Santa Clarita Post-Acute Care Center

Based on observation, interview, and record review, the facility failed to ensure the water flush bag was labeled with the correct information for one of one sampled resident (Resident 47). This failure had the potential to cause fluid overload (body holds onto more water than it can manage) or dehydration (body loses or uses more fluids than it takes in) to the resident. Findings: During a review of Resident 47's admission Record (AR), the AR indicated the facility admitted the resident on 12/29/2024, with diagnosis of hemiplegia (the severe or complete loss of motor function on one side of the body) and hemiparesis (weakness or partial paralysis affecting only one side of the body) following cerebral infarction (supply of blood to the brain becomes blocked, cutting off oxygen and vital nutrients) affecting left non-dominant side, muscle weakness generalized (an overall, whole-body reduction in physical strength), and encounter for attention to gastrostomy (a routine medical visit for the routine care, cleaning, or changing of a feeding tube). During a review of Resident 47'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 ensure residents who need respiratory care are provided care consistent with professional standards of practice for two of two sampled residents (Resident 9 and 114) reviewed under the Respiratory care area by failing to: 1.Ensure oxygen (O2) was administered per physician orders at four (4) liters per minute (LPM, a measurement of flow rate) to Resident 9 on 6/1/2026 and 6/2/2026. 2.Ensure O2 was administered per facility policy and procedure (P&P) with a physician's order and monitored while in use for Resident 114. These deficient practices had the potential to place residents at risk for respiratory distress with a delay in necessary care and treatment. Findings: 1.During a review of Resident 9's Face Sheet (FS - admission record), the FS indicated the facility originally admitted the resident on 2/24/2026 and most recently admitted the resident on 5/14/2026, with diagnoses that included chronic myelomonocytic leukemia (CMML - a blood…

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 of two food scoopers (used to scoop dry goods food) were clean. This failure had the potential to for the food scooper to carry harmful germs, bacteria, or chemical residues which can contaminate the residents' meals and increase the rise of foodborne illness to the residents.Findings:During a concurrent observation and interview on 6/1/2026 at 8:06 a.m. in the kitchen with the Dietary supervisor, there were one of two food scoopers on top of a food preparation table that had a white residue. Dietary Supervisor (DS) stated this food scooper must be cleaned after each use to prevent contamination risk to the residents. During a review of the facility's policy and procedure (P&P) titled, Sanitation, dated 2023, the P&P indicated the utensils shall be kept clean.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to maintain complete clinical records in accordance with accepted professional standards and practices for one of three sampled residents (Resident 110) reviewed during the closed records (death) task by failing to ensure Registered Nurse (RN) 2 documented the vital sign numeric values (measurements of the body's most basic functions including temperature [Temp], blood pressure [BP], heart rate [HR/pulse] and respiratory rate [RR], and oxygen saturation level [O2 sat- a measurement of how much oxygen the blood is carrying as a percentage]) for the night shift (11 p.m. to 7 a.m.) on [DATE]. This resulted in an incomplete documentation in Resident 110's medical chart. Findings: During a review of Resident 110's Face Sheet (FS, admission Record), the FS indicated the facility admitted the resident [DATE] with diagnoses including displaced fracture of right femur (hip fracture), presence of right artificial hip joint, essential (primary) hypertension (high…

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 all parts of the call light system (CL, an alerting device for nurses or other personnel to assist a patient when in need) were functional for one of eight sampled residents (Resident 67) investigated under the Environment task. This deficient practice had the potential to result in the delay of care and services and falls with injury in residents. Findings: During a record review of Resident 67's Face Sheet (FS, admission Record), the FS indicated Resident 67 was originally admitted to the facility on [DATE] and most recently admitted [DATE] with diagnoses including sepsis (a life-threatening blood infection), muscle weakness, unsteadiness of feet, and urinary tract infection (UTI- an infection in the bladder/urinary tract). During a review of Resident 67's History and Physical (H&P), dated 6/1/2026, the H&P indicated the resident had the capacity to understand but could not make medical decisions. During a review of Resident 67'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 ensure safe and sanitary food preparation practices by failing to ensure [NAME] 1 verified the internal temperature of grilled chicken prior to service on 2/11/2026 for four of four sampled residents (Resident 4, Resident 5, Resident 6, and Resident 7). This deficient practice had the potential to result in unsafe food temperatures, allowing harmful bacterial growth and increasing the risk of foodborne illness in a medically compromised resident population who received meals prepared in the facility kitchen. Findings:a. During a review of Resident 4's admission Record (AR), the AR indicated the facility admitted Resident 4 on 10/29/2019 and readmitted the resident on 10/28/2024 with diagnosis that included Alzheimer's Disease (a disease characterized by a progressive decline in mental abilities), type two diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), and essential (primary)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow professional standards of practice for two of three sampled residents (Resident 1 and Resident 3) by failing to: 1. Ensure licensed nurses monitored Resident 1's medical status after the resident's changes of condition (COC) on 11/15/2025 and 11/29/2025. 2. Ensure Resident 1's physician order for oxygen therapy (O2 therapy - a treatment that provides a person with supplemental or extra oxygen) at two liters per minute was followed. On 1/30/2025, Resident 1's oxygen therapy was at three liters per minute (lpm - unit of measurement). 3. Ensure licensed nurses monitored Resident 3's gastrointestinal (stomach and intestines) status after the resident's COC on 12/4/2025. These deficient practices had the potential to place Resident 1 and Resident 3 at risk for undetected and worsening medical conditions which could negatively impact the residents' health and safety.Findings: During a review of Resident 1's admission Record (undated), the admission…

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

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program regarding Coronavirus disease 2019 (COVID-19, a viral infection that is highly contagious and easily transmits from person to person, causing respiratory problems and may cause death) for two of eight sampled facility staff (Licensed Vocational Nurse [LVN] 1 and Certified Nursing Assistant [CNA] 1) by failing to:1.Ensure CNA 1's N95 mask (respiratory protective device designed to achieve a very close facial fit and very efficient filtration of airborne particles) was worn while inside a COVID-19 isolation room (a set of precautions used to prevent the spread of COVID-19).2. Ensure LVN 1 wore the N95 mask properly while inside the facility. LVN 1's N95 mask was not covering the nose and mouth while at a resident care area. 3. Ensure LVN 1 performed hand hygiene (hand washing with soap and water and use of alcohol-based hand sanitizer) before touching the computer at nurse station 2.These deficient practices placed other residents and staff at risk for…

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

Based on observation, interview, and record review, the facility failed to ensure a resident received services with reasonable accommodation for one of three sampled residents (Resident 4), who was at risk for falls, had the call light (an alerting device for residents to call for assistance) within Resident 4's reach.This deficient practice had the potential for not meeting Resident 4's needs for assistance. Findings:During a review of Resident 4's admission Record (undated), the admission Record indicated the facility admitted the resident on 3/26/2010 with diagnoses including hemiplegia (inability to move one side of the body) and hemiparesis (weakness on one side of the body) following cerebrovascular disease (a medical condition affecting the blood supply to the brain) affecting the right dominant side, type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar [glucose]), and essential hypertension (an abnormally high blood pressure that was not a result of a medical condition).During a review of Resident 4's History and Physical (H&P - 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 and record review, the facility failed to ensure a comprehensive, person-centered care plan with measurable objectives and interventions for one of three sampled residents (Resident 1) was created and implemented. The facility failed to develop and implement an individualized care plan with interventions addressing Resident 1's food preferences as indicated in the resident's medical records.This deficient practice resulted to Resident 1 being served food identified as the resident's food dislike.Findings:During a review of Resident 1's admission Record (undated), the admission Record indicated the facility admitted the resident on 8/19/2025 with diagnoses including type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar [glucose]), depression (a constant feeling of sadness and loss of interest, which stops the individual from doing normal activities), and epilepsy (a condition that affects the brain and causes frequent seizures [sudden, uncontrolled body movements and changes in behavior that occurs because of abnormal…

