Intercommunity Healthcare & Rehabilitation Center

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) received treatment and care in accordance with professional standards of practice by failing to ensure Resident 2 was not administered Carvedilol (used to treat high blood pressure) when Resident 2's systolic blood pressure (SBP) was less than 110 and when heart rate (HR) was lower than 60 beats per minute (BPM) as ordered by physician. This deficient practice had the potential to cause Resident 2 hypotension (blood pressure is too low) with dizziness and fainting which can lead to fall and injuries. Findings: During a review of Resident 2's admission Record dated 3/17/2025, the admission record indicated the resident was admitted to the facility on [DATE], and was readmitted on [DATE], to the facility with diagnoses of, but not limited to, Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), Atrial-Fibrillation (an irregular heartbeat, 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 observation, interview, and record review, the facility failed to ensure residents on tube feeding received treatment and care in accordance with professional standards of practice by failing to:1. Elevate the head of the bed while receiving formula through the gastrostomy tube ([GT] - a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems) for one of three sampled residents (Resident 40). This deficient practice had the potential to cause aspiration (inhalation of foreign materials) that could lead to pneumonia (lung infection) for Resident 40. Findings:During an observation on 7/22/2025 at 10:13 a.m. in Resident 40's room, Resident 40's was in bed lying flat on her back while the TF was running.During a review of Resident 40's admission Record (front page of the chart that contains a summary of basic information about the resident), the admission Record indicated, Resident 40 was initially admitted to 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 observation, interview, and record review, the facility failed to label and properly disposed discontinued medications per the facility's policy.This deficient practice had the potential to result in the residents accidentally ingesting unknown medications and increased the risk of diversion (any use other than that intended by the prescriber) of unknown medications.Findings:During a concurrent observation and interview on [DATE], with Licensed Vocational Nurse (LVN) 4, in medication storage room for station 1 and 2, there was an unlocked discontinued medication storage cabinet observed with 24 opened and unlabeled medications in a plastic cup inside of the cabinet. There was no pharmaceutical waste bin (a container, often color-coded, designed for the safe disposal of unused, expired, or contaminated medications) observed nearby. LVN 4 stated that all discontinued medications should be labeled and disposed of in blue pharmaceutical waste bins for safety to prevent accidental ingestion. LVN 4 stated,…

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 that one of three sampled residents (Resident 2), had monitoring for complications related to Xarelto (an anticoagulant medication used to treat and prevent harmful blood clots) a medication that may increase the risk of bleeding. This deficient practice placed Resident 2 at risk of bleeding a possible side effect of anticoagulant medication. Findings: During a review of Resident 2's admission Record dated 3/17/2025, the admission record indicated the resident was admitted to the facility on [DATE] and was readmitted on [DATE] to the facility with diagnoses of, but not limited to, Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), Atrial-Fibrillation (an irregular heartbeat, or arrhythmia that can lead to blood clots, stroke, heart failure and other heart-related complications). During a review of Resident 2's Minimum Data Set (MDS-a resident assessment tool) dated 4/12/2025, 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.

Based on observation, interview, and record review the facility failed to follow up on dental services for one of six sampled residents (Resident 32).This deficient practice had the potential to place Resident 32 at risk for poor self-esteem and weight loss.Findings:During a review of Resident 32's admission Record (Face Sheet), the admission Record indicated Resident 32 was admitted to the facility 6/6/2024 with diagnoses of moderate protein-calorie malnutrition (inadequate intake of food) and dysphagia (difficulty swallowing).During a review of Resident 32's Minimum Data Set (MDS, a resident assessment tool) dated 6/3/2025, the MDS indicated Resident 32 was cognitively (mental processes that relate to acquiring knowledge and understanding through thought, experience, and the senses) intact.During a review of Resident 32's Dental Notes dated 6/21/2024, the Dental Notes indicated Resident 32 was evaluated by the dentist and was noted to be edentulous (no teeth) and had old dentures with an inadequate fit. The Dental Note indicated Resident 32 requested new dentures with smaller…

