Cottage Crest Post Acute

Based on observation, interview, and record review, the facility failed to ensure fortified diets (diet to increase calories) were identified and communicated during lunch tray line meal service for ten residents who were on fortified diet as recommended by the dietitian and ordered by the physician.This failure had the potential to result in residents not receiving required nutritional fortification (adding extra vitamins and minerals to food), leading to inadequate nutritional intake, and unintended weight loss.Findings:During an observation on 5/3/2026 at 12:05 p.m. during lunch tray line, [NAME] (CK) 1 did not communicate the fortified diet orders written on the meal tickets to CK 2 who was serving the food.During an interview on 5/3/2026 at 12:58 p.m. with CK 1, CK 1 one stated she had forgotten to communicate the fortified diets to CK 2. CK 1 stated the importance of communicating the fortified diet orders was to ensure the residents receive the calories needed. CK 1 stated if the fortified diet orders were not communicated during tray line, there would be potential for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to ensure the Responsible Party (RP) for one of four sampled residents (Resident 1), who did not have the capacity to make decisions, was advised of Resident 1's dental needs and a consent was obtained from Resident 1's RP prior to Resident 1's tooth extraction. This deficient practice resulted in the extraction of Resident 1's tooth without the knowledge or consent of Resident 1's RP. This deficient practice had the potential for Resident 1 to be subjected to an unnecessary procedure and/or to suffer complications such as discomfort/pain, bleeding, and infection.Findings: During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE]. Resident 1 had diagnoses including metabolic encephalopathy (a disease that affects the brain causing confusion) and dementia (a progressive state of decline in mental abilities). During a review of Resident 1's Minimum Data Set ([MDS] a resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 2) care plan was revised after Resident 2 fell on [DATE].This deficient practice had the potential for the nursing staff to be unaware of Resident 2's current fall-risk precautions and interventions, which could delay or negatively impact the delivery of her care and potentially lead to further falls.Findings:During a review of Resident 2's admission Record (Face Sheet), the Face Sheet indicated Resident 2 was admitted to the facility on [DATE] with diagnoses including metabolic encephalopathy (temporary or permanent damage to the brain due to lack of glucose, oxygen or other metabolic agent, or organ dysfunction), dementia (a progressive state of decline in mental abilities), and difficulty walking.During a review of Resident s's Minimum Data Set ([MDS] a resident assessment tool) dated 7/8/2025, the MDS indicated Resident 2 was not able to make decisions that were reasonable and consistent and required…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of eight sampled residents (Resident 1) was provided with his preferred activities. This failure resulted in Resident 1 feeling sad and frustrated and had the potential to further affect Resident 1's emotional well-being, which may impact his quality of life and mental health. Findings:During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis including depression (a mood disorder that cause feelings of persistent feeling of sadness and loss of interest affecting the way a person feel, think and behave that affects the normal day to day activities). During a review Resident 1's History and Physical (H&P), dated 9/19/ 2025, the H&P indicated Resident 1 had the capacity to understand and make decisions.During a review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool), dated 2/12/2026, 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 Based on interview and record review, the facility failed to ensure Registered Nurse (RN) 1 accurately documented vital signs (essential measurements taken by the healthcare team providers to check the body's most basic and life sustaining functions) for one of three sampled residents (Resident 2) when Resident 2 had a change of condition on 12/25/2026 and was transferred to a General Acute Care Hospital via 911 for further evaluation. This deficient practice had the potential for Resident 2's change of condition to be unrecognized, undetermined, or inadequately identified. This deficient practice also had the potential to negatively impact Resident 2's health status, interrupt the continuity of care, and impair timely and accurate communication among facility team members and with emergency personnel. Findings:During a review of Resident 2's admission Record (Face Sheet), the Face Sheet indicated Resident 2 was admitted to the facility on [DATE] with diagnoses including metabolic encephalopathy (temporary 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.