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 of three sampled residents (Resident 2) was free from significant medication errors by failing to ensure the physician orders were followed. The facility failed to ensure Resident 2's midodrine hydrochloride (HCl) oral tablet (a medication, taken by mouth, used to treat low blood pressure that causes severe dizziness or fainting) 10 milligrams (mg - unit of measurement) was administered and documented at the scheduled time. This deficient practice placed Resident 2 at risk for inadequate blood pressure management which can cause hypotension (low blood pressure) and irregular heartbeat. Findings:During a review of Resident 2's admission Record (undated), the admission Record indicated the facility admitted the resident on 1/6/2020 with diagnoses including cerebral palsy (a group of conditions that affect movement and posture), hypotension, and heart failure (a progressive heart disease that affects pumping action of the heart muscles).During a review of Resident 2's Physician Orders, dated…

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 a resident's food preference was followed for one of three sampled residents (Resident 1). The facility served Resident 1 with fish that Resident 1 disliked.This deficient practice had the potential to result in decreased meal satisfaction and affect Resident 1's nutritional status. Findings:During a review of Resident 1's admission Record (undated), the admission Record indicated the facility admitted the resident on 8/19/2025 with diagnoses including type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar [glucose]), depression (a constant feeling of sadness and loss of interest, which stops the individual from doing normal activities), and epilepsy (a condition that affects the brain and causes frequent seizures [sudden, uncontrolled body movements and changes in behavior that occurs because of abnormal electrical activity in the brain]). During a review of Resident 1's Physician Order, dated 8/19/2025, the Physician Order indicated the resident's diet was controlled…

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 three sampled resident's (Resident 1) concerns were investigated and documented in the grievance form as indicated on the facility's policy and procedures (PnP). This deficient practice had the potential to violate residents' rights to have grievances addressed.Findings: During a review of Resident 1's admission Record, the admission Record indicated the facility admitted the resident on 6/25/2024 with diagnoses including multiple sclerosis (a long-lasting disease that affects the brain and spinal cord), schizophrenia (mental disorder in which people interpret reality abnormally), and bipolar disorder (mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration). During a review of Resident 1's History and Physical (H&P - a medical examination that involves a doctor taking a patient's medical history, performing a physical exam, and documenting their findings), dated 5/26/2025, the H&P indicated Resident 1 had the capacity to understand and make decisions. 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.

Based on record review and interview, the facility failed to ensure one of three sampled residents (Resident 1) was treated with dignity and care in a manner that promotes maintenance or enhancement of their quality of life by failing to ensure Resident 1's right to refuse care was respected. This deficient practice had the potential to negatively affect Resident 1 psychosocially (involving mental, emotional, social, and spiritual aspects of a person's life). Findings: During a review of Resident 1 ' s admission Record, the admission Record indicated the facility admitted Resident 1 on 3/15/2025 with diagnoses including bilateral (pertaining to, involving, or affecting two or both sides) primary osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage) of knee, muscle weakness (generalized), and pain to right shoulder and ankle and joints of right foot. During a review of Resident 1 ' s Minimum Data Set (MDS – a resident assessment tool), dated 3/19/2025, the MDS indicated Resident 1 had the ability to understand and be understood. The MDS…

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 2. During a review of Resident 248's admission Record, the admission Record indicated the facility admitted the resident on 1/24/2025 with diagnoses including fracture (a crack or break in a bone) of shaft of right tibia (also known as shin bone the large bone located between the knee and ankle), unsteadiness on feet, and generalized muscle weakness. During a review of Resident 248's H&P dated 1/25/2025, the H&P indicated the resident can make her needs but cannot make medical decisions. During a review of Resident 248's MDS, dated [DATE], the MDS indicated the resident had severely impaired cognition (mental action or process of acquiring knowledge and understanding) and required substantial/maximal assistance to total assistance from staff with all activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). During a review of Resident 248's care plan (CP) on risk for falls and injuries due to shaft right tibia fracture initiated on 1/27/2025, the CP…

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 residents were treated with respect and dignity including the right to be free from physical restraints (any manual method, physical or mechanical device, material or equipment that is attached or adjacent to the resident's body that he or she cannot easily remove that restricts freedom of movement or normal access to one's body) for four of four sampled residents (Residents 37, 63, 78, and 248) reviewed for physical restraints care area by failing to ensure: 1. Residents 37 and 63 had a physician's order, an informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered), a restraint assessment, and a care plan for restraint bed placed against the wall. 2. Residents 78 and 248 had a physician's order, a restraint assessment, obtain an informed consent (process in which residents or resident representatives are given important…

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 a comprehensive person-centered care plan for four (4) of six (6) residents reviewed for unnecessary medications (Resident 7, 37, 53 and 55) by failing to: 1. Develop and implement a care plan for methenamine hippurate (an antibiotic) for Resident 37. 2. Implement the Care Plan (a document outlining a detailed approach to care customized to an individual resident's need) for providing non-pharmacological (not involving medications or drugs) interventions for the use of trazodone (a psychotropic [any medication capable of affecting the mind, emotions, and behavior] used for insomnia [difficulty sleeping]) for Resident 7. As a result, Resident 7 did not have non-pharmacological interventions provided as outlined in the Care Plan between 2/1/2025 and 2/11/2025. 3. Implement the Care Plan for providing non-pharmacological interventions for the use of Haldol (a brand name for haloperidol [a psychotropic medication used to treat…

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's licensed nursing staff failed to provide care in accordance with professional standards by failing to: 1. Rotate (a method to ensure repeated injections are not administered in the same area) the insulin administration site (subcutaneous (beneath the skin) for one (1) out of one sampled resident (Resident 73) reviewed for insulin (a hormone that lowers the level of glucose [a type of sugar] in the blood). 2. Rotate subcutaneous insulin medication administration sites for one of five (5) sampled residents (Resident 63) investigated under unnecessary medications. These deficient practices had the potential to result in adverse effect (unwanted, unintended result) of same site subcutaneous administration of insulin such as excessive bruising, lipodystrophy (abnormal distribution of fat) and cutaneous amyloidosis (is a condition in which clumps of abnormal proteins called amyloids build up in the skin). Cross Reference F760 Findings: a. During a review of Resident 73's admission Record, the admission Record indicated the facility…