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 foods that aligned with one of six sampled residents (Resident 51's) ethnic (of or relating to large groups of people classed according to common racial, national, tribal, religious, linguistic [language], or cultural origin or background) preferences. This deficient practice resulted in Resident 51 disliking the food provided and at times refused to eat meals provided by the facility. Findings:During a review of Resident 51's admission Record (face sheet), the admission Record indicated Resident 51 was admitted to the facility 11/2/2025 with diagnosis including major depressive disorder (persistent feelings of sadness or loss of interest) and anxiety disorder (mental disorder characterized by significant and uncontrollable feelings of worry and fear). The admission Record indicated Resident 51's primary language was Spanish.During a review of Resident 51's Minimum Data Set (MDS, a resident assessment tool) dated 4/30/2025, the MDS 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 develop and/or implement an individualized person-centered care plan to meet the residents' needs for one of three sampled residents (Resident 5) by failing to develop an individualized/person-centered care plan to address Resident 5's preferred activities. This deficient practice had the potential to negatively affect the delivery of necessary care and services.Findings:During a review of Resident 5's admission Record dated 5/19/2016, the admission record indicated the resident was admitted to the facility on [DATE] and was readmitted on [DATE] to the facility with diagnoses of, but not limited to, chronic respiratory failure (lungs gradually lose their ability to effectively exchange gases oxygen and carbon dioxide). Dependent on ventilator (a medical device to help support or replace breathing) status.During a review of Resident 5's Minimum Data Set (MDS-a resident assessment tool) dated 4/18/2025, section C indicated Resident 3's cognition level is…

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, Licensed Vocational Nurse (LVN 2) failed to rinse G-tube (gastrostomy tube, a feeding tube inserted through the abdominal wall directly into the stomach) syringe after medication administration on one of two sampled residents (Resident 1). This deficient practice had the potential to spread infection. Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1's was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including gastroesophageal reflux disease (digestive disorder where stomach acid frequently flows back into the esophagus, causing irritation and symptoms like heartburn). hemiplegia (complete paralysis on one side of the body) and hemiparesis (hemiparesis refers to partial or weakness on one side of the body), dysphagia (difficulty swallowing) and gastrostomy tube (GT- a soft tube surgically inserted directly into the stomach to administer medication, fluids and nutrition)…

