Norwalk Skilled Nursing & Wellness Centre, LLC

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to conduct Interdisciplinary Team (IDT- a group of medical professionals from different disciplines who work together to help a resident achieve their goals) meetings quarterly and as needed for one of three sampled residents (Resident 32).This failure resulted in Resident 32 and Resident 32's Responsible Party (RP) to be unaware of the plan of care and experience worry while waiting for mammogram (x-ray of the breast to detect signs of breast cancer) results for three months. Findings: During a review of Resident 32's admission record, the admission record indicated Resident 32 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including diabetes (a disorder characterized by difficulty in blood sugar control and poor wound healing), arthritis (a chronic progressive disease-causing inflammation in the joints and resulting in painful deformity and immobility), and kidney failure (condition where kidneys lose the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility staff failed to inform, and give notice of and information of a room change for one of three sampled resident's (Resident 75) . This deficient practice had the potential to affect Resident 75's self-esteem, self-worth, and cause confusion due to sudden room change. Findings:During a review of Resident 75's admission Record, the admission Record indicated Resident 75 was originally admitted to the facility on [DATE] with diagnoses including encephalopathy (a change in the brain function due to injury or disease) unspecified, Alzheimer's disease (a disease characterized by a progressive decline in mental abilities) unspecified and muscle weakness ( a reduced ability of muscles to generate force, making it harder to perform tasks that require effort, even with a maximal effort). During a review of Resident 75's history and physical (H&P) dated 11/9/2024, the H&P indicated resident 75 had fluctuating capacity to understand and make decisions. 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 there was an appropriate indication for the use of antipsychotic (medication used to treat mental illness) medication for one of six sampled residents (Resident 4) when Resident 4 had haloperidol (a medication used to treat certain mental health) on an as-needed (prn) basis without a specific diagnosis or documented justification for administration of haloperidol. The deficient practice had the potential for use of unnecessary medications on Resident 4.Findings: During a review of Resident 4's admission Record, the admission Record indicated the facility admitted Resident 4 on 9/30/2021, and readmitted on [DATE] with diagnoses including depression (a mental health condition characterized by persistent sadness and a loss of interest in activities that were once enjoyable) and vascular dementia (mental illness marked by a decline in thinking skills caused by condition that disrupt blood flow to the brain, leading to damage in blood vessels 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 interview and record review, the facility failed to accurately document the 's Minimum Data Set (MDS - a resident assessment tool) for one of five sampled residents (Resident 3). This failure had the potential to result in a delay of care or not receiving the appropriate services or treatment. Findings: During a review of Resident 3's admission record , the admission record indicated Resident 3 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including cellulitis (a skin infection that causes swelling and redness) of left finger, sepsis (a life-threatening blood infection), and contractures (a stiffening/shortening at any joint, that reduces the joint's range of motion) of hands, knees, and elbows. During a review of Resident 3's Minimum Data Set (MDS - a resident assessment tool), dated 4/3/2025, the MDS indicated Resident 3's cognition (ability to learn, reason, remember, understand, and make decisions) was severely impaired, and was dependent (helper does all…

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 person-centered care plan for one of two sampled residents (Resident 4) for the used of antipsychotic medication, haloperidol (a medication used to treat certain mental health illnesses) .This failure had the potential to result in inappropriate medication use, lack of behavioral monitoring, and increased risk of adverse drug effects. Findings: During a review of Resident 4's admission Record, the admission Record indicated the facility admitted Resident 4 on 9/30/2021, and readmitted on [DATE] with diagnoses including depression (a mental health condition characterized by persistent sadness and a loss of interest in activities that were once enjoyable) and vascular dementia (decline in thinking skills caused by condition that disrupted blood flow to the brain, leading to damage in blood vessels and brain tissue). During a review of Resident 4's physician Progress note, dated 5/19/2025, the progress note indicated Resident 4 did not have 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 two sampled residents' (Resident 40) care plan for smoking was updated. The deficient practice had the potential to result in poor quality of care and a delay in care and services.Findings:During a review of Resident 40's admission Record, the admission record indicated Resident 40 was originally admitted to the facility on [DATE] with diagnosis including acute respiratory failure (when the air sacs of the lungs cannot release enough oxygen into the blood), and congestive heart failure (CHF-a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling).During a review of Resident 40's Minimum Data Set ([MDS] a resident assessment tool) dated 5/16/2025, the MDS indicated Resident 40's cognition (ability to think and reason) was moderately impaired. The MDS indicated Resident 40 needed set up assistance when eating and oral hygiene supervision with toileting hygiene and partial assistance…