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 five (5) of six (6) sampled residents (Resident 5, 7, 53, 55 and 71) drug regimen was free from unnecessary medications (any medication in excessive dose, excessive duration, without adequate monitoring) in accordance with the facility policy and procedure by failing to: 1. Limit the use of lorazepam (generic name for Ativan) as needed order to fourteen days or specify a duration or provide a stop date for Resident 71. 2. Limit the use of Ativan (a psychotropic medication used for anxiety [a feeling of fear, dread, and uneasiness]) as needed order to fourteen days or specify a duration or provide a stop date for Resident 5. 3. Provide non-pharmacological (that do not involve medications or drugs) interventions (therapies) for insomnia [difficulty sleeping]) with the use of trazodone (a psychotropic [any medication capable of affecting the mind, emotions, and behavior] used for insomnia) between 2/1/2025 and 2/11/2025 for Resident 7. 4. Provide…

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 that its medication error rate was less than five (5) percent (%). Two (2) medication errors out of 29 total opportunities contributed to an overall medication error rate of 6.9% affecting one (1) of three (3) residents observed for medication administration (Resident 196.) The medication errors were as follows: 1. Resident 196 received metoprolol (a medication used to for hypertension [HTN - a condition in which the blood vessels have persistently raised pressure]) and aspirin (a medication used to prevent cerebrovascular accident [CVA] - stroke] from having atrial fibrillation [irregular, fast heart rate]), at a different time than ordered by Resident 196's physician. These failures had the potential to result in Resident 196 to experience medication adverse effects (unwanted, uncomfortable, or dangerous effects that a medication may have) and the potential to result in Residents 196's health and well-being to be negatively…

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 residents were free of any significant medication errors (means the observed or identified preparation or administration of medications or biologicals which is not in accordance with the prescriber's order, manufacturer's specifications, and accepted professional standards): 1. For one (1) out of one sampled resident (Resident 73) reviewed for insulin (a hormone that lowers the level of glucose [a type of sugar] in the blood) care area by failing to rotate (a method to ensure repeated injections are not administered in the same area) the subcutaneous (beneath the skin) insulin administration sites. 2. For 1 of five (5) sampled residents (Resident 63) reviewed under unnecessary medications by failing to rotate (a method to ensure repeated injections are not administered in the same area) subcutaneous (beneath the skin) insulin medications (a hormone that lowers the level of glucose [a type of sugar] in the blood) administration sites. These deficient practices had the potential for adverse effect (unwanted,…

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 safe and sanitary food storage and food preparation practices in the kitchen reviewed during the kitchen facility task by failing to: 1. Ensure food items in the walk-in refrigerator were labeled according to facility policy. 2. Ensure used cloths and towels were stored per facility policy. 3. Ensure the walk-in freezer temperature was maintained per facility policy and procedure. These deficient practices had the potential to result in harmful bacterial growth and cross contamination (the process by which bacteria or other microorganisms are unintentionally transferred from one substance or object to another, with harmful effect) that could lead to foodborne illness (a disease caused by consuming food or drinks that are contaminated by germs or chemicals) in 89 of 93 medically compromised residents who received food from the kitchen. Findings: a. During an initial kitchen observation tour on 2/11/2025 at 7:50 a.m., observed the walk-in refrigerator with the Dietary Supervisor (DS). In the walk-in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to dispose of garbage and refuse properly reviewed during the kitchen facility task by failing to ensure the surrounding area of the dumpster (large trash container designed to be emptied into a truck) did not have three tied clear bags of trash and one open trash bag containing items including disposable gloves, dirty rags, a Styrofoam (brand of plastic) cup, and a food wrapper. This failure had a potential to attract birds, flies, insects, and rodents resulting in the transmission and spread of infection to 89 of 93 facility residents. Findings: During an observation on 2/11/2025 at 3:16 p.m., observed multiple large dumpsters outside the facility at the end of the parking lot. Observed on the ground behind the dumpsters an open trash bag containing items including disposable gloves, dirty rags, a Styrofoam cup, and a food wrapper. No staff were present. During a follow-up observation on 2/12/2025 at 7:45 a.m., observed on the ground…

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

Based on observation, interview, and record review, the facility failed to provide care in a manner that maintained or enhanced a resident's dignity and respect in full recognition of their individuality for one (1) of 1 sampled resident (Resident 249) reviewed under the dignity care area by failing to ensure the resident's urinary drainage bag (a container connected to a hollow tube inserted into the bladder to drain or collect urine) was provided with a privacy cover. This deficient practice had the potential to affect Resident 249's self-esteem, self-worth, and sense of independence. Findings: During a review of Resident 249's admission Record, the admission record indicated the facility admitted Resident 249 on 2/5/2025 with diagnoses including urinary tract infection (UTI - an infection in the bladder or urinary tract), unsteadiness on feet, and generalized muscle weakness. During a review of Resident 249's Admission/readmission Initial Assessment, dated 2/5/2025, the Admission/readmission Initial Assessment form indicated Resident 249 was able to understand others and make 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.

Based on observation, interview, and record review, the facility failed to provide reasonable accommodation of resident needs and preferences by failing to ensure the call light (an alerting device for nurses or other nursing personnel to assist a resident when in need) was within reach for one (1) of 1 sampled resident (Resident 248) reviewed under the Environment task. This deficient practice had the potential to result in the delay of care and services and possible injury to residents when they are unable to call for assistance. Findings: During a review of Resident 248's admission Record, the admission Record indicated the facility admitted the resident on 1/24/2025 with diagnoses including fracture (a crack or break in a bone) of shaft of right tibia (also known as shin bone the large bone located between the knee and ankle), unsteadiness on feet, and generalized muscle weakness. During a review of Resident 248's History and Physical (H&P), dated 1/25/2025, the H&P indicated the resident can make her needs but cannot make medical decisions. During a review of Resident 248'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 maintain resident's privacy by failing to pull/close the privacy curtains during medication administration affecting two (2) of three (3) sampled residents (Resident 5 and 196) observed during medication administration. This deficient practice had the potential to result in unauthorized exposure of the resident's treatment and care potentially resulting in psychosocial harm. Findings: During a review of Resident 5's admission Record (a document containing demographic and diagnostic information), the admission Record indicated the facility originally admitted the resident on 5/23/2007 and re-admitted the resident on 10/13/2023 with diagnoses including hemiplegia (partial or complete paralysis on one side of the body) and hemiparesis (partial paralysis or weakness on one side of the body), bipolar disorder (a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration, making it difficult to carry…

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 implement its abuse reporting policy and procedure (P&P) by failing to report an allegation of injury of unknown origin to the State Survey Agency (Department of Public Health) within two hours for one of one sampled resident (Resident 93) reviewed under the Abuse care area. This deficient practice had the potential to place the resident at risk for elder abuse. Findings: During a review of Resident 93's admission Record, the admission Record indicated the facility originally admitted the resident on 1/15/2025, and readmitted on [DATE], with diagnoses including dislocation (an injury where the ends of two bones separate at a joint) of internal left hip prosthesis (artificial body part), fracture (bone that is broken in at least two places) of unspecified part of neck of left femur (thigh bone), dementia (a progressive state of decline in mental abilities), and generalized muscle weakness. During a review of Resident 93's Minimum Data Set (MDS - a…

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

Based on interview and record review, the facility failed to revise one of two sampled residents (Resident 6) care plans to reflect the updated interventions provided to Resident 6 reviewed for Nutrition care area. This deficient practice had the potential to place the resident at risk for a delay in necessary interventions. Findings: During a review of Resident 6's admission Record, the admission Record indicated the facility admitted the resident on 3/22/2017 with diagnoses including type 2 diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), contracture (a stiffening/shortening at any joint, that reduces the joint's range of motion) of right and left hands, and both eyes visual loss. During a review of Resident 6's History and Physical (H&P), dated 11/21/2024, the H&P indicated the resident did not have the capacity to understand and make medical decisions. During a review of Resident 6's Minimum Data Set (MDS-a resident assessment tool), dated 11/28/2024, the MDS indicated the resident had no speech (absence of spoken…