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 re-admit one of three sampled residents (Resident 1), after Resident 1 was transferred on 10/1/2024 to a General Acute Care Hospital (GACH) for evaluation of a possible small bowel obstruction (SBO-a blockage in the small intestine that prevents food, liquids, gas and stool from passing through normally), and the GACH cleared Resident 1 to return to the facility on [DATE]. This deficient practice resulted in Resident 1 being unable to return to the skilled nursing facility (SNF) that has been considered his home, for about 12 months, once deemed appropriate for transfer back to the SNF. Resident 1 had an unnecessarily prolonged stay of 14 days at the GACH placing Resident 1 at risk for unmet care needs, disorientation, confusion, psychosocial harm from being displaced and risk of acquiring infections. Findings: During a review of Resident 1 ' s admission Record dated 10/25/2024, the admission Record indicated Resident 1, was admitted to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to observe infection control measures on nine of 20 sampled residents (Resident 3,17, 20, 22, 33, 37, 60, 68 and 76) by failing to: a.Ensure the soiled tracheostomy (an opening surgically created through the neck into the trachea [also known as windpipe] to allow air to fill the lungs) supplies of (Resident 68 was disposed properly by the licensed staff. b.Ensure Certified Nursing Assistant (CNA) 3 wore personal protective equipment (PPE, specialized clothing or equipment worn by an employee for protection against infectious materials) who was on Enhanced Barrier Precaution (EBP, infection control intervention using gown and gloves during high contact resident care activities designed to reduce the transmission of multi-drug resistant organisms) during mealtime for Resident 33. c.Ensure physician observed Contact Isolation precautions (precautions used for disease, germs and infection that are spread by touching the patient and items 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 follow through with the Preadmission Screening and Resident Review (PASARR-a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care) recommendation for three of three sampled residents. Facility failed to a. Obtain a PASARR Level II evaluation for Residents 54 and 36 and Level I evaluation for Resident 4 during admission. This deficient practice had the potential to result in inappropriate placement and unidentified specialized services for three of three sampled residents (Resident 36,54 and 4). Findings: a. During a review of Resident 54's admission Record (face sheet), the face sheet indicated Resident 54 was admitted to the facility on [DATE] and readmitted on [DATE]. Resident 54's diagnoses included metabolic encephalopathy (chemical imbalance in the blood affecting the brain), atrial fibrillation (irregular heartbeat), hypertension (high blood pressure), dementia (a decline 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 interview and record review, the facility failed to ensure a plan of care was formulated for two of three sampled residents: a.Resident 50 who was prescribed an anticoagulant medication (a medication used to lower the risk of stroke or blood clot in people); and b.Resident 68 who was prescribed an anti-anxiety medication (a medication used to treat excessive worry and feelings of fear, dread, and uneasiness). These failures have the potential for delayed in the delivery of care and services to Resident 50 and Resident 68. Findings: a. During a review of Resident 50's admission Record (Face sheet), the face sheet indicated Resident 50 was admitted at the facility on 2/21/2024 and was readmitted on [DATE] with a diagnosis including chronic respiratory failure (a condition that usually happens when the airways that carry air to the lungs become narrow and damaged), anxiety disorder (a condition in which a person has excessive worry and feelings of fear, dread and uneasiness) and long-term use 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 observation, interview, and record review the facility failed to ensure measurement of siderails to the bedframe and mattress were implemented and documented prior to installation of a full side rails to the bed of four of four sampled residents (Resident 55 and Resident 69, 14 and 80). This failure had the potential to physical harm from possible entrapment (when a person is trapped by the bed rail in a position they cannot move from) from the use of bed rails for Resident 55 and Resident 69, 14 and 80. Findings: a.During a record review of Resident 55's admission Record (Face sheet), the face sheet indicated Resident 55 was admitted at the facility on 4/26/2022 and was readmitted on [DATE] with diagnoses including chronic respiratory failure (a condition that usually happens when the airways that carry air to the lungs become narrow and damaged) and traumatic brain injury (a condition that occurs when a sudden trauma, such as a blow or jolt to the head, causes damage to the brain). During a review 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 non-pharmacological interventions (intervention that does not primarily use medication) were ordered for three of three sampled residents (Resident 50,68, and 75) who were prescribed psychotropic (any drug or substance that affects how the brain works and causes changes in mood, awareness, thoughts, feelings, or behavior) medications. This failure had the potential to result in use of unnecessary psychotropic drugs for Resident 50, 68, and 75 that can lead to side effect (effect of a drug or other type of treatment that is in addition to or beyond its desired effect) and adverse drug reaction (unintended, harmful events attributed to the use of medicines). Findings: a. During a review of Resident 50's admission Record (Face Sheet) the face sheet indicated Resident 50 was admitted on [DATE] and was readmitted on [DATE] at the facility with diagnoses including chronic respiratory failure (a condition that usually happens when the airways that 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.

Based on observation, interview and record review, the facility failed to ensure a dietary aide was knowledgeable on how to identify the amount of chlorine level in the dish washing machine by failing to: a. Ensure the chlorine level is 50 to 100 parts per million (PPM, concentration of chlorine used to sanitize dishes) of the dishwashing machine after the final rinse. b. Ensure the dish washing machine was checked and monitored for the right temperature of water and correct amount of chlorine before using. These failures had the potential to place residents at risk for food-borne illnesses due to improper testing of chlorine level of the dishwashing machine. Findings: a. During a concurrent kitchen tour observation and interview on 8/19/2024, at 8:45 a.m. with Dietary Aide (DA 1), observed DA 1 ran the dishwashing machine and took a test strip to check the chlorine level of the water on the surface of a pitcher and resulted to 100 ppm. DA 1 stated the facility is using low temperature dish washing machine and she stated the chlorine level should be 200 ppm. DA 1 took another test…