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 out of three residents (Resident 44) received assistance with toileting hygiene as needed. The deficient practice had the potential increased risk of skin breakdown and loss of dignity.Findings:During a review of Resident 44's admission Record, the admission Record indicated Resident 44 was readmitted to the facility on [DATE] with diagnoses including weakness, Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), and type 2 diabetes mellitus (disorder characterized by difficulty in blood sugar control and poor wound healing).During a review of Resident 44's Minimum Data set ([MDS], A resident assessment tool), dated 6/25/2025, the MDS indicated Resident 44's cognitive skills (functions your brain uses to think, pay attention, process information, and remember things) for daily decision-making was intact. The MDS indicated Resident 44 needed moderate…

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

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 with a diagnosis of Diabetes Meletus Type II (DM - a condition wherein the body can not regulate consumption and use of sugar which may result in poor wound healing) (Resident 28)'s:a. Physician was notifiedb. Change of condition (COC) was initiatedWhen Resident 28 had repeated hyperglycemic (level of blood sugar is higher are higher than normal [reference range70-99 milligram/deciliter (mg/dL- a unit of measurement used to express blood glucose levels) mg/dl]) events. This failure had the potential to result in delayed interventions, life-threatening emergencies such as diabetic ketoacidosis (a serious complication of diabetes where the body starts breaking down fat for energy instead of sugar at a very fast rate, producing substances that are harmful to the body), resulting in dehydration, potentially life -threatening conditions.Findings: During a review of Resident 28's admission Record, the admission Record…

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 accident risks and hazard interventions for two of Three sampled residents (Resident 38 and Resident 75) by: 1.Failed to ensure there was no smoking sign for a Resident 38 who is on oxygen.2.Failed to ensure Resident 75's bed was in the lowest position.3.Failing to ensure Resident 75 was placed in a low bed ( a bed frame designed to sit closer to the ground than a traditional bed). This deficient practice had the potential to result in injury . Findings:a.During a review of Resident 38's admission Record, the admission Record indicated, Resident 38 was initially admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease (a long term lung disease that blocks airflow to the lungs making it difficult to breathe), cardiomyopathy (a disease of the heart muscle that makes it harder for the heart to pump blood) and hypertension( high blood pressure). During a review of Resident 38's Minimum Data Set (MDS - a…

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

Facility failed to ensure that the urinary catheter bag (a urine drainage bag is a small bag that collects urine when you have a catheter inserted into your bladder) for one of three sampled residents (Resident 8) did not touch the floor.This failure had the potential to result in contamination of the catheter system and an increased risk of urinary tract infection (UTI an infection in your urinary system, which includes your kidneys, bladder, and urethra) or other complications for Resident 8.Findings: During a review of Resident 8's admission Record, the admission Record indicated the facility admitted Resident 8 on 3/18/2025 with diagnoses including multiple sclerosis (a chronic, often disabling disease that attacks the central nervous system [brain and spinal cord]), malignant neoplasm (a cancerous tumor) of bladder and Extended- spectrum beta-lactamase (ESBL an antibiotic resistant infectious organism). During a review of Resident 8's History and Physical (H&P), dated 3/19/2025, the H&P indicated, Resident 8 did not have the capacity to understand and make decisions. During a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement 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) orders, in accordance with physician orders and facility policy and procedures (P&P) titled, Feeding Tube - Medication Administered, for one of five sampled residents (Resident 28) by failing to ensure: (Cross Reference F726, F759 and F760) Resident 28's GT placement was checked by aspiration prior to medication administration via GT Resident 28's GT was flushed with prescribed amount of water before medication administration Resident 28 was administered medication via GT by gravity (utilizing the natural downward pull of gravity to deliver the medication into the stomach through the GT/feeding tube) in accordance with facility's P&P This deficient practices had the potential to increase the risk of medication errors, which could result in Resident 28's GT becoming…