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 out of seventeen sampled residents (Resident 10, Resident 23, Resident 44, and Resident 45) related to: 1. Resident 45's usage of Apixaban (a blood thinner medication). 2. develop and implement care plans of bowel and bladder retraining and bowel incontinent for Resident 10. 3. develop and implement care plans of bowel and bladder retraining and bowel incontinent for Resident 44. 4. develop and implement care plans of hypoglycemia [a condition in which a person's blood sugar (glucose) level is lower than normal] for Resident 23. These deficient practices could result in the Resident's needs not being met, negatively impacting their well-being, and leading to suboptimal patient outcomes. Findings: 1. During a review of Resident 45's admission Record (Face Sheet), the admission Record indicated Resident 45 was admitted to the facility 1/28/2025 with diagnoses of paroxysmal atrial…

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 three of three sampled residents (Resident 10, Resident 44, and Resident 3) who were incontinent (unable to voluntarily control retention of urine or feces in the body) of bowel and bladder, were provided a retraining and/or toileting program to regain the resident's normal bowel and bladder function as much as possible by failing to: A. ensure Resident 10's bowel and bladder assessment was done and follow through quarterly, and Resident 10 received bowel and bladder retraining as the assessment indicated. B. Ensure Resident 44's bowel and bladder assessment was conducted upon admission, and that Resident 44 participated in the bowel and bladder retraining program. C. Ensure Resident 3 was offered a bowel and bladder training to restore as much bladder function as possible. This failure had a potential to result in Resident 10, Resident 44, and Resident 3's inability to regain control of bowel and bladder function and can lead to a loss of…

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

Based on observations, interviews, and record reviews, it was determined that the facility did not store food in a sanitary manner, which is necessary to prevent the growth of microorganisms. These microorganisms can cause foodborne illnesses, such as those resulting from contaminated food with pathogenic bacteria, viruses, parasites, or toxins. This issue affected 47 out of the 50 residents at the facility due to the following deficiencies: A. Ensuring food items were dated, labeled, and discarded properly. B. Ensuring [NAME] (CK) 2 performed hand hygiene (washing Hands) and changed gloves between tasks during trayline (Resident's trays are assembled and check for accuracy before food is delivered to them). This failure had the potential to impact residents, resulting in exposure to pathogens and placing them at risk for foodborne illnesses. Symptoms of such illnesses include upset stomach, cramps, nausea, vomiting, diarrhea, and fever, potentially leading to serious medical complications and hospitalization. Findings: A. During a concurrent observation and interview on 5/27/2025,…

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 report the outbreak (urgent emergencies accompanied by rapid efforts to save lives and prevent further cases) of corona virus- 19 (COVID-19, a highly contagious infection, caused by a virus that can easily spread from person to person) to the State Agency (CDPH, California Department of Public Health) starting on 5/14/2025 for six out of six sampled Residents (Resident 12, Resident 30, Resident 37, Resident 40, Resident 44, and Resident 45). These deficient practices had the potential for continued spread of the COVID-19 infection to all the facility's residents and staff. Findings: 1. During a review of Resident 12's admission Record (Face Sheet), the admission Record indicated Resident 12 was admitted to the facility 1/2/2025 with diagnoses of pneumonia (infection in the lungs), and neoplasm of the prostate (prostate cancer). During a review of Resident 12's Minimum Data Set (MDS, a resident assessment tool) dated 3/13/2025, 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 Based on interview and record review, the facility failed to implement their policy and procedure (P/P) for Antibiotic Stewardship (the effort to measure and improve how antibiotics (a medication used to kill bacteria and to treat infections) are prescribed by clinicians and used by patients) for two of five sampled residents (Resident 43 and Resident 154) who were prescribed antibiotics without meeting criteria. This deficient practice had the potential for Resident 43 and Resident 154 to develop antibiotic resistance (not effective to treat infection) from unnecessary or inappropriate antibiotic use. Findings: During a review of Resident 43's admission Record (Face Sheet), the admission Record indicated Resident 43 was admitted to the facility on [DATE] with diagnoses of type 2 diabetes (a long-term condition in which the body has trouble controlling blood sugar and using it for energy) with a foot ulcer (wound), osteomyelitis (bone infection), and complete amputation (removal) of the right foot at the ankle…