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 change of condition (COC, major decline or improvement in a resident's status that will not resolve itself without intervention) for one of eight sampled residents (Resident 60) with limited range of motion (ROM, full movement potential of a joint [where two bones meet]) concerns by failing to: 1.Report Resident 60's decline in ROM of both wrists and both hands to the physician in accordance with the facility's job description titled, Restorative Nursing Assistant, and policy and procedure tilted, Change in a Resident's Condition or Status. This failure resulted in Resident 60 from not receiving interventions to improve ROM, including intervention to prevent contractures (condition of shortening and hardening of muscles, tendons, or other tissue, often leading to joint stiffness). Findings: During a review of Resident 60's admission Record, the admission Record indicated Resident 60 was initially admitted to the facility on [DATE]…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure an accurate Minimum Data Set Assessment (MDS, a standardized assessment and care screening tool) for restraint who is using full side rails for one of one sampled resident (Resident 14). This deficient practice has the potential to result in Resident 14 not receiving the necessary care and treatment. Findings: During a review of the Face sheet dated 8/23/24 indicated Resident 14 was admitted on 9/29/ 20, and readmitted 11/ 20/20, with diagnosis including Epilepsy (a brain disorder that causes recurring, unprovoked seizures), intellectual disabilities, convulsions (a sudden, violent, irregular movement of a limb or of the body, caused by involuntary contraction of muscles) During a review of the History & Physical (H&P) dated 10/13/23, indicated Resident 14 does not have the capacity to understand and make decisions. During a review of the Active Order Summary Report dated 8/1/24 indicated Resident 14 had an order for [Restraint]…

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 foot care to one of four sampled residents(Resident 38) by: 1.Failing to check and monitor if a podiatry service ( diagnose and treat any foot or ankle problem) is needed for Resident 38 's toenails who had thick and overgrown toenails. This failure had the potential to cause discomfort and for Resident 38's toenails to cut into the skin due to their length. Findings: During a review of Resident 38's admission Record, the admission Record indicated the resident was initially admitted on [DATE] and was readmitted on [DATE] to the facility with diagnoses that included unspecified dementia(loss of cognitive functioning such as thinking, remembering and reasoning which can affect and interfere with daily life and activities), history of traumatic brain injury(brain dysfunction caused by an outside force usually a violent blow to the head) and polyneuropathy( condition in which person's peripheral nerves are damaged). During a review 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 observation, interview, and record review, the facility failed to accurately account for the use of a controlled substance (a medication with a high potential for abuse) on Controlled Drug Record (CDR- a log signed by the nurse with the date and time each time a controlled substance is given to a resident) for one resident (Resident 44) in one out of three medication carts reviewed (Middle Medication Cart Sub-Acute). This failure had the potential to result in unintended use of Tramadol (a controlled substance used to relieve and manage pain) and placed the facility and Resident 44 at risk for medication errors, drug loss and diversion. Findings: During a review of Resident 44's admission Record (a document containing demographic and diagnostic information), dated 8/22/2024, the admission record indicated Resident 44 was originally admitted to the facility on [DATE] and readmitted on [DATE], with diagnosis including, but not limited to, polyneuropathy (a medical term to describe weakness, numbness and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to remove an expired insulin (a medication used to treat high blood sugar) per manufacturer's requirements, affecting one resident (Resident 56) in one of three inspected medication carts (Medication Cart 3 Back Cart.) This failure had the potential to result in hyperglycemia (a medical term used to describe high blood sugar) and/or hospitalization for Resident 56 because of receiving an expired insulin that could have been ineffective or toxic due to improper storage conditions. Findings: During a review of Resident 56's admission Record, dated 8/21/2024, the admission record indicated Resident 56 was originally admitted to the facility on [DATE] and readmitted on [DATE], with diagnosis including, but not limited to, Type 2 Diabetes Mellitus (a medical condition characterized by the inability to control blood sugar) without complications. During a review of Resident 56's Minimum Data Set ([MDS], a standardized assessment and care screening…