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 necessary respiratory care services for two of three sampled residents (Resident 28 and 53) by not following the facility's own policy and procedure. a. For Resident 28, Facility failed to receive the physician's order for the use of oxygen and date on the nasal cannular (NC- a simple device used to deliver oxygen to the nose) while in use. b. For Resident 53, Facility failed to date on the NC while in use. a. During a review of Resident 28's admission Record, the admission Record indicated the facility admitted Resident 28 on 1/7/2022 and readmitted on [DATE] with diagnosis including chronic obstructive pulmonary disease (COPD-a common lung disease that makes it hard to breathe). During a review of Resident 28's History and Physical (H&P), dated 6/6/2025, indicated, Resident 28 did not have the capacity to understand and make decisions. During a review of Resident 28's Minimum Data Set (MDS- a resident assessment tool), dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure one of three hemodialysis ([HD]a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) residents (Resident 5) received dialysis care and services based on professional standards. The facility failed to:a. Ensure Resident 5's fluid intake was being monitored.b. Ensure Resident 5 was assessed after the resident returned from the dialysis center. These deficient practices had the potential to result in complications from dialysis like fluid overload, infection and low blood pressure. Findings:During a review of Resident 5's admission Record, the admission Record indicated Resident 5 was originally admitted to the facility on [DATE] with diagnoses including end stage renal disease (ESRD -irreversible kidney failure) and dependence on renal dialysis.During a review of Resident 5's Minimum Data Set (MDS), a resident assessment tool, dated 6/4/2025, 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.

Based on observation, interview, and record review, the facility failed to ensure Licensed Vocational Nurse (LVN) 2 was competent in administering medication via a gastrostomy tube (GT and/or Enteral Feeding Tube, a tube inserted through the abdomen that delivers nutrition and/or medication directly to the stomach) in accordance with the facility's policy and procedure (P&P) titled, Medication Administration with Enteral Formulas Competency Validation.This failure had the potential for the facility not to be able to assess the skills necessary to provide services to assure resident safety.Findings:During a concurrent interview and record review on 7/17/2025, at 2:54 p.m., with Director of Staff Development (DSD), reviewed Licensed Vocational Nurse (LVN) 2 employment file. DSD stated new hire staff are followed for hand hygiene. DSD stated she follows staff during competency review for simple medication pass observation with return demonstration. DSD stated GT/Feeding Tube medication administration requires a return demonstration and is documented on a form titled, Medication…