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 the interview and record review, the facility did not obtain informed consent for one of the five residents (Resident 45) who was diagnosed with depression-a mood disorder characterized by persistent sadness and loss of interest that can affect daily life-and was being treated with the medication Celexa (a medication that treats depression) . This deficient practice had the potential for Resident 45 to not be informed of the risks and benefits of Celexa. Findings: During a review of Resident 45's admission Record (Face Sheet), the admission Record indicated Resident 45 was admitted to the facility 1/28/2025 with diagnoses of paroxysmal atrial fibrillation (a rapid and irregular heartbeat), coronary artery disease (CAD, a narrowing or blockage of your coronary arteries, which supply oxygen-rich blood to your heart), and congestive heart failure (CHF, a serious condition in which the heart doesn't pump blood as efficiently as it should). During a review of Resident 45's Minimum Data Set (MDS, a resident assessment tool) dated 4/30/2025, the MDS indicated Resident 45 was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility did not ensure that residents received appropriate treatment and care for hypoglycemic episodes in accordance with professional standards of practice. Specifically, for one of three sampled residents (Resident 23), the facility failed to ensure the resident consumed a meal after receiving insulin and did not monitor blood glucose levels or provide necessary treatment during the hypoglycemic episode. This failure led to Resident 23's preventable hospitalization for further evaluation and treatment. Findings: During a review of Resident 23's admission Record, the admission Record indicated, Resident 23 was initially admitted to the facility on [DATE] and last re-admission was on 11/2/2024 with diagnoses including Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) and dementia (a progressive state of decline in mental abilities). During a review of Resident 23's History and Physical (H&P), dated 11/2/2024,…

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.

Based on the interview and record review, the facility did not monitor anticoagulant (blood thinning medication) usage for one out of six sampled residents (Resident 45). This deficient practice had the potential for complications related to anticoagulant use including bleeding to go unnoticed for Resident 45. Findings: During a review of Resident 45's admission Record (Face Sheet), the admission Record indicated Resident 45 was admitted to the facility 1/28/2025 with diagnoses of paroxysmal atrial fibrillation (a rapid and irregular heartbeat), coronary artery disease (CAD, a narrowing or blockage of your coronary arteries, which supply oxygen-rich blood to your heart), and congestive heart failure (CHF, a serious condition in which the heart doesn't pump blood as efficiently as it should). During a review of Resident 45's Minimum Data Set (MDS, a resident assessment tool) dated 4/30/2025, the MDS indicated Resident 45 was cognitively (mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) intact and was taking anticoagulant…

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, it was noted that one tube of Triamcinolone Acetonide External Cream 0.5% (used to treat rashes) belonging to Resident 26 was not labeled or dated in medication cart 1. This deficient practice had the potential for the medication to be used after it was expired. Findings: During a review of Resident 26's admission record (face sheet), the admission Record indicated Resident 26 was admitted to the facility [DATE] with diagnoses of type 2 diabetes (a long-term condition in which the body has trouble controlling blood sugar and using it for energy) and history of falling. During a review of Resident 26's Minimum Data Set (MDS, a resident assessment tool) dated [DATE], the MDS indicated Resident 26 had moderate cognitive impairment (problems with a person's ability to think, learn, remember, use judgement, and make decisions). During a review of Resident 26's Physician's Orders, an order was placed [DATE] for Triamcinolone Acetonide External Cream 0.5 %…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure one of four sampled resident (Resident 2) touch pad call light (enables residents with limited movement to call for help) and telephone were within Resident 2 ' s reach. This failure had Resident 2 to feel frustrated, useless and had the potential for her needs not met which could result to delay of care and services. Findings: During a review of Resident 2 ' s admission Record, the admission Record indicated Resident 2 was admitted to the facility on [DATE], with diagnoses including transient ischemic attack ([TIA] a brief interruption of blood flow to the brain that causes stroke-like symptoms) and cognitive (ability to think, understand, learn, and remember) communication deficit (having trouble communicating due to problems with thinking skills like memory, attention, reasoning, or organization, often caused by a brain injury). During a review of Resident 2 ' s History and Physical (H&P), dated 2/22/24, the H&P indicated,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement its abuse prevention policy by failing to report an unusual occurrence of an acute (sudden and severe onset) right femoral neck fracture (a particular type of hip fracture that occurs at hip region below the ball-and-socket joint ) and right temporal (side of the head behind the eye between the forehead and the ear) hematoma (a closed wound where blood collects and fills a space inside your body because it can't flow or drain out) of unknown cause to the State Survey Agency (California Department of Public Health-CDPH) within 24 hours of the occurrence for one of three sample residents (Resident 1). This failure had the potential to result in a delay of an onsite inspection by CDPH to ensure injuries from unknown origins were investigated timely and lead to a delay in prevention of potential ongoing unknown injuries. Findings: During a review of Resident 1 ' s admission Record, the admission Record indicated, Resident 1 was admitted to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) was not verbally abused (using words to name call, bully, demean, frighten, intimidate, or control another person) by certified nursing assistant (CNA 1). This deficient practice caused Resident 1 to feel offended and cry hysterically (to cry in an uncontrolled state of anger, excitement, or panic) when CNA 1 re-entered Resident 1's room. Findings: During a review of Resident 1's admission Assessment, the admission Assessment indicated Resident 1 was admitted to the facility on [DATE] with diagnoses of primary lateral sclerosis (a progressive neuromuscular (nerves and muscles) condition that causes worsening muscle weakness and/or stiffness), generalized anxiety disorder (a mental health condition that causes people to experience excessive and persistent worry about everyday things), and encounter for palliative care (specialized medical care for people living with a serious illness. This type of care…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to create a person-centered care plan for diabetes (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) for one of three sampled residents (Resident 2). This deficient practice had the potential for Resident 2 to have episodes of hypoglycemia (occurs when your blood sugar level drops too low for your body to function normally) and/ or hyperglycemia (elevated blood sugar) related to her diagnosis of diabetes. Findings: During a review of Resident 2 ' s admission Record, the admission Record indicated Resident 2 was admitted to the facility on [DATE] with diagnoses including type 2 diabetes, malignant neoplasm of the breast (breast cancer), secondary malignant neneoplasm (cancer spread to the bone), and immunodeficiency (a state in which the immune system's ability to fight infectious diseases and cancer is compromised or entirely absent). During a review of Resident 2 ' s History and Physical (H&P) report dated 8/13/2024,…