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: a. Ensure staff's personal items were not stored in the refrigerator and dry storage area. b. Ensure frozen food items were safely stored in the freezer. c. Ensure open food items are stored properly in the storage area. d. Ensure the [NAME] performed hand washing and change of glove after and before switching tasks in the kitchen. e. Ensure the drain area of ice machine was clean and free of grime. These failures had the potential to expose residents to food-borne illnesses (any illness resulting from ingestion of food contaminated with bacteria, viruses, or parasites) and put residents at risk for cross contamination (unintentional transfer of harmful bacteria from one object to another). Findings: a. During an initial kitchen tour observation on 8/19/2024, at 8:13 a.m. a tumbler was stored in the reach in refrigerator. [NAME] (CK2) stated the tumbler belonged to a kitchen personnel and should not be stored in the refrigerator. During a concurrent observation and interview on 8/19/2024, at 8: 16 a.m. with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop and/or implement a care plan to meet the needs for one of three sampled residents (Resident 1). Resident 1 was assessed at risk for elopement (leaving an institution without notice or permission) and required a wander guard (a system used to alarm staff of a potential elopement of a resident) to be applied. This deficient practice resulted a wander guard not being applied to Resident 1 and Resident 1 eloping from the facility on 11/26/2023. This deficient practice had the potential for Resident 1 to sustain an injury and/or death. Findings: During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was originally admitted to the facility on [DATE] and was readmitted to the facility on [DATE] with diagnoses including dementia (a progressive loss of memory), unsteadiness on feet, and anxiety (extreme worry). During a review of Resident 1's Minimum Data Set ([MDS]) a standard assessment and care screening…

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 one of three sampled residents (Resident 1), who was assessed as at risk for elopement (leaving an institution without notice or permission) with a wander guard, per their elopement Risk Evaluation. This deficient practice resulted in Resident 1 eloping from the facility on 11/26/2023, without a wander guard in place. This deficient practice had the potential for Resident 1 to sustain an injury and/or death. Findings: During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was originally admitted to the facility on [DATE] and was readmitted to the facility on [DATE] with diagnoses including dementia (a progressive loss of memory), unsteadiness on feet, and anxiety (extreme worry). During a review of Resident 1's Minimum Data Set ([MDS]) a standard assessment and care screening tool), dated 11/10/2023, the MDS indicated Resident 1's cognitive (the ability to think, reason, and 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 the necessary care and services for one of four sampled residents (Resident 1) by: a. Failing to notify the responsible party of Resident 1 that an intruder entered Resident 1's room through the sliding door. This deficient practice potentially affected the delivery of care and services for Resident 1. b. Failing to assess Resident 1 for any physical or psychological problems after the intruder was observed in Resident 1's room. This deficient practice potentially placed Resident 1 at risk for unidentified harm that the intruder might have caused. Findings: During a review of Resident 2's Face sheet, the face sheet indicated, Resident 2 was admitted to the facility on [DATE] with the diagnosis chronic obstructive pulmonary disease (lung disease that causes restricted airflow and breathing problems), major depressive disorder, insomnia (inability of sleep), and anxiety. During a review of Resident 2's H&P, the H&P indicated that Resident 2 has…

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 sliding door for one (Resident 1) of four sampled resident's rooms were secured and locked after certified nurse assistant (CNA) 1 and licensed vocational nurse (LVN) 1 identified an intruder in the patio on 8/20/2023 at 10:10 p.m. This deficient practice resulted in the intruder entering the facility through Resident 1's sliding door and ending up in Resident 2's room on 8/20/2023 at 10:15 p.m., risking the health and safety of the residents and staff of the facility. Findings: During a review of Resident 1' s Face sheet (admission record), the face sheet indicated Resident 1 was admitted to the facility on [DATE] with the diagnosis of stroke (when blood flow to the brain is blocked or there is sudden bleeding in the brain) affecting the left side, major depressive disorder ( mood disorder that causes a persistent feeling of sadness and loss of interest and can interfere with daily life), and anxiety (persistent worry or fear that can…

