility and fragile skin condition dated 3/14/22, indicated an intervention, .Apply heel protector to left foot when in bed for off loading.A review of Resident 5's physician's order dated 9/22/25, indicated, Apply heel protector on left foot…

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 respiratory services were provided according to acceptable standards of practice for two of two residents (55, 60) when:1. Resident 55's nasal cannula (device delivering oxygen into the nostrils) and oxygen tubing were not changed per facility's protocol.2. The director of business development (DBD) picked Resident 60's nasal cannula off the floor and placed it into the resident's nostrils.These deficient practices had the potential to place the residents at risk for respiratory infection and compromised oxygen therapy effectiveness.Findings: 1. A review of Resident 55's admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses to include pneumonia (a respiratory illness). A review of Resident 55's physician orders dated 12/16/25, indicated, Oxygen at 2 L/Min [liters per minute] via nasal cannula for SOB [shortness of breath] every shift. On 12/16/25 at 10:11 A.M., an observation was conducted…

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 cook was competent to carry out dietary functions according to standards of practice when the cook did not prepare pureed foods according to the recipe.This failure had the potential to create a choking hazard, lessen nutritional value, and contribute to weight loss for the 12 residents on a pureed diet.Findings:A review of the facility's therapeutic diet menu dated 12/16/25 indicated there were 12 residents on a pureed diet.On 12/18/25 at 11 A.M., an observation during prepping of pureed foods was conducted with the Cook, (CK) 1. CK 1 stated the pureed menu for the day was mixed vegetables, chicken stroganoff, and bread. CK 1 put mixed vegetables in the blender and then put the blended vegetables in a metal container. CK 1 looked at the recipe, then proceeded to put water in a pitcher, held it up, and put thickener in it. CK 1 turned to the Kitchen Manager (KM) to ask if it was correct. The KM stated it was not and took the pitcher away from CK 1 and dumped the water with thickener into the sink.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide food that accommodated a resident's preference for one of 19 sampled residents (Resident 34).This failure had the potential to affect Resident 34 appetite and meal intake and lead to frustration.Findings:According to the admission Record, Resident 34 was admitted to the facility on [DATE] with a diagnosis of Type 2 Diabetes Mellitus with hyperglycemia (high blood sugar).On 12/16/25 at 8:32 A.M., an observation and interview was conducted with Resident 34 while in Resident 34's room. Resident 34 was sitting in his wheelchair with a meal tray on top of the side table. The meal tray consisted of milk, juice, fruit cup, dry cereal, toast and two sausage patties. Resident 34's tray card (a paper indicating diet orders and any preferences or allergies) indicated dislikes of egg, sausage patties, pancakes and sweet bread. Resident 34 stated often the tray does not match his tray card. Resident 34 stated you see, says right here 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.

Based on observation, interview, and record review, the facility failed to follow appropriate infection prevention and control practices when:1. There was an expired box of tomatoes stored in the refrigerator.2. [NAME] (CK) 1 did not perform hand hygiene between gloves changes.These failures had the potential to result in foodborne illness to an already vulnerable population.Findings:1. On 12/16/25 at 7:36 A.M., an initial facility kitchen tour, observation and interview was conducted with Kitchen Manager (KM). In refrigerator number two, there was a small box of tomatoes with a used by date of 12/14/25 written on the box. The KM stated the box of tomatoes should have been thrown away. The KM stated expired food could cause residents to become ill. The KM stated her expectation was for the staff to have discarded the box of tomatoes.On 12/19/25 at 4:20 P.M., an interview was conducted with Administrator (ADM). The ADM stated there should never be expired food in the kitchen and staff should have thrown the expired box of tomatoes away. The ADM stated his expectation was for the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure documentation in the medical record was complete and accurate for 2 of 19 residents (95, 17) when:1. There was no documentation the nurse communicated Resident 95's condition and obtained a new order for megace (appetite stimulant) from the provider.2. Non-applicable and irrelevant additional medication directions were attached to Resident 17's levothyroxine (medication for underactive thyroid).As a result, the rationale could not readily be determined for the treatment that was provided to Resident 95. In addition, there was the potential to cause confusion during medication administration for Resident 17.Findings: 1. A review of Resident 95's admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses to include chronic kidney disease and stroke. A review of Resident 95's physician order dated 12/12/25, indicated the resident was to take megace 40 milligrams/milliliter, 5 milliliters once a day.…