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 monitor the blood sugar levels for one of three sampled residents (Resident 2) who had type 2 diabetes (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) and was receiving insulin (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication). This deficient practice had the potential to cause hypoglycemia (occurs when your blood sugar level drops too low for your body to function normally). Findings: During a review of Resident 2 ' s admission Record, the admission Record indicated Resident 2 was admitted to the facility 8/9/2024 with diagnoses of type 2 diabetes, malignant neoplasm of the breast (breast cancer), secondary malignant neoplasm of the bone (breast cancer spread to the bone), and immunodeficiency (a state in which the immune system's ability to fight infectious diseases and cancer is compromised or entirely absent). During a review of Resident 2…

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

Based on interview, and record review, the facility failed to provide adequate Restorative Nursing Assistant ([RNA] -a certified nursing assistant (CNA) with specialized training in rehabilitation skills who assists the restorative team with supervised and delegated restorative programs) staff to provide range of motion ([ROM]- the amount of movement that a particular joint or series of joints can achieve in a specific direction), splint (a rigid support for restricting movement of an injured part) application, and ambulation to 28 of 54 residents on RNA program. This failure had the potential to result in 28 residents being at risk for further ROM decline and contracture (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints). Findings: A review of All Facilities Letter (AFL) dated 1/23/2018 indicated, effective July 1,2018, SB 97 (Chapter 52, Statutes 2017) requires SNFs, except those that are a distinct part of general acute care or a state- owned hospital or development center, to provide a minimum of 3.5…

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 Licensed Vocational Nurses (LVN) 1, LVN 2 and LVN 5 were trained to administer medications via gastrostomy tube (g-tube - a surgically placed tube used to administer mediations or food directly into the stomach) with the appropriate technique and/or in accordance with physician's orders for three out of three sampled residents for g-tube administration (Resident 19, Resident 6 and Resident 47.) This failure had the potential to result in g-tube complications and infection for Resident 19, Resident 6 and Resident 47. Findings: a. During a review of Resident 19's admission Record (a document containing demographic and diagnostic information), dated 6/4/2024, the admission record indicated, Resident 19 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including encounter for attention to gastrostomy. During a review of Resident 19's Order Summary Report (a list of all currently active medical orders),…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to: 1. Ensure availability of metoprolol tartrate (a medication used to treat high blood pressure), apixaban (a medication used to prevent and reduce the risk of blood clot), furosemide (a medication for heart failure and high blood pressure), amoxicillin (a medication used to treat infection), lidocaine (a medication used to treat localized pain) cream, and tussin DM ([Generic name - guaifenesin and dextromethorphan] a medication used to provide cough relief) in accordance with physician orders or professional standards of practice for five of nine sampled residents (Residents 6, 26, 209, 210 and 211.) 2. Maintain accurate medication administration records as per facility's policies and procedures (P&P) titled, Medication Administration for two of nine sampled residents (Resident 19 and 209.) These failures resulted in falsification of medication administration records, and failed to provide medications in accordance with the physician'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 and interview, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen by: 1. Failing to dispose expired food from the fridge. 2. Failed to store food in the appropriate section. 3. Failed to do proper hygiene when entering the kitchen. These deficient practices had the potential to result in pathogen (germ) exposure to residents and placed residents at risk for developing foodborne illness (food poisoning) with symptoms including upset stomach, stomach cramps, nausea, vomiting, diarrhea and fever and can lead to other serious medical complications and hospitalization. During a concurrent observation of the refrigerator and interview on 6/4/2024 at 8:26a.m. with Dietary Aide 1 (DA 1). DA 1 stated the cilantro in the bag that was dated 5/9/2024 is supposed to be good for one week and was supposed to be thrown away. It was noted the cilantro was changing color and was turning yellow. It was additionally observed there was an avocado, ginger, yellow pepper, and one lemon in the bin with no date. During a concurrent…