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 residents received care consistent with professional standards of practice to prevent pressure ulcers/injury (the breakdown of skin integrity due to pressure) for one (1) of 1 sampled resident (Resident 12) reviewed for pressure injury by failing to ensure: 1. The resident was turned every two (2) hours. 2. The staff documented the position the resident was placed every time they turned the resident. 3. Licensed Vocational Nurse (LVN) 1 and Certified Nursing Assistant (CNA) 6 documented the reason when the resident refused to turn on 2/12/2025. These deficient practices had the potential for development and worsening of pressure ulcers/injuries to residents. Findings: During a review of Resident 12's admission Record, the admission Record indicated the facility admitted the resident on 10/29/2019, and readmitted the resident on 10/28/2024, with diagnoses including pressure ulcer of sacral region stage four (4) (full thickness…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the resident environment was free of accident hazards for two of four (4) sampled residents (Resident 19 and 66)) reviewed for accidents by failing to ensure: 1. Resident 19's bilateral fall mat (a cushioned mat that reduces the risk of injury from a fall) did not have furniture or equipment on top of them. 2. To accurately complete Resident 66's risk for falls after a fall incident on 10/11/2024. 3. Conduct an interdisciplinary team (IDT - a collaboration of healthcare professionals who work together to plan and coordinate patient care) meeting after Resident 66 fell on [DATE] and 11/13/2024. These deficient practices had the potential to increase the risk of injury to the resident, if the resident slips, trips, and falls by hitting the hard surface of the equipment or furniture that is on top of the fall mat. Findings: 1) During a review of Resident 19's admission Record, the admission Record indicated the facility admitted 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 residents with a urinary catheter (also known as an indwelling catheter, a hollow tube inserted into the bladder to drain or collect urine) received appropriate care and services to prevent urinary tract infections (UTI - an infection in the bladder/urinary tract) for one (1) out of 1 sampled resident (Resident 249) reviewed for urinary catheter or UTI care area when the facility failed to ensure Residents 249's urinary catheter tubing did not have a loop while hanging on the side the bed. This deficient practice had the potential for the resident's urine not to flow freely which may lead to development of UTI. Findings: During a review of Resident 249's admission Record, the admission Record indicated the facility admitted Resident 249 on 2/5/2025 with diagnoses including UTI, unsteadiness on feet, and generalized muscle weakness. During a review of Resident 249's Admission/readmission Initial Assessment, dated 2/5/2025, the Admission/readmission Initial Assessment form indicated Resident 249 was able…

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 staff providing care and services to the resident who has a feeding tube (are soft plastic tubes through which liquid nutrition travels through the gastrointestinal tract [the series of organs that food and liquids pass through as they are digested, absorbed, and leave the body as feces]) are aware of, competent in, and utilize facility protocols regarding feeding tube nutrition and care for one of one sampled resident (Resident 22) reviewed for tube feeding by failing to ensure the water flush bag was labeled with the name, room number, and the rate of the water flush. This deficient practice had the potential to result in altered nutritional status that can lead to over or under hydration, gastrointestinal infection to the resident. Findings: During a review of Resident 22's admission Record, the admission Record indicated the facility admitted the resident on 8/28/2023, and readmitted the resident on 12/29/2024, with diagnoses including gastrostomy (a surgical procedure used to insert a tube,…

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 respiratory care provided to residents were consistent with professional standards of practice for two of two sampled residents (Residents 22 and 346) reviewed for respiratory care by failing to ensure: 1. Resident 22's suction canister (a temporary storage container for secretions or fluids removed from the body) was labeled with the date it was last changed. 2. Resident 346's oxygen tubing (a flexible, clear tube used to deliver oxygen from a source like a tank or concentrator to a patient's nose or mouth) was labeled with the date it was last changed and was off the floor. 3. Resident 346's nebulizer (a small machine that turns liquid medicine into a mist that can be easily inhaled) mask and tubing (this allows the medicine to enter the lungs directly) were kept in a plastic bag with the name of the resident and the date it was provided. The deficient practices had a potential for residents to develop complications such as respiratory infections of using a nebulizer and oxygen tubing caused by…

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: 1. Reconcile (the process of comparing transactions and activity to supporting documentation) one medication emergency kit ([ekit] - storage container for emergency use medications) containing controlled substances ([CS] -drugs which have a potential for abuse and may also lead to physical or psychological dependence,) in one (1) of one (1) inspected medication carts (Medication Cart Station 1). 2. Include the verifying signatures of either the Director of Nursing (DON) or a Registered Nurse (RN) along with Licensed Vocational Nurse (LVN) on the Medication Count Sheet accountability logs for four (4) of four (4) sampled CS records awaiting disposal (removal, destroying) stored inside a locked cabinet. As a result, control and accountability of controlled substances and those awaiting final disposition (process of returning and/or destroying unused medications) did not follow state and federal regulations and facility policy and procedures. These deficient practices increased the opportunity for controlled…

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 the licensed pharmacist during drug regimen review provided a recommendation on the use of an antibiotic as a prophylaxis for UTI to one of two sampled residents (Resident 37) reviewed for antibiotic use by failing to: 1. Ensure the use of methenamine hippurate as a prophylaxis (an attempt to prevent disease) for urinary tract infection (UTI, a bacterial infection in the urinary system, which includes the kidneys, ureters, bladder, and urethra), an antibiotic (medicines that fight bacterial infections in people and animals) had an order for monitoring for signs and symptoms of UTI to evaluate its effectiveness. 2. Follow-up with the attending physician the reason for prolonged use of methenamine hippurate as a prophylaxis for UTI, as it was ordered since 9/2/2023. This deficient practice created the risk for Resident 37 to receive excessive dosages of methenamine hippurate which may cause adverse effects (an undesired effect of a drug or other type of treatment, such as surgery) and can result in overdosage or…

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 resident's drug regimen was free from unnecessary drugs to one of two sampled residents (Resident 37) reviewed for antibiotic (medicines that fight bacterial infections in people and animals) use by failing to ensure Resident 37's methenamine hippurate used as a prophylaxis (an attempt to prevent disease) for urinary tract infection (UTI, a bacterial infection in the urinary system, which includes the kidneys, ureters, bladder, and urethra) was not used for excessive duration and without adequate monitoring for signs and symptoms of UTI. This deficient practice had the potential to cause adverse effects (an undesired effect of a drug or other type of treatment, such as surgery) from the continued use of this medication. Cross Reference F756 Findings: During a review of Resident 37's admission Record, the admission Record indicated the facility admitted the resident on 3/4/2023, with diagnoses including thrombocytopenia (a condition that occurs when the platelet count in the blood is too low), gastro-esophageal…