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 abuse reporting and investigating policy and procedure by not reporting an allegation of physical abuse for one of four sampled resident (Resident 1) to the California Department of Public Health (CDPH) and the Ombudsman (a state agency that investigates, reports on, and assists in settling complaints against facilities). Resident 2 allegedly kicked at Resident 1 ' s feet and attempted to run a table into Resident 1's head. This deficient practice had the potential for the underreporting of abuse incidents, and a delay in investigation a physical abuse allegation, placing Resident 1 at risk for further abuse. 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 malignant neoplasm of brain (a cancer that spreads to other areas of the brain and spine) and cerebrovascular disease (group of disorders of the heart and 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 interview and record review, the facility failed to implement its abuse prevention policy by failing to submit the results of the investigation of an allegation of physical abuse to the state agency (California Department of Public Health [CDPH]) within 5 working days of the incident for one of four sampled residents (Resident 1). This deficient practice delayed the CDPH investigation of the allegation of physical abuse, potentially placing Resident 1 at risk for further abuse and violation of resident rights. 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 malignant neoplasm of brain (a cancer that spreads to other areas of the brain and spine) and cerebrovascular disease (group of disorders of the heart and blood vessels) with hemiplegia (paralysis of one side of the body) and hemiparesis (muscle weakness on one side of the body). During a review of Resident 1 ' s Minimum Data Set…

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 complete the comprehensive Minimum Data Set ([MDS] part of the U.S. federally mandated process for clinical assessment of all residents in Medicare-Medicaid certified nursing homes) within the regulatory timeframe for 21 of 22 sampled residents. This deficiency had the potential to negatively affect the provision of necessary care and services. Findings: During a review of the Centers for Medicare & Medicaid Services (CMS) public document titled, Long-Term Care Facility Resident Assessment Instrument ([RAI] a manual to offer clear guidance on how to complete the RAI [RAI -an assessment and planning tool] correctly) 3.0 User's Manual , dated October 2019, indicated that the MDS completion date must be no later than 14 days after the Assessment Reference Date ([ARD] refers to the last day of the observation [ process of observing resident in order to gain information] period that the assessment covers for the resident). During a review of the facility's undated policy and procedure (P/P) titled, Resident Assessment, the 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure: 1. One Influenza (Flu) vaccine vial was labeled with an open date. 2. One Tuberculin protein purified derivative [(PPD), protein used in the diagnosis of tuberculosis (bacterial infection of the lungs)] multidose vial was dated with an open date. 3. Resident 11's humulin insulin (medication used to control high blood sugar) vial was labeled with an open date. 4. Resident 368's Tramadol ([controlled substance] medication to treat moderate to severe pain) 50 milligram (mg) bubble pack (sealed card that packages doses of medication) was stored in the medication cart eight days after the resident was discharged from the facility. 5. Personal belongings for Resident 50 including a razor, coins, paper money, and one brass colored ring from an unidentified resident were not stored in the Station 1 medication cart. These deficient practices had the potential for licensed nurse to administer expired medications to residents, drug diversion…

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 two of 24 sampled residents (Residents 43 and 119), who required staff's assistance with meals, were cared for with dignity and respect by sitting and not standing while feeding the residents during mealtimes. This deficient practice potentially violated Residents 43 and 119 rights, and had the potential to negatively affect the resident's self-esteem and self-worth. Findings: a. During an observation on 12/7/2021 at 7:50 a.m., Certified Nursing Assistant 2 (CNA 2) was observed standing while feeding Resident 119 eggs. Resident 119, was observed slumped down in the bed and positioned on her right side facing the door of the room. CNA 2 stated Resident 119 kept sliding down after she was repositioned. CNA 2 stated standing while feeding residents was not the facility's standard of practice and stated she should have been seated while feeding Resident 119. During a review of Resident 119's admission Record (face sheet), the face…