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

Based on observation and interview, the facility failed to dispose of garbage and refuse properly by not completely covering two (2) of 2 dumpsters (a large trash container designed to be emptied into a truck) and two smaller carts for an unknown length of time. This deficient practice had a potential to attract flies, insects, cats, and other animals to the dumpster area placing 54 of 59 facility residents getting food from the kitchen cross-contamination (a transfer of harmful bacteria from one place to another). During a concurrent observation and interview on 6/4/2024 at 12:32p.m. with Dietary Manager (DM), it was observed there were two big garbage dumpsters full and overflowing and the lids were unable to be closed for both of the bins. Additionally, there were two extra carts in the front of the big dumpsters with disposable places with no lid. The DM stated the trash was picked up yesterday and will have another trash pickup on 6/4/2024. The DM stated the garbage bins are supposed to be sealed as it might attract flies, rodents, and cause infestation. During a review 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 interview and record review, the facility failed to identify unresolved quality deficiencies, some of which had been cited on previous surveys, and ensure actions were developed and implemented to attempt to correct the deficiencies through the quality assessment and assurance (QAA) process as evidenced by the severity and number of deficiencies cited involving sufficient staffing, significant medication error, providing medications as physician ordered, and maintaining medication in stock. This failure had potential to result in 54 of 54 residents residing in the facility not receiving services and care they need. Findings: During a review of the facility's Census and Direct Care Service Hours Per patient Day (DHPPD), dated from 4/1/2023 to 4/30/2024, the DHPPD indicated as follow: a. 4/15/2024-Actual CNA DHPPD 2.24 b. 4/16/2024- Actual CNA DHPPD 2.40 c. 4/17/2024- Actual CNA DHPPD 2.40 d. 4/19/2024- Actual CNA DHPPD 2.29 e. 4/20/2024- Actual CNA DHPPD 2.06 During an interview on 6/6/2024, 3:21 p.m., with RNA 1, RNA 1 stated, there are two RNAs in the facility and they…

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 two of 18 sampled resident (Resident 7 and Resident 44 ) were offered an advance directive (a legal document that specifies what actions should be taken for your health if you are no longer able to make decisions for yourself) and provided information regarding the advance directive. This failure had the potential to violate the residents' and/or the representatives' right to be fully informed of the option to formulate their advance directives and had the potential to cause conflict with the residents' wishes regarding health care. Findings: 1. During a review of Resident 7 admission Record, the admission record indicated Resident 7 was originally admitted to the facility on [DATE] and re-admitted to the facility o 4/27/2023 with diagnoses of but not limited to chronic obstructive pulmonary disease (COPD-a chronic inflammatory lung disease that causes obstructed airflow from the lungs), diabetes (a group of diseases that affect how the body uses…