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 necessary care was provided consistently for a resident who was receiving hospice service (a program designed to provide a caring environment for meeting the physical and emotional needs of the terminally ill) for one of one sampled residents (Resident 30) reviewed for Hospice and End of Life care area by, failing to ensure the hospice aide (HA) visited according to the hospice plan of care for Resident 30. This deficient practice had the potential to negatively affect the resident's physical comfort, psychosocial well-being, and had the potential to result in a delay or a lack of necessary care and services. Findings: During a review of Resident 30's admission Record, the admission Record indicated the facility originally admitted the resident on 8/14/2024 and readmitted on [DATE] with diagnoses including malignant neoplasm (an abnormal growth of cells that invade and spread to other parts of the body) of colon (tube-like organ of the…

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

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections by failing to ensure: 1. Resident 20's urinal bottle (a container for collecting urine that is used by people who are unable to use a bathroom toilet) was labeled with the name and room number for one of 24 sampled residents (Resident 20) during an initial pool screening. 2. Clean linens, clean clothing, and clean curtains were not placed on the ground in the Clean Linen Folding area during a review of the Infection Control task The deficient practices had a potential to spread infections and illnesses among residents. Findings: 1. During a review of Resident 20's admission Record, the admission Record indicated the facility admitted the resident on 10/29/2012, and readmitted the resident on 12/28/2021, with diagnoses that included hemiplegia (total paralysis of the arm, leg, and trunk on the same…

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 implement its policy and procedure (P&P) for reporting all allegations of abuse immediately within two hours of being made aware for one of three sampled residents (Resident 1). This deficient practice resulted in a delay of notifying the necessary agencies, delay in conducting the facility's investigation and may have placed Resident 1 at risk for further abuse. Findings: During a review of Resident 1's admission Record, the admission Record indicated the facility admitted the resident on 1/10/2025 with diagnoses including nondisplaced fracture of lower epiphysis(separation) of left femur (thigh bone - a type of broken bone in the femur), subsequent encounter for closed fracture with routine healing and morbid (severe) obesity due to excess calories. During a review of Resident 1's History & Physical (H&P), dated 1/12/2025, the H & P indicated Resident 1 was obese and can make needs known, but cannot make medical decisions. During a concurrent interview and record review on 2/5/2025 on 4:02 p.m. with the Administrator…

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 thoroughly investigate a sexual abuse (when someone touches another person in a sexual manner without consent) allegation for one of three sampled residents (Resident 1). This deficient practice had the potential to result in unidentified abuse in the facility and failure to protect Resident 1 from abuse. Findings: During a review of Resident 1 ' s admission Record, the admission Record indicated the facility admitted the resident on 1/10/2025 with diagnoses including nondisplaced fracture of lower epiphysis(separation) of left femur (thigh bone - a type of broken bone in the femur), subsequent encounter for closed fracture with routine healing and morbid (severe) obesity due to excess calories. During a review of Resident 1 ' s History & Physical (H&P), dated 1/12/2025, the H & P indicated Resident 1 was obese and can make needs known, but cannot make medical decisions. During a concurrent interview and record review on 2/5/2025 on 4:02 p.m. with the Administrator (Admin), the facility's policy and procedure (P&P)…

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 develop and implement a comprehensive person-centered care plan (a written or electronic record containing all the information the resident needs to effectively manage their own health) for one of three sampled residents (Residents 1) by failing to ensure Resident 1 had a care plan regarding change of condition. This deficient practice had the potential to result in inconsistent implementation of the care plan that may lead to a delay or lack of delivery of care and services. Findings: A review of Resident ' s 1 admission Record indicated the facility admitted the resident on 1/17/2024, with diagnoses including pressure ulcer of the hips (the most severe stage of pressure ulcers and involve full-thickness skin loss that extends through the fascia and into muscle, bone, tendon, or joint tissue). A review of Resident 1's History and Physical, dated 1/19/2024, indicated that resident can make needs known but cannot make medical decisions. A review of Resident 1's Change of Condition Assessment, dated on 8/3/2024, 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 interview and record review, the facility failed to monitor one of three sampled residents (Resident 1) after having a change of condition. This deficient practice could result to Resident 1 encountering serious health issues that may go undetected, leading to complications and potentially life-threatening situations. Findings: A review of Resident ' s 1 admission Record indicated the facility admitted the resident on 1/17/2024, with diagnoses including pressure ulcer of the hips (the most severe stage of pressure ulcers and involve full-thickness skin loss that extends through the fascia and into muscle, bone, tendon, or joint tissue). A review of Resident 1's History and Physical, dated 1/19/2024, indicated that resident can make needs known but cannot make medical decisions. A review of Resident 1's Change of Condition Assessment, dated on 8/3/2024, indicated that Resident 1 had productive cough. During a concurrent interview and record review on 8/17/2024, at 9:55 a.m., License Vocational Nurse (LVN 1) stated there were no progress notes regarding Resident 1 ' 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 a resident received care consistent with professional standards of practice to prevent developing a pressure ulcer (PU - a localized injury to the skin and or underlying tissue usually over a bony prominence as a result of pressure, or a pressure in combination with shear [occur when forces are applied to body tissues or parts that cause these tissues to move in opposite directions]) for one of three sampled residents (Resident 1) by: 1. Failing to inform the Physician on 6/23/2024 of Resident 1 ' s PU. 2. Failing to inform Family Member 1 (FM 1) of Resident 1 ' s PU on 6/23/2024. These deficient practices resulted in delay of obtaining appropriate instructions from the physician for proper management and violated FM 1 ' s right to be informed. Findings: During a record review of Resident 1 ' s admission Record, it indicated the facility admitted Resident 1 on 6/9/2024 with diagnoses that included fracture (bone break) of unspecified (unconfirmed) part of neck of left femur (thigh bone), generalized muscle weakness,…

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 a resident received care consistent with professional standards of practice to prevent developing a pressure ulcer (PU – a localized injury to the skin and or underlying tissue usually over a bony prominence as a result of pressure, or a pressure in combination with shear [occur when forces are applied to body tissues or parts that cause these tissues to move in opposite directions]) for one of three sampled residents (Resident 1) by: 1. Failing to inform the Physician on 6/23/2024 of Resident 1 ' s PU. 2. Failing to provide treatment to Resident 1 ' s PU from 6/23/2024 to 7/3/2024. 3. Failing to inform Family Member 1 (FM 1) of Resident 1 ' s PU on 6/23/2024. 4. Failing to develop a care plan to address Resident 1 ' s PU on 6/23/2024. 5. Failing to accurately assess Resident 1 ' s Braden Scale (a standardized, evidence-based assessment tool commonly used in health care to assess and document a client ' s risk for developing pressure injuries) on 6/24/2024. As a result, Resident 1 developed a PU. On 7/3/2024,…

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 remove intravenous catheter (IV-a thin, flexible tube inserted into a vein, usually in the back of the hand, the lower part of the arm, or the foot to draw blood or give fluids) for one of three sampled residents (Resident 1) when Resident 1 completed the IV fluids hydration on 6/29/2024. This deficient practice had the potential to cause infection and discomfort. Findings: During a record review of Resident 1 ' s admission Record indicted the facility admitted Resident 1 on 6/9/2024 with diagnoses that included fracture (bone break) of unspecified (unconfirmed) part of neck of left femur (thigh bone), generalized muscle weakness and dementia (the loss of cognitive functioning, thinking, remembering, and reasoning to such an extent that it interferes with a person's daily life and activities). During a record review of Resident 1 ' s History and Physical dated 6/10/2024 indicated Resident 1 can make needs known but cannot make medical decisions. During…