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 ensure one of five residents sampled (Resident 5) received the influenza vaccine in accordance with the Center for Disease Control (CDC) recommendations and facility policy.This failure had the potential to place Resident 5 at risk for acquiring, transmitting, or experiencing complications from influenza (a contagious respiratory illness caused by influenza viruses that infects the nose, throat, and sometimes lungs).Findings:A review of Resident 5's admission Record indicated Resident 5 was admitted to the facility on admission date on 11/27/21 with a diagnosis of Vascular Dementia (a cognitive decline caused by damaged blood vessels in the brain, which reduces blood flow, oxygen, and nutrients, impacting thinking, memory, and behavior), Type II Diabetes Mellitus with Hyperglycemia (high blood sugar)On 12/19/25 at 2:15 P.M., an interview and record review was conducted with the Infection Preventionist Nurse (IP). The IP reviewed Resident 5's immunization record. The IP stated the last date Resident 5 received an influenza…

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 accurately code a fall incident on the Minimum Data Set (MDS - a federally mandated resident assessment tool) for one of three sampled residents (Resident 4).This deficient practice placed Resident 4 at risk for ineffective care planning, monitoring of fall risks and inaccurate health status sent to the federal database. Findings:A review of Resident 4's admission Record indicated Resident 4 was admitted to the facility on [DATE] with diagnoses which included history of Paroxysmal Atrial Fibrillation(an irregular and often very rapid heart rhythm).A record review of Resident 4's clinical chart indicated: - Resident 4's Intradisciplinary (IDT) note dated 10/14/25 1357 (1:57 P.M.) indicated, .fall incident: 10/12/25 11:00 AM.Reported unwitnessed fall when res. Noted by LN sitting at bedside, remains on same baseline orientation.- Resident 4's progress note dated 10/12/25 11:38 (11:38 A.M.) indicated, .LN found resident on the floor sitting on 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 on interviews and record reviews, the facility failed to follow proper infection control procedures for one of five sampled residents (Resident 1) to prevent the spread of pediculosis (lice-tiny, parasitic insects [about the size of a sesame seed] that feed on blood in the scalp/skin and cause intense itching that can lead to open sores and infection) when the facility failed to assess, screen, or monitor exposed former and new roommates during a room change.This deficient practice placed four residents (Resident 1's roommates) at risk for undetected lice and possible outbreaks (further spread) in the facility.Findings:A review of Resident 1's admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses which included history of Cervical Disc Disorder (injuries to a disc [shock absorber between the bones in your neck], or multiple discs, located between the cervical [seven small bones that make up your neck] bones).A record review of Resident 1's clinical chart 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 interview and record review, the facility failed to ensure a resident received treatment and care in accordance with professional standards of practice when Licensed Nurses (LNs) failed to consistently follow physician's order related to eye drop therapy for one of one sampled resident (Resident 1) reviewed for ophthalmic (eye) medication. This failure had the potential to place Resident 1 at risk of vision loss and blindness. Findings: Resident 1 was readmitted to the facility on [DATE] with diagnoses which included glaucoma (damage to the optic nerve often related to high pressure in the eye that can cause vision loss and blindness), per the facility's admission Record. A review of Resident 1's clinical record was conducted. Resident 1's physician's order dated 6/7/25, indicated Resident 1 was to receive two eye drop medications. One of the physician's orders were as follows: - Latanoprost (ophthalmic solution) to be given on both eyes for glaucoma. A review of Resident 1's medication administration…

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

Based on interview and record review, the facility failed to provide a sufficient number of staff to answer call lights and deliver personal care in a timely manner for three of four sampled residents (1, 3 and 4), and six residents identified in the resident council meeting minutes. As a result, there was the potential for residents not to get their minimum daily care needs met. Findings: During a telephone interview with Resident 1's family member (FM) on 7/2/25 at 8:40 A.M., the FM stated Certified Nursing Assistants (CNAs) come after 30 minutes to an hour. The FM stated there were multiple occasions when she needed assistance to change Resident 1's incontinence brief, the staff informed FM the CNA assigned to Resident 1 was either on break or on one on one (1:1, sitters or constant observation) monitoring of another resident. FM 1 stated she ended up changing Resident 1's incontinence brief. During a concurrent observation and an interview of Resident 3 on 7/2/25 at 11:45 A.M., Resident 3 was observed alert and smiling, and asked another resident (Resident 4) to express his…