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 staff interviews, the facility failed to complete a comprehensive assessment of each resident's functional capacity for 21 of 22 sampled residents. Cross Reference F640. This deficiency had the potential to incorrectly identify each resident's preferences and goals of care, and their functional and health status. Findings: During a review of the Centers for Medicare & Medicaid Services (CMS) public document titled, Long-Term Care Facility Resident Assessment Instrument ([RAI] a manual to offer clear guidance about how to use the RAI 3.0 User's Manual, dated October 2019, indicated the MDS completion date must be no later than 14 days after the Assessment Reference Date ([ARD] refers to the last day of the observation [process of observing resident in order to gain information] period that the assessment covers for the resident). During a review of the facility's policy and procedure (P/P) titled, Resident Assessment, (undated), the P/P indicated the following,The Minimum Data Set shall be completed for each resident regardless of payer status in facilities…

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 initiate and implement a comprehensive care plan for one of one sampled residents (Resident 21), after Resident 21 verbalized to the Director of Nursing (DON) and Administrator (ADM) that she felt uncomfortable interacting with Resident 56. This deficient practice resulted in Resident 21 wanting to avoid Resident 56 and not wanting to participate in group activities. Findings: During a review of Resident 21's admission Record, the admission Record indicated Resident 21 was admitted to the facility on [DATE]. Resident 21's diagnoses included chronic obstructive pulmonary disease ([COPD] group of diseases that cause airflow blockage and breathing-related problems), morbid obesity (100 pounds [unit of measurement] or more above ideal [healthiest weight for a person's height] body weight), generalized anxiety disorder (mental disorder causing difficultly in controlling anxiety [a feeling of worry, nervousness, or unease] and staying focused…

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 staff failed to ensure one of one sampled resident (Resident 45) received the minimum amount of oxygen required based on the resident's oxygen saturation (the amount of oxygen traveling through your body with your red blood cells) according to physician's order. This deficient practice had the potential to cause complications associated with oxygen therapy. Findings: During a review Resident 45's admission Record, the admission Record indicated the resident was admitted to the facility on [DATE], and readmitted on [DATE]. Resident 45's with diagnosis included congestive heart failure ([CHF] a condition in which the heart can not pump enough blood to the body's other organs, end-stage renal disease ([ESRD] the stage of renal impairment that appears irreversible and permanent, and requires a regular course of dialysis [treatment that filters and purifies the blood using a machine] or kidney transplantation to maintain life), dementia (long term and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to administer the correct dosage of Docusate Sodium (stool softener) capsule and properly dispose of a Lovenox (blood thinner) injection syringe into the biohazard container for one of six sampled residents (Resident 46). These deficient practices resulted in Resident 46 receiving an inaccurate dose of medication which had the potential to result in constipation (difficulty in emptying the bowels), and the improper disposal of a syringe had the potential to cause injury to staff. Findings: a. During a review of Resident 46's admission Record, the admission Record indicated the resident was admitted to the facility on [DATE], and readmitted on [DATE]. Resident 46's diagnoses included multiple sclerosis (chronic autoimmune [attack of healthy cells) disorder affecting movement, sensation, and bodily functions), functional quadriplegia (paralysis [inability to move] of all four limbs), long term use of anticoagulants (blood thinner), and heart…

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 infection control practices were followed by failing to don (put on) gloves and use an alcohol swab to disinfect a resident's abdomen prior to administering a subcutaneous (under the skin) injection. These deficient practices resulted in improper infection control practices performed by staff placing the residents at risk for infection. Findings: During an observation of a medication pass on 12/8/21 at 8:22 a.m. with Licensed Vocational Nurse 4 (LVN 4), LVN 4 was observed verifying the physician order on the electronic medication administration record (eMAR) for Lovenox injection 40 milligrams ([mg] unit of measurement) subcutaneously for Resident 46. LVN 4 administered the Lovenox injection in the right lower abdomen. LVN 4 did not perform hand hygiene, did not don gloves, and did not cleanse the abdomen with alcohol prior to administering the subcutaneous injection. During an interview on 12/8/21 at 8:42 a.m. with LVN 4, LVN 4 stated she was supposed to perform hand hygiene after she gave Resident 46…

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.