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 maintain complete and accurate medical records in accordance with accepted professional standards for one of three sampled residents (Resident). On 6/24/2024 and 7/1/2024 Resident 1 ' s Situation Background Assessment and Recommendation (SBAR) Communication Form (form that provides communication between members of the health care team) nurses did not accurately document date and time the physician and the family were called. This deficient practice had the potential to result in confusion in the care and services rendered to Resident 1 and resulted in inaccurate information entered into Resident 1 ' s medical record. Findings: During a record review of Resident 1 ' s admission Record indicated the facility admitted Resident 1 on 6/9/2024 with diagnoses that included fracture (bone break) of unspecified (unconfirmed) part of neck of left femur (thigh bone), generalized muscle weakness and dementia (the loss of cognitive functioning, thinking, remembering, and reasoning to such an extent that it interferes with a person'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 observation, interview, and record review, the facility failed to ensure that a resident with a urinary indwelling catheter (a flexible plastic tube inserted into the bladder that helps provide continuous urinary drainage) received proper care and services that included to anchor (secure) the urinary catheter tubing to the resident ' s thigh for one of four sampled residents (Resident 4). This deficient practice had the potential to result in urinary catheter dislodgement (forcefully pulled out of a secure position) causing urethral (the tube through which urine leaves the body) tearing that may result in pain, bleeding, and infection. Findings: A review of Resident 4 ' s admission Record indicated the facility admitted the resident on 10/29/2019 with diagnoses that included stage 4 pressure ulcer (full thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage, or bone in the ulcer), type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar [glucose]), and dementia (impaired ability…

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 implement infection control measures for five of seven sampled staff (Medical Records Assistant [MRA], Licensed Vocational Nurse 1 [LVN 1], LVN2, LVN 3 and Director of Staff Development Assistant [DSDA]) while the facility had a Coronavirus Disease 2019- (COVID-19, highly contagious viral respiratory infection that spreads from person to person through droplets releases when an infected person coughs, sneezes or talks) outbreak (more cases of a disease than expected in a specific location over a specific time period) when: 1. Medical Records Assistant (MRA) was walking in the hallway by the front lobby with no protective mask. 2. Licensed Vocational Nurse 1 (LVN 1) standing outside Resident 1's room preparing medications beside a medication cart with N95 hanging on her neck with nose and mouth visible. 3. LVN 2 standing in front of Resident 3's room with his medication cart. LVN 2's N95 is hanging on his neck with nose and mouth visible. 4. LVN 3 seated by Nurse's Station B, in front of a computer with no…

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 record reviews, the facility failed to involve the resident's Power of Attorney (POA-a person legally or non-legally appointed to make decisions on behalf of a patient who lacks capacity) of one of three sampled residents (Resident 1) regarding the decision to cancel Resident 1's health insurance. This deficient caused the POA to not receive needed medical information that Resident 1 had canceled his health insurance for 1/2024 and to make an informed decision regarding Resident 1's care. Findings: A review of Resident 1's admission Record indicated the facility initially admitted the resident on 11/1/2023 with diagnoses including hemiplegia (inability to move one side of the body) and hemiparesis (one?sided weakness) following cerebral infarction (disrupted blood flow to the brain due to problems with the blood vessels that supply it). The admission Record indicated Power of Attorney/Family Member 2 (POA/FM 2) was the resident's representative. A review of Resident 1's Advance Health Care Directive Form, dated 11/19/2023, indicated Resident 1's POA 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.

Based on observation, interview and record review, the facility failed to provide care in a manner that maintained or enhance a resident's dignity and respect in full recognition of their individuality by failing to ensure Certified Nursing Assistant 3 (CNA 3) knocked and asked permission before entering a resident's room for one of one random observations (Resident 76). This deficient practice had the potential to affect the residents' sense of self-worth and self-esteem. Findings: A review of Resident 76's admission Record indicated the facility admitted the resident on 6/15/2023 and readmitted the resident on 9/8/2023 with diagnoses including dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), blindness on one eye, and repeated falls. A review of Resident 76's History and Physical (H&P) dated 10/10/2023, indicated the resident did not have the capacity to understand and make decisions. A review of Resident 76 's Minimum Data Set (MDS, a standardized assessment and screening tool) dated 12/9/2023, indicated the resident…

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

Based on observation, interview, and record review the facility failed to: 1. Assess a resident for self-administration of medication of insulin via an insulin pump (provides non-stop insulin [a hormone that lowers the level of sugar in the blood] delivery through a tubeless, waterproof insulin pump with no multiple daily injections) for one of two sampled residents (Resident 70) investigated during review of insulin care area. 2. Assess if a resident was capable and trained to perform self-administration of medication safely before leaving the medications at bedside for one of 13 random observations conducted during resident screening. These deficient practices had the potential to violate the resident's right to be assessed for capacity and be informed of their ability to self-administer medications and had the potential to result in unsafe medication administration. Findings: 1. A review of Resident 70's admission Record indicated the facility admitted the resident on 9/28/2023 and readmitted the resident on 12/22/2023, with diagnoses including type 2 diabetes (a problem in the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan (contains relevant information about a resident's conditions, goals of treatment, specific actions that must be performed, and a plan for evaluation): 1. For two out of two sampled residents (Residents 70 and 85) investigated during review of insulin use by failing to ensure Resident 70 and Resident 85 had a care plan on insulin (a hormone that lowers the sugar in the blood) use addressing rotation (a method to ensure repeated injections are not administered in the same area) of subcutaneous (beneath the skin) administration sites. This deficient practice had the potential for ineffective treatment to normalize blood glucose (also called blood sugar) levels and placed the residents at increased complications of insulin use on residents. 2. For one of two sampled residents (Resident 81) investigated during review of accidents care area by failing to ensure Resident 81 had a care plan for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility: 1. Failed to update the resident's care plans (contains relevant information about a resident's conditions, goals of treatment, specific actions that must be performed, and a plan for evaluation) for two of two sampled residents (Resident 57 and Resident 67) investigated during review of pressure injury care area by failing to: a. Ensure Resident 67's care plan was updated to reflect the intervention for Z-flex heel boot (a protective boot designed to prevent pressure and pressure sores on the heel area) on for skin maintenance. b. Ensure Resident 57's care plan was updated to reflect the intervention for low air loss mattress (LALM - a mattress designed to distribute the patient's body weight over a broad surface area and help prevent skin breakdown) for skin maintenance. 2. Failed to ensure Resident 64's care plan was updated to reflect the intervention call light within reach to prevent injuries from falls during one of 23 random observations.…