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 ensure a clean, safe and comfortable homelike environment when insects were observed in a resident ' s room and the screen of the sliding door was in disrepair. These failures had the potential to negatively impact the residents' health and well-being. Findings: On 4/22/25, the Department received a complaint related to physical environment. On 4/29/25 at 9:56 A.M., an unannounced on-site visit was conducted. On 4/29/25 at 5:17 P.M., a joint observation of Resident 5 and Resident 6 ' s room, an interview of Resident 5 and Resident 6, and an interview were conducted with the Maintenance Supervisor (MS). Resident 5 stated she had placed an insect trap because she was afraid the insects would come to them. Resident 5 stated the screen door was slightly open and did not know if it was broken. Resident 5 stated she did not go to the patio. The MS checked the insect trap and noted big black insect. The MS stated the sliding door was opened. The MS stated, Sometimes the resident opens the sliding door. On 5/13/25 at 3:13 P.M., a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to identify in a timely manner the development of pressure injuries (skin damaged by lack of movement for staying in a position for too long) for one of three sampled residents reviewed for pressure injuries/ wounds. In addition, the facility did not consistently provide treatments for Resident 1 ' s existing surgical wounds in his right foot. As a result, Resident 1 developed a new pressure wound on his coccyx (tailbone). In addition, Resident 1 ' s surgical wounds in his right foot did not heal properly, developed an infection and eventually Resident 1 underwent an amputation (surgical removal of a limb) of his right leg. Findings: Resident 1 was admitted to the facility on [DATE] with diagnoses which included orthopedic aftercare following surgical amputation, diabetes (high blood sugar) and generalized muscle weakness, per the facility ' s admission Record. A review of Resident 1 ' s minimum data set (MDS, a federally mandated resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of four residents (Resident 3) received food that accommodated her food preferences. This failure had the potential for Resident 3's wishes to be ignored. In addition, this failure had the potential to result in decreased food intake and weight loss. Findings: On 4/22/25, the Department received a complaint related to Dietary Services. On 4/29/25 at 9:56 A.M., an unannounced on-site visit was conducted. Resident 3 was admitted to the facility on [DATE], with diagnoses which included surgical after care after a surgery according to the facility ' s admission Record. On 4/29/25 at 11:59 A.M., a joint review of Resident 3 ' s dietary record and an interview was conducted with the Certified Dietary Manager (CDM). The CDM stated she spoke to Resident 3 on 4/14/25 and found out Resident 3 preferred vegan diet and requested tofu. The CDM stated the facility did not have tofu. The CDM stated the kitchen provided Resident 3 with some green salad. The…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure a pain medication (med/s) was available for one of three sampled residents reviewed for pain management (Resident 1). This failure had the potential to cause the resident unnecessary pain, negatively affecting the resident's quality of life. Findings: Resident 1 was readmitted to the facility on [DATE] with diagnoses which included chronic ulcer (sore) of the left foot and gout (a type of inflammatory arthritis that causes pain and swelling in your joints), per the facility's admission Record. A record review was conducted of Resident 1. Resident 1's History and Physical (H & P), dated [DATE], indicated the attending physician (AP) documented Resident 1 had the capacity to make own decisions. A record review was conducted of Resident 1. Resident 1's minimum data set (MDS - a federally mandated resident assessment tool), dated [DATE], indicated Resident 1's brief interview for mental status (BIMS, ability to recall) score was 15/15…

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 interview and facility documents review, the Licensed Nurse (LN) 1 failed to verify a provider's discharge plan related to opioid (powerful pain-reducing medications, an example is hydrocodone/ acetaminophen) medication upon discharge for one of three sampled residents (Resident 1). The lack of communication between the provider and the facility's LNs had the potential for miscommunication with the transition of care to the receiving facility for Resident 1. Findings: On 12/18/24, the Department received a complaint related to resident's discharge. On 12/23/24, an unannounced visit to the facility was conducted. A review of Resident 1's admission Record, indicated Resident 1 was admitted to the facility on [DATE], with diagnoses which included lumbar fracture (broken vertebrae in the lower back). On 12/23/24, a review of Resident 1's discharge notes completed by Nurse Practitioner (NP, is a healthcare provider who teamed with the attending physician) was conducted. The NP notes dated 10/7/24, indicated,…