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 a. Ensure one of 18 sampled residents (Resident 7)'s assessment entries on the Minimum Data Set (MDS- an assessment and care screening tool) related to the section in the MDS called Swallowing/Nutrition Status was accurately documented to reflect Resident 7's nutritional approaches. b. To conduct an accurate fall assessment for one of three sampled residents (Resident 36). This failure had the potential to result in a negative effect on Resident 7 and Resident 36's plan of care and delivery of necessary services, care and treatment. Findings: a. During a review of Resident 7 admission Record, the admission record indicated Resident 7 was originally admitted to the facility on [DATE] and re-admitted to the facility o 4/27/2023 with diagnoses of but not limited to chronic obstructive pulmonary disease (COPD-a chronic inflammatory lung disease that causes obstructed airflow from the lungs), diabetes (a group of diseases that affect how the body uses 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure, residents did not develop an adverse effect (an undesired effect of a medication or other type of treatment) due to receiving antipsychotic medications used to treat mental health conditions like schizophrenia (a serious mental disorder in which people interpret reality abnormally), bipolar disorder (a mental health condition that causes extreme mood swings that include emotional highs and lows), Seroquel, Risperdal and Ativan and for two of 18 sampled residents (Resident 18 and Resident 25). The facility failed to: 1. Ensure Resident 25, who had a physician's order to discontinue administration of Seroquel 25 milligrams ([mg]- a unit of measure of weight) dated 5/14/2024, was not administered Seroquel for an additional 20 days, a total of 20 extra doses from 5/14/2024 to 6/4/2024. 2. Ensure the licensed nurses monitored Resident 25 for psychotropic medication adverse effects including Seroquel and Depakote Sprinkles. 3. Ensure…

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 free from significant medication errors for two of seven sampled residents (Residents 26 and 209) by failing to administer metoprolol tartrate (a medication used to treat high blood pressure [BP]), clonidine (a medication used to treat high blood pressure), metoprolol succinate (a medication used to treat high blood pressure) extended release (ER - a medication formulation aiding the medication release slowly over time), apixaban (a medication used to prevent and reduce the risk of blood clot), and furosemide (a medication for heart failure and high blood pressure) in accordance with physician orders or professional standards of practice. These failures had the potential to result in significant medical complications resulting in hospitalization or death due to stroke (a medical condition when something blocks blood supply to brain or when blood vessel in the brain bursts), poor blood pressure control, edema (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 implement infection control measures by failing to: 1.Ensure Certified Nurse Assistant (CNA) 1 performed hand hygiene during and after caring for Resident 31. 2.Ensure CNA 2 wore proper Personal Protective Equipment ([PPE]- equipment used to prevent or minimize exposure to hazards) during the care of Resident 6 who was on enhanced precaution (a level of infection control that requires interventions such as wearing gloves and a gown) and exposed Resident 211 who was not on any precaution for possible cross contamination (the physical movement or transfer of harmful bacteria from one person, object or place to another). These failures resulted in compromised infection control measures to prevent the spread of Covid-19 (a contagious disease caused by the virus) and other infections among residents, staff, and visitors of the facility. 3.observe infection control measures by not practicing hand hygiene, disinfecting their work area, or wearing…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure one of 18 sampled residents (Resident 7)'s documentation of a significant change of condition (COC-documentation of a resident's sudden change from baseline) was done when Resident 7 was transferred to the hospital. This failure had the potential to result in resident 7 not receiving the appropriate care and necessary treatment. Findings: During a review of Resident 7 admission Record, the admission Record indicated Resident 7 was originally admitted to the facility on [DATE] and re-admitted to the facility o 4/27/2023 with diagnoses of but not limited to chronic obstructive pulmonary disease (COPD-a chronic inflammatory lung disease that causes obstructed airflow from the lungs), diabetes (a group of diseases that affect how the body uses blood sugar), chronic kidney disease (a gradual loss of kidney function that occurs over a period of months to years, or abnormal kidney structure) and cardiomyopathy (diseases of the heart muscles). During a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow through and accurately assess with the Preadmission Screening and Resident Review (PASARR- a comprehensive evaluation that ensures people who have been diagnosed with serious mental illness, intellectual, and/or developmental disabilities are able to live in the most independent settings while receiving the recommended care and interventions to improve their quality of life) level I and level II evaluation for four of four sampled residents (Resident 22, Resident 6, and Resident 1) to determine the facility's ability to provide the special need of the residents. This deficient practice placed Resident 22, Resident 6, and Resident 1 at risk of not receiving the necessary care and services they need. Findings: A. During a review of Resident 22's admission Record, the admission Record indicated, Resident 22 was admitted to the facility on [DATE] with diagnosis including anxiety disorder (persistent and excessive worry that interferes with daily…