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's licensed nursing staff failed to provide care in accordance with professional standards by failing to: 1. Rotate (a method to ensure repeated injections are not administered in the same area) subcutaneous (beneath the skin) administration sites of insulin (a hormone that lowers the level of sugar in the blood) to one out of five sampled residents (Resident 70) investigated under unnecessary medications. 2. Rotate subcutaneous administration sites of insulin to one out of one sampled resident (Resident 85) investigated under insulin. The deficient practice had the potential for adverse effect (unwanted, unintended result) of same site subcutaneous administration of insulin and heparin such as lipodystrophy (abnormal distribution of fat) and cutaneous amyloidosis (a rare disease that occurs when a protein called amyloid builds up in organs). Cross Reference with F760 Findings: 1. A review of Resident 70's admission Record indicated the facility admitted the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide care consistent with professional standards of practice to prevent pressure ulcer/injury (ulcers that happen on areas of the skin that are under pressure from lying in bed, sitting in a wheelchair, or wearing a cast for a long period) for four (4) out of five random observations (Residents 57, 67, 85, and 27) investigated under pressure ulcer care area, by failing to: 1. Ensure Resident 57's low air loss mattress (LALM - a mattress designed to distribute the patient's body weight over a broad surface area and help prevent skin breakdown) was set according to the physician's order. 2. Ensure Resident 67's Z-flex heel boot (a protective boot designed to prevent pressure and pressure sores on the heel area) was applied according to the physicians' order. 3. Set the low air loss mattress according to physician's order (110 to 120 pounds [lbs., a unit of weight]) for Resident 27. 4. Ensure Resident 27's low air-loss mattress was set according to the…

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

Based on interview and record review, the facility failed to monitor hemodialysis (dialysis, a procedure to remove waste products and excess fluid from blood when the kidneys are no longer healthy enough to do this work adequately) treatment complications by not performing post dialysis assessment for three days as ordered, for one of two sampled resident (Resident 63) investigated addressing dialysis care area. This deficient practice placed Resident 63 at risk for complications of dialysis such as redness at the catheter site, edema (too much fluid trapped in the body's tissues), and excessive bleeding. Findings: A review of Resident 63's admission Record indicated the facility admitted the resident on 10/5/2021 and readmitted the resident on 1/2/2024, with diagnoses including pneumonia (an infection that inflames the air sacs in one or both lungs) and dependence in renal dialysis. A review of Resident 63's History and Physical Examination, dated 1/6/2024, indicated the resident does not have the capacity to understand and make decisions. A review of Resident 63's Order Summary…

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 safe and sanitary food storage and food preparation practices in the kitchen when: 1. Various items of food were not discarded after passing their use by date (date when a product may no longer be safe to eat). 2. The red bucket (container used to hold sanitizing product) in the three-compartment sink did not maintain the recommended sanitizer strength according to manufacturer's guidelines. These deficient practices had the potential to result in harmful bacteria growth and cross-contamination (the physical movement of transfer of harmful bacteria from one person, object, or place to another) that could lead to foodborne illness (any illness of a toxic or infectious nature contracted through consumption of contaminated water or food) in 92 of 95 medically compromised residents who receive food from the kitchen. Findings: 1. During a concurrent observation and interview with the Dietary Supervisor (DS), on 2/6/2024, at 7:57 a.m., inside the kitchen's walk-in refrigerator, the following items 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 keep the call light (an alerting device for nurses or other nursing personnel to assist a patient when in need) within reach of the resident for two out of five sampled residents (Resident 6 and Resident 64) investigated during review of environment facility task. This deficient practice had the potential to result in the resident not being able to call for facility staff assistance and delay in the provision of necessary care and services that can negatively affect the resident's comfort and well-being. Findings: a. A review of Resident 6's admission Record indicated the facility admitted the resident on 3/22/2017, with diagnoses including visual loss of both eyes, hypertension (high blood pressure), and osteoarthritis (is a degenerative joint disease, in which the tissues in the joint break down over time). A review of Resident 6's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 12/5/2023, indicated the resident had severely impaired cognition (mental action or process of…

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

Based on interview and record review, the facility failed to ensure one of three randomly sampled residents (Resident 304) reviewed for changes in Medicare coverage were provided with the Notice of Medicare Non-Coverage (NOMNC) appeal process in a timely manner. This deficient practice had the potential to result in the resident and or their representative not being able to exercise their right to file an appeal. Findings: A review of Resident 304's admission Record indicated the facility admitted the resident on 9/4/2023, with diagnoses including displaced fracture (a partial or complete break in the bone) of right femur (thigh bone) and acute post hemorrhagic anemia (a condition that develops when the body lose a large amount of blood quickly). A review of Resident 304's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 9/8/2023, indicated the resident had the ability to make self-understood and understand others. A review of Resident 304's Skilled Nursing Facility (SNF) Beneficiary Notification Review form indicated the resident last covered day of…

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

Based on observation, interview, and record review, the facility failed to ensure the window of the resident was free from draft due to deteriorating window seal to one of five sampled residents observed during review of environment facility task (Resident 70). The deficient practice violated the resident's rights to a safe, clean, sanitary, and homelike environment. Findings: A review of Resident 70's admission Record indicated the facility admitted the resident on 9/28/2023 and readmitted the resident on 12/22/2023, with diagnoses including type 2 diabetes (a problem in the way the body regulates and uses sugar as a fuel) with diabetic neuropathy (nerve damage caused by diabetes) and type 2 diabetes mellitus with foot ulcer (an open sore on the foot). A review of Resident 70's History and Physical (H&P), dated 12/15/2023, indicated the resident had the capacity to understand and make medical decisions. A review of Resident 70's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 12/31/2023, indicated the resident had the ability to make self-understood…

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 notice of transfer before transfers and discharges for two of three sampled residents reviewed under hospitalization (Resident 63 and 82) by failing to: 1. Provide Resident 63 the notification of transfer or discharge on [DATE] and send a copy of the notification to the long-term care ombudsman (resident advocate). 2. Provide Resident 82's responsible party the notification of transfer or discharge on [DATE] and send a copy of the notification to the long-term care ombudsman. These deficient practices had the potential for Resident 63 and 82 to have an unsafe discharge. Cross-reference F625 Findings: 1. A review of Resident 63's admission Record indicated the facility originally admitted Resident 63 on 10/5/2021 and readmitted the resident on 1/2/2024 with diagnoses including, but not limited to, pneumonia (infection that inflames air sacs in one or both lungs) and generalized muscle weakness. A review of Resident 63's History and Physical…

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 bed hold notice to a resident before transfer to the general acute care hospital (GACH) for two of three sampled residents reviewed under hospitalization (Resident 63 and 82). This deficient practice had the potential for Resident 63 and 82 to not know if they had a place to return to after hospitalization. Cross-reference F623 Findings: 1. A review of Resident 63's admission Record indicated the facility originally admitted Resident 63 on 10/5/2021 and readmitted the resident on 1/2/2024 with diagnoses including, but not limited to, pneumonia (infection that inflames air sacs in one or both lungs) and generalized muscle weakness. A review of Resident 63's History and Physical (H&P), dated 1/6/2024, indicated Resident 63 does not have the capacity to understand and make decisions. A review of Resident 63's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 1/6/2024, indicated Resident 63 had moderate cognitive…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents who were incontinent of bladder received appropriate treatment and services to prevent urinary tract infections (UTI, common infections that happen when bacteria infect the urinary tract) for two of two sampled residents (Resident 300 and 7) being investigated under urinary catheters (a tube that is inserted into the bladder, allowing urine to drain) by failing to: 1. Place a leg strap (an elasticized thigh strap to anchor catheters in place) to secure Resident 300's suprapubic catheter (urinary catheter that is inserted into the bladder). 2. Ensure Resident 7's suprapubic catheter tubing was free from coils. These deficient practices had the potential for Resident 300 and Resident 7's suprapubic catheters to be dislodged requiring reinsertion of the catheter tubing and increase the potential for both residents to get UTI. Findings: 1. A review of Resident 300's admission Record indicated the facility admitted 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 provide appropriate treatment and services to prevent complications of enteral feeding (EF - a form of nutrition that is delivered into the digestive system as a liquid) for one of one sampled resident (Resident 67) investigated under the tube feeding care area by failing to ensure the EF bottle was labelled properly per facility's policy. This deficient practice had the potential to place Resident 67 at risk for complications of enteral feeding such as diarrhea or vomiting which may lead to dehydration. Findings: A review of Resident 67's admission Record indicated the facility admitted the resident on 2/15/2023 and readmitted on [DATE], with diagnoses including generalized muscle weakness, dysphagia (a condition in which swallowing is difficult or painful), and gastrotomy (GT - a surgical procedure to insert a tube through the abdomen and into the stomach used for feeding, usually via a feeding tube). A review of Resident 67s History…