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

Based on observation, interview, and record review, the facility failed to follow isolation precautions when contact droplet isolation (a type of isolation requiring a gown, gloves, mask and eye protection prior to entering the room) was delayed for one resident (Resident 48) with Covid-19. This failure had the potential to place residents and staff at risk of exposure to Covid-19 and cause the spread of infection. Findings: On 8/19/24 at 8 A.M., during the entrance conference for the facility's annual recertification survey, the Administrator (Admin)stated Resident 48 was sent to the hospital on 8/18/24 and tested positive for Covid-19. The Admin stated Resident 48 was expected back to facility on 8/19/24. On 8/19/24 at 8:52 A.M., an observation and interview was conducted in Resident 48's bedroom. Resident 48 was observed in his room with two roommates. Resident 48 was not wearing a face mask. Resident 48 stated he had returned from the hospital a few minutes earlier with Covid. On 8/19/24 at 8:55 A.M., an observation was conducted in the hallway outside Resident 48's room. A sign…

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 written information regarding formulating an Advance Directive (AD - a written instruction such as a living will, relating to the provision of treatment and services when the individual is unable to make decisions) was provided to the residents and/or the resident's representative (RR), for nine of 10 residents reviewed for Advance Directive (Residents 15, 25, 40, 58, 61, 78, 82, 83, and 284). This failure had the potential for the residents to not be aware of their right to formulate an AD. Findings: On September 22, 2022, Residents 15, 25, 40, 58, 61, 78, 82, 83, and 284's records were reviewed: 1. Resident 15 was admitted to the facility on [DATE], with diagnoses which included orthopedic aftercare (type of care dealing with corrections of the bones and muscles). The Minimum Data Set (MDS - an assessment tool), dated September 9, 2022, indicated Resident 15 had a BIMS (Brief Interview for Mental Status) score of 13 (cognitively intact). The…

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

Based on observation, interview, and record review, the facility failed to ensure expired food items were not stored in the refrigerator, readily available for use. This failure had the potential to result in foodborne illness to an already vulnerable facility population. Findings: On September 19, 2022, at 11:10 a.m., an initial tour of the kitchen was conducted with the Certified Dietary Manager (CDM). The following food items were observed stored inside the refrigerator and freezer: - One plastic jar of Dijon mustard, approximately half full, was observed with an open date of November 23, 2021 and a used by date of June 2022. The opened jar of mustard had a Best By date of June 29, 2022 printed on the product label. In a concurrent interview, the CDM stated the mustard was expired and should not have been stored in the refrigerator, readily available for use. - An opened carton box of whole kernel corn was observed in the freezer with a date label of June 6, 2022. A bag of frozen corn kernels, weighing approximately three pounds, was observed inside the carton box readily…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the PASRR (Preadmission Screening and Resident Review - a federally required document to ensure residents are appropriately placed for services) was coded accurately for diagnosis of mental illness, for one of one resident reviewed for PASRR (Resident 40). This failure had the potential for Resident 40 to not receive the care and necessary services under the appropriate setting. Findings: On September 20, 2022, Resident 40's record was reviewed. Resident 40 was admitted to the facility on [DATE], with diagnoses which included dementia (decline in mental status), depressive disorder (mood disorder), and bipolar disorder (mood disorder). The PASRR, dated November 29, 2021, did not indicate Resident 40 had a diagnosis of mental health disorders. On September 26, 2022, at 12:04 p.m., an interview with the Director of Nursing (DON) was conducted. She stated Resident 40 was admitted with a mental health conditions which included depressive disorder…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to develop a comprehensive care plan for oxygen administration, for one of one resident reviewed for oxygen use (Resident 6). This failure had the potential to negatively impact the resident's quality of care and had the potential for staff to not be aware of the resident's care needs and provide appropriate treatment. Finding: On September 19, 2022, at 11:50 a.m., Resident 6 was observed in bed, with oxygen (O2) via nasal cannula (NC - a tube used to deliver oxygen through the nose). Resident 6's oxygen administration was observed at three liters per minute (LPM). In a concurrent interview with Resident 6, she stated she uses O2 continuously due to shortness of breath. Resident 6's record was reviewed. Resident 6 was admitted to the facility on [DATE], with diagnoses which included acute respiratory failure (lung failure). The physician's order, dated August 10, 2021, indicated, .Continuous O2 via NC at 3LPM . On September 22, 2022, at 9:17…