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 a baseline care plan for two of three sampled residents (Resident 25 and Resident 36) by: 1. Failing to address multiple falls and a fall with injury by initiating an at risk for fall care plan, the use of psychotropic medication (medication capable of affecting the mind, emotions, and behavior) in the care plan for Resident 25 who was on Ativan (generic name Lorazepam is used to treat anxiety) Rexulti (generic name Brexpiprazole is an antipsychotic (medication used to treat a collection of symptoms that affect your ability to tell what's real and what isn't) medication to treat major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest) and dementia (a group of symptoms that affects memory and thinking)-related agitation. 2. Failing to initiate an at risk for fall care plan and address Resident 36's history of seizures. These deficient practices had the potential to negatively affect 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 ensure and implement their policy and procedure on fall prevention for one of three sampled residents (Resident 52) by: 1. Failing to develop person-centered interventions/approaches addressing Resident 25's high risk for falls. 2. Failing to revise the fall risk care plan for multiple falls, doing a post fall assessment, and doing proper neurological checks (assessing mental status and level of consciousness). 3. Failing to identify potential risk factors of psychotropic medications (any medications that affect behavior, mood, thoughts, or perception) Resident 25 was taking. This deficient practice resulted in Resident 25 having six falls between 4/11/2024 to 5/24/2024 with a bump and bruising on the right eyebrow. During a review of Resident 25's admission Record, the admission record indicated Resident 25 was admitted to the facility on [DATE] with diagnoses including cerebral infarction (disrupted blood flow to the brain caused by issues with the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure one of 18 sampled residents (Resident 47) received the pneumonia (an infection that inflames the air sacs in one or both lungs) vaccine (a substance introduced into the system to help the body fight against infections). This failure resulted in enhancing the potential for Resident 47 developing pneumonia and getting hospitalized on [DATE] and again on 5/6/2024. During a review of Resident 47's admission Record, the admission record indicated Resident 47 was originally admitted to the facility on [DATE] with diagnoses of but not limited to contractures (permanent shortening of muscle fibers, leading to muscle and joint stiffness), tachycardia (an abnormal heart rate over 100 beats a minute), dysphagia (difficulty in swallowing), and anoxic brain damage (damage to the brain due to a lack of oxygen supply). During a review of Resident 47's History and Physical (H&P), dated 7/26/2023, the H&P indicated, Resident 47 does not have the capacity to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to provide sufficient staffing to accommodate residents' needs for two out of four sampled residents (Resident 1, Resident 2). This deficient practice had the potential for call lights not to be answered promptly, showers not being given, and a decrease in Resident ' s quality of care. Findings: During a review of Resident 1 ' s admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses of essential hypertension (high blood pressure), reduced mobility (ability to move around freely), and history of falling. During a review of Resident 1 ' s Minimum Data sSt (MDS, a standardized assessment and care screening tool) dated 11/21/2023, the MDS indicated Resident 1 had no cognitive impairments (no confusion or problems with memory and judgement). During a review of Resident 2 ' s admission Record, the admission Record indicated Resident 2 was admitted to the facility on [DATE] with diagnoses of history of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one out of three sampled residents (Resident 1), who had history of wandering (traveling aimlessly from place to place) was provided with a one to one (1:1) sitter at all times. This deficient practice had the potential for Resident 1 to elope (leave the facility without staff knowledge, may present an imminent threat to the patient's health or safety), exposing her to dangerous elements outside such as harsh weather, accident, and dehydration and starvation. Findings: During a review of Resident 1 ' s admission Record, the admission Record indicated Resident 1 was initially admitted to the facility on [DATE] and was readmitted [DATE] with diagnoses of Alzheimer ' s disease (a brain disorder that causes progressive memory loss and cognitive [thinking, reasoning, or remembering] decline) and unspecified psychosis (symptoms that affect the mind, where there has been some loss of contact with reality). During a review of Resident 1 ' s Minimum Data…

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: 1.Ensure one of three sampled residents (Resident 1), who had a history of wandering (a person that roams around and becomes lost or confused about their location) was supervised and monitored. 2. Ensure Resident 1 had an air tag (small tracking device used to track the location) in place as stated in Resident 1 ' s care plan. 3.Ensure facility implement interventions for Resident 1's risk of elopement and wandering behavior. These failures resulted in Resident 1 leaving the facility unsupervised on 11/2/2023, entering another Resident 2 ' s room uninvited on 10/26/2023, holding Resident 2 on the shoulder making Resident 2 nervous and screaming inside her room and multiple incidents where Resident 1 was found inside another resident ' s room. Findings: During a review of Resident 1 ' s admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including Alzheimer ' s disease, (a brain disorder that slowly destroys…