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 implement and maintain an infection control program by failing to replace the humidifier bottle (medical device that increase the humidity while using supplemental oxygen) when it ran out of fluid for one of three residents (Resident 34) during a random observation being investigated under the respiratory facility task. This deficient practice had the potential to cause irritation to Resident 34's nasal (referring to the nose) passages. Findings: A review of Resident 34's admission Record indicated the facility admitted the resident on 4/19/2017 and readmitted the resident on 3/9/2021, with diagnoses including chronic obstructive pulmonary disease (COPD - a group of diseases that cause airflow blockage and breathing-related problems) and hypertension (high blood pressure). A review of Resident 34's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 1/8/2024, indicated the resident had moderately impaired cognition (mental action or process of acquiring knowledge and…

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

Based on interview and record review, the facility failed to ensure residents were free from unnecessary drugs for one of five sampled residents (Resident 60) being investigated under unnecessary medication facility task by failing to monitor and document Resident 60's postural/orthostatic hypotension- (a drop in blood pressure [hypotension] due to a change in body position when a person moves to a more vertical position: from sitting to standing or from lying down to sitting or standing postural/orthostatic hypotension and can lead to falls and injuries of the residents) readings while taking Latuda (an antipsychotic medication-used to treat disordered thinking associated with severe mental illness) per physician's order. This deficient practice had the potential to result in overuse of an antipsychotic medication and antidepressant medication, without monitoring for the effectiveness and/or ineffectiveness of the medication and can lead to adverse drug reactions. Findings: A review of Resident 60 's admission Record indicated the facility admitted the resident on 3/1/2020, with 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 follow the meal plan calendar on 2/7/2024, during breakfast by failing to prepare the breakfast at an appetizing temperature to one of eight sampled residents (Resident 70) being investigated under dining observation facility task. This deficient practice had the potential for Resident 70 to have a decrease in food intake and weight loss. Findings: A review of Resident 70's admission Record indicated the facility admitted the resident on 9/28/2023 and readmitted on [DATE], with a diagnosis of type 2 diabetes mellitus (a problem in the way the body regulates and uses sugar as a fuel). A review of Resident 70's History and Physical (H&P), dated 12/15/2023, indicated the resident had the capacity to understand and make decisions. A review of Resident 70's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 12/31/2023, indicated the resident had the ability to make self-understood and understand others. The MDS…

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

Based on observation, interview, and record review, the facility failed to maintain mechanical, electrical, and patient care equipment in safe operating condition for one of five sampled residents (Resident 82) investigated under Environment when Resident 82's bed controller (device used to change the height and angle of the bed) cable was open with exposed wires. This deficient practice had the potential to place Resident 82 at risk for injury. Findings: A review of Resident 82's admission Record indicated the facility originally admitted Resident 82 on 10/12/2023 and readmitted the resident on 11/25/2023 with diagnoses including, but not limited to, generalized muscle weakness and lack of coordination. A review of Resident 82's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 1/15/2024, indicated Resident 82 had moderate cognitive impairment (when a person has trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life), required setup or clean-up assistance with eating, required partial or moderate…

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

Based on observation, interview, and record review, the facility failed to follow its infection prevention and control program regarding Coronavirus disease 2019 (COVID-19, a viral infection that is highly contagious and easily transmits from person to person, causing respiratory problems and may cause death) for three of nine facility staff (Certified Nursing Assistant 1 [CNA 1], CNA 2, and Housekeeping 2 [HKP 2]) by failing to ensure CNA 1, CNA 2, and HKP 2 wore the N95 mask (respiratory protective device designed to achieve a very close facial fit and very efficient filtration of airborne particles) properly. CNA 2 was providing care to Resident 3 while CNA 2 ' s N95 mask was not worn properly. The facility also failed to ensure that COVID-19 screening was done on all visitors entering the facility. These deficient practices placed other residents and staff at risk for exposure and contracting COVID-19. Findings: On 2/1/2024 at 8:35 a.m., during an observation, the surveyor entered the facility but was not instructed to screen for COVID-19. The Administrator (ADM) and 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 provide dignity to three of six sampled residents (Resident 1, 3, and 4) by, failing to ensure staff were not standing over the residents while assisting the residents to eat. This deficient practice had the potential to affect the residents' self-worth. Findings: a. A review of Resident 1's admission Record indicated the facility admitted the resident on 6/12/2023 with diagnoses that included dysphagia (difficulty swallowing) oropharyngeal (the part of the throat at the back of the mouth behind the oral cavity) phase, muscle wasting and atrophy (decrease in size or wasting away of a body part or tissue), and dementia (the loss of cognitive functioning - thinking, remembering, and reasoning - to such an extent that it interferes with a person's daily life and activities). A review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 6/19/2023, indicated Resident 1 had the capability 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 and record review, the facility failed to implement infection prevention and control program by: 1. Failing to conduct coronavirus disease 2019 (COVID-19, a highly contagious viral illness that can lead to mild respiratory issues to severe pneumonia [a lung infection causing symptoms like cough, fever, and difficulty breathing]) response testing according to the facility's COVID-19, Prevention and Control policy and procedure for six out of 10 sampled staff (Licensed Vocational Nurse [LVN] 1, LVN 2, LVN 3, LVN 4, Certified Nursing Assistant [CNA] 2, and Dietary Aide [DA] 1). 2. Failing to develop staff COVID-19 testing policy and procedure regarding the appropriate timing, documentation, and submission of the staff's COVID-19 test results. 3. Failing to ensure all facility contracted staff were fit-tested for the use of N-95 (a respirator mask that provides a high level of filtration efficiency) yearly for 17 out of 17 staff. These deficient practices had the potential to result in increased transmission of COVID-19 infections among residents and staff. Findings:…

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

Based on observation, interview, and record review, the facility failed to provide one of three sampled residents (Resident 6) with her preferred method of showering, when staff was observed only offering Resident 6 a bed bath. This deficient practice had the potential negative effect on Resident 6's quality of life. Findings: A review of Resident 6's admission Record indicated the facility admitted the resident on 8/3/2022 and readmitted the resident on 8/14/2023 with diagnosis that included Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination), muscle weakness (generalized), and anemia (a condition that develops when your blood produces a lower-than-normal amount of healthy red blood cells). A review of Resident 6's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 8/1/2023, indicated Resident 6 had the capability to understand and be understood. The MDS indicated that Resident 6 required extensive assistance with bed mobility, transferring,…

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.