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 medications and medical supplies were labeled and stored according to the facility policy and manufacturer's guidelines, when: 1. The pharmacy label on the medication bubble pack did not match the physician's order on the Medication Administration Record (MAR), for one of 11 residents reviewed during the medication administration observation (Resident 236). This failure had the potential to result in Resident 236 to not receive the correct frequency and dosage of the medication prescribed by the physician; 2. One opened vial of tuberculin testing solution (test for tuberculosis - lung infection) was not labeled with a date when it was opened, and readily available to administer. This failure had the potential to not be able to determine the effect and potency of the tuberculin testing solution; and 3. Expired medical supplies were stored and readily available for use. This failure had the potential for residents of the facility 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 dietary document review, the facility failed to ensure the lunch menu was followed on 8/9/19. This failure had the potential for residents to have their nutritional status compromised when they were served food items they were not expecting, or did not like. Findings: On 10/8/19 at 9:58 A.M., a confidential group interview was conducted. The confidential group stated the facility regularly served food with gravy on it. Six out of 12 confidential residents stated they did not like the gravy and felt it was served on everything. On 10/8/19, a record review of the facility's weekly menu was conducted. The lunch menu indicated on 10/9/19, Roasted chicken, roasted red skin potatoes, french cut green beans, wheat dinner roll, margarine, fruit gelatin with marshmallow, milk, beverage of choice. On 10/9/19 at 11:38 A.M., an observation of the lunch tray line and meal plating was conducted. The dietary staff plated all the roasted chicken with gravy, including those plates for residents on a regular diet (no dietary restrictions). On 10/9/19 at 12:40…

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 ensure food was consistently served at an appetizing temperature for 6 out of 12 residents interviewed during a confidential group interview. This failure to serve food at an appetizing temperature may result in decreased food intake resulting in weight loss, and could further compromise the nutritional status. Findings: On 10/8/19 at 9:58 A.M., a confidential group interview was conducted. Six out of 12 confidential group residents stated the food at the facility was so-so. The confidential residents stated food was served mainly warm. The confidential residents stated cold items were not very cold and hot items were not very hot. The confidential residents further stated they did not consider the temperature of their food to be appetizing. On 10/9/19 at 11:38 A.M., an observation of the lunch tray line and meal plating was conducted. Food temperatures were taken by dietary staff at the beginning of meal distribution and revealed that all hot food temperatures were greater that 165°F. The temperature of cold beverages 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.

Based on observation, interview, and record review, the facility failed to ensure food was stored and prepared in a safe/sanitary manner and in accordance with standards of practice when: 1. Resident ice cream and cake were not properly covered when stored. In addition, ready to use produce was slimy and moldy. 2. Food and beverages were not properly dated and labeled. 3. Meat was not defrosted according to acceptable standards of practice. 4. Dietary staff did not consistently use gloves in the tray line while plating food. Failure to ensure safe and effective food service operations may result in exposing resident food to cross contamination and bacterial growth which may result in foodborne illness. Foodborne illness may further compromise the medical and nutritional status of the residents. Findings: 1. On 10/8/19 at 7:40 A.M., the facility's kitchen was inspected with DA 1. In the reach-in freezer there was ice cream stored in a large container without a lid. DA 1 stated the ice cream should not have been stored in the freezer without being secured with a lid. On 10/8/19 at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a resident's (18) bedroom was clean, comfortable, and homelike. This failure had the potential to negatively impact Resident 18's quality of life. Findings: Resident 18 was admitted to the facility on [DATE]. On 10/8/19 at 2:44 P.M., a joint observation and interview was conducted with Resident 18. Resident 18 was in her bedroom with her overbed table next to her bed. The overbed table was missing the top layer of veneer (a thin wood layer). The surface of the resident's overbed table was composed of a rough, particle board type material. Resident 18 stated she did not like her overbed table and thought it was ugly. Resident 18 stated the overbed table was so scratchy, she used it to file down her fingernails. Resident 18 further stated if she spilled water on her overbed table it got absorbed and the surface stayed wet. Resident 18's bed was next to the sliding glass door leading to the patio area. The curtains to the sliding…