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, for one out of three sampled resident's (Resident 1): a. Develop resident centered interventions for the care plan for noncompliance. b. Implement the comprehensive care plan for pain by not to monitoring and recording the Resident 1's pain characteristic, quality, location, onset, duration, aggravating factors, and relieving factors. This deficient practice had the potential to negatively affect Resident 1's pain management and care. Findings: During a review of Resident 1's admission Record, the admission record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including hemiplegia (one sided weakness) and hemiparesis (unable to move one side of body) following cerebral infarction (lack of blood flow to the brain), chronic kidney (organ that filters waste out of the blood) disease (damage to kidneys), and neuropathy (damage to nerves leads to pain, weakness, numbness and tingling). During a review of Resident 1's Minimum…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to conduct an interdisciplinary team (IDT-health care providers who have knowledge of the residents needs and are involved in the resident's care) care conference discussing one of three sampled resident's (Resident 2) rehabilitation (set of interventions designed to optimize functioning and reduce disability in individuals with health conditions in interaction with their environment) plans after physical therapy ([PT] care that aims to ease pain and help residents function, move, and live better) was discontinued on 8/8/2023. This failure resulted in Resident 2 feeling frustrated and not involved in their plan of care. Findings: During a review of Resident 2's admission record, the admission record indicated Resident 2 was admitted to the facility on [DATE] with diagnoses including morbid obesity (some 80-100 pounds [unit of measurement] over their ideal body weight), lack of coordination (prevents person from being able to control position of their arms…

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 Certified Nurse Assistant (CNA) 1, failed to perform hand hygiene (a general term for cleaning your hands by hand washing with soap and water or the use of an antiseptic hand rub, also known as alcohol-based hand rub (ABHR) after gloves were removed and prior to entering another resident room. This failure placed all the residents, and staff risk for cross contamination (the physical movement or transfer of harmful bacteria from one person, object, or place to another), and had the potential for spread of infection. Findings: During a concurrent observation and interview on 8/16/23 at 10:00 am with CNA 1, observed CNA 1 removed her gloves and exited the resident room. CNA 1 re enter the room and grabbed a plastic bag containing a razor she got from resident's bedside table. CNA 1 exited the room and pushed trash cart and dirty linen cart down the hallway. CNA 1 proceeded to enter another resident room without doing hand hygiene. CNA 1 stated she failed to perform hand hygiene because she did not perform patient care to 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to update the care plan for one of four sampled residents (Resident 1) after Resident 1 hit Resident 2 on the arm unprovoked. This deficient practice resulted in Resident 1 not having interventions to address her behaviors and placed other residents at risk for repeated resident to resident altercations. Findings: A review of Resident 1 ' s admission Record (AR) indicated Resident 1 was admitted to the facility on [DATE] and last readmitted on [DATE] with diagnoses including Alzheimer ' s disease (a progressive disease beginning with mild memory loss and possibly leading to loss of ability to carry on a conversation and respond to the environment), and schizophrenia (serious mental illness that affects how a person thinks, feels, and behaves). A review of Resident 1's history and physical (H/P), indicated the resident had no capacity to understand and make decisions. A review of Resident 1's Minimum Data Set (MDS) a standardized assessment…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to supervise Resident 1 with a known history of striking out to prevent Resident 2 from being hit. This deficient practice resulted in Resident 2 physically hit at the left arm and placing 55 other residents of the facility at risk for abuse. Findings: A review of Resident 1 ' s admission Record (AR) indicated Resident 1 was admitted to the facility on [DATE] and last readmitted on [DATE] with diagnoses including Alzheimer ' s disease (a progressive disease beginning with mild memory loss and possibly leading to loss of ability to carry on a conversation and respond to the environment), and schizophrenia (serious mental illness that affects how a person thinks, feels, and behaves). A review of Resident 1's history and physical (H/P), indicated the resident had no capacity to understand and make decisions. A review of Resident 1's Minimum Data Set (MDS) a standardized assessment and care-screening tool, dated 7/26/2023, indicated Resident 1 '…

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.