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 conduct an IDT care conference after each MDS assessment for 2 of 18 sampled residents (48, 73). As a result, there was a potential for resident care issues to not be addressed. Findings: 1. Resident 48 was admitted to the facility on [DATE] with diagnoses that included heart failure and spinal stenosis, per the admission Record. The clinical record was reviewed on 10/9/19. There was an annual MDS assessment in the EMR, dated 8/20/19. However, there was no IDT care plan conference done after the 8/20/19, MDS assessment. The last IDT care plan conference for Resident 48 was 5/21/19, five months prior. During an interview on 10/10/19 at 12:15 P.M., the DON stated the MDS coordinator or the SSD scheduled the IDT care plan conference for the residents. When interviewed on 10/10/19 at 4:12 P.M., the SSD stated there was an IDT care plan conference scheduled for Resident 48, but he refused to attend. The SSD acknowledged she had not rescheduled and the IDT…

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 a resident's (66) narcotic (a controlled drug with high abuse potential) pain medication order was clarified with the physician when the order was unclear and incomplete. This failure had the potential for Resident 66 to receive the pain medication when it was not appropriate. Findings: Resident 66 was admitted to the facility on [DATE], per the admission Record. On 10/9/19, a record review was conducted. Resident 66's physician's orders, dated 8/31/19, indicated, Oxycodone-acetaminophen tablet 10-325 mg by mouth every four hours as needed for pain. On 10/10/19 at 3:18 P.M., a joint interview and record review was conducted with LN 1. LN 1 reviewed Resident 66's physician's order for oxycodone-acetaminophen and stated the order did not have pain parameters. LN 1 stated pain parameters were a required part of a physician's order for pain medication. LN 1 stated to give for pain was not specific enough. LN 1 stated oxycodone-acetaminophen was…

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 1 of 18 sampled resident's (88) end of life wishes were documented consistently. As a result, there was the potential for an error in the event of an emergency. Findings: Resident 88's clinical record was reviewed on [DATE]. Resident 88 was admitted to the facility on [DATE], with diagnosis that included high blood pressure, insomnia, falls, and Alzheimer's disease, per the facility's admission Record. According to the current clinical EMR record, Resident 88's end of life preferences were to have CPR, full treatment, long-term artificial nutrition including a feeding tube. Resident 88 had a Physician's Order for Life Sustaining Treatment (POLST) form, signed by the physician on [DATE]. The POLST documented the residents end of life preferences to be: Do Not Resuscitate, comfort focused treatment, and no artificial means of nutrition. The DON was interviewed on [DATE] at 9:54 A.M. The DON stated Resident 88 had been on hospice for her Alzheimer'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 record review, the facility failed to: 1. Thoroughly investigate each of Resident 76's falls; 2. Consistently conduct fall IDT meetings after Resident 76 fell, and; 3. Develop and implement resident specific interventions in an effort to prevent further falls for Resident 76. As a result, Resident 76 sustained five falls over a four month period, and on the fifth fall, fractured a hip. Resident 76 suffered pain and became more dependent on staff for ADLs. Findings: Resident 76 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses to include left hip fracture, aftercare following joint replacement surgery, unsteadiness on feet, and other abnormalities of gait and mobility, per the facility's admission Record. On 10/8/19 at 3:22 P.M., an observation was conducted of Resident 76's room. Resident 76's name placard outside the door had the resident's first and last name. There was no visual indication by the resident's name that the resident was part of 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 the pharmacy label on a medication pack matched the physician's order and MAR for 1 of 5 residents selected for unnecessary medication review (73). The facility also failed to ensure the physician's order for a medication indicated the total dosage to be given for 1 of 5 residents selected for unnecessary medication review (73). As a result, there was a potential for a medication error. Findings: 1. Resident 73 was admitted to the facility on [DATE] with diagnoses that included dementia and paranoid personality disorder (odd or eccentric ways of thinking, paranoia, an unrelenting mistrust and suspicion of others), per the admission Record. On 10/10/19, the clinical record was reviewed. On 6/10/19, the physician ordered olanzapine (an antipsychotic) 5 mg tablet, give 0.5 tablet by mouth one time a day for Bipolar disorder. The DON was interviewed on 10/10/19 at 12:15 P.M. The medication bubble pack for Resident 73's olanzapine was reviewed with…

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.