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 ensureA. Licensed Vocational Nurse (LVN) 2 failed to perform hand hygiene (hand washing using soap and water, and cleaning hands with waterless or alcohol-based hand sanitizers) for one of five sampled resident (Resident 28) during medication administration observation. This failure placed Resident 28 at risk for the spread of infection between residents and staff and had potential to result in cross contamination (physical movement or transfer of harmful bacteria from one person, object, or place to another). B. One of three residents (Resident 62)'s peripheral intravenous catheter IV ( [IV] a flexible tube inserted into a vein for medication administration) was labeled and dated . This deficient practice had the potential to result in the sterility infection at the IV site. Add to Based on: Findings: A. During a review of Resident 28’s admission Record, the admission Record indicated the resident was admitted to the facility on [DATE] 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 ensure one of three sampled residents (Resident 1), whose cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) was severely impaired, and who was assessed at risk for elopement (the act of leaving a facility unsupervised and without prior authorization), was monitored to prevent him eloping from the facility. This deficient practice resulted in Resident 1 eloping from the facility, on 4/1/2025 at approximately 7 p.m. Resident 1 was found by a good Samaritan on 4/2/2025, approximately 14 miles from the facility, he was transferred to a General Acute Care hospital (GACH) for evaluation before being readmitted to the facility on [DATE]. This deficient practice had the potential for Resident 1 to continue to be missing, injury and death. Findings: During a review of Resident 1's admission Record (Face Sheet), the Face Sheet 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 Certified Nursing Assistant (CNA) 1 was competent to use the mechanical lift (a device used to transfer a resident from one surface to another) to transfer a resident (Resident 1) from bed to shower chair in accordance with professional standards of practice. This failure resulted in Resident 1 falling from the sling and suffering a head injury when CNA 1 transferred Resident 1 from bed to shower chair without assistance from another staff member. Findings: During a review of Resident 1 ' s admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including morbid obesity (having too much body fat), dementia (a progressive state of decline in mental abilities) and chronic kidney disease (a long-term condition that occurs when the kidney are damaged and can ' t filter blood properly). During a review of Resident 1 ' s History and Physical (H&P) dated 5/10/2024, the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to maintain and calibrate (the process than ensures the reading and functionality of a device is accurate and in full working order) on 2 of 5 mechanical lifts (a device used to transfer residents from a bed to a chair or other similar places) mechanical lift 1 and mechanical lift 2 for use to transfer residents of the facility from one surface to another in the facility. This deficient practice had the potential to cause injury to any resident if the mechanical lift that was used to determine the weight of the resident was inaccurate. The inaccurate weight of the resident could lead to the wrong sling being used to transfer residents based on the height and weight of the resident. Findings: During a concurrent observation and interview on 11/27/2024 at 10:30 a.m. with the Maintenance Supervisor (MS), Restorative Nursing Assistant (RNA) 1 and RNA 2 and the Director of Nursing (DON), the RNAs are demonstrating the use of the mechanical lift 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure the comprehensive care plan indicating two- person assist with using a mechanical lift (a device that helps safely transfer people with limited mobility from one place to another) was followed for one of three sampled residents (Resident 1), This deficient practice resulted in Resident 1 sliding out of the mechanical lift's sling and sustaining a bump on the right parietal (located near the back and top of the head) area of the head. Findings: During a record review of the admission Record for Resident 1, the admission Record indicated Resident 1 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of morbid obesity (having too much body fat), dementia (a progressive state of decline in mental abilities) and chronic kidney disease (a long-term condition that occurs when the kidney are damaged and can't filter blood properly). During a record review of Resident 1's History and Physical (H/P) dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to ensure one of five sampled resident's (Resident 1) debit and credit cards were documented on their Personal Effects Inventory form, Resident 1 was made aware of the risk involved in keeping her debit and credit cards at her bedside and Resident 1 was offered a place to safely keep her debit and credit cards. This deficient practice resulted in Resident 1 being unaware of her rights as it pertained to her personal valuables and it had the potential for Resident 1's personal belongings to be lost, stolen and for her funds to be inappropriately used by unauthorized persons. 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]. During a review of Resident 1's Minimum Data Set ([MDS] a standardized assessment and care screening tool), dated 9/9/2024, the MDS indicated Resident 1 was able to make decisions that were reasonable…

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 an observation, interview, and record review the facility failed to ensure facility staff including, Social Service Director, (SSD), Registered Nurses (RNs), Licensed Vocational Nurses (LVNs) and certified nursing assistants (CNAs) had competencies needed to care for residents with mental disorders and psychosocial disorders) for 38 sampled residents (Resident 1). The facility failed to: 1. Intervene when Resident 1 was observed sobbing (crying spells) and was accusing CNA 1 of putting poison in his water pitcher on 9/14/2024 at 12:15 a.m. This deficient practice resulted in a lack of care plan interventions to address Resident 1's symptoms of depression and Resident 1 did not receive the necessary care, services, and interventions to address Resident 1's emotional, behavioral, and psychosocial (support given to help meet the mental, emotional, social, and spiritual needs of patients) needs. Resident 1 had delusional thoughts and was crying and upset. Four hours later, Resident 1 committed suicide by…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review the facility's Quality Assurance Performance Improvement (QAPI, a data driven proactive approach to improvement used to ensure services are meeting quality standards) failed to identify resident care issues, develop, implement appropriate plans of action, and evaluate measures necessary to provide behavioral health care and services for the treatment of the resident's emotional and mental condition by ensuring: 1.Resident 1 who had a diagnosis of depression and history of suicidal thoughts from previous admission on [DATE] was assessed, monitored closely and primary care physician notified after observed having crying spells, anxiety (feeling of uneasy and worried), fear and verbalized Certified Nursing Assistant (CNA )1 put poison in his water pitcher on 9/14/2024 at 12:15 a.m. This failure resulted in Resident 1 not receiving the necessary care and services to address Resident 1's mental and emotional health needs and led to Resident 1's death by committing suicide (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 ensure that a competency and skill set review on four of five sampled staff employees were completed according to the facility ' s policy and procedure. This failure had the potential to put residents at risk for not receiving care in a safe and competent manner. Findings: During a review of Certified Nursing Assistant ' s (CNA1) Employee Performance Review ( formal assessment of an employee ' s work performance by identifying strengths, weaknesses , helping set goals and assist with skill development) , the Performance Evaluation Review indicated CNA1 was evaluated on 3/29/2022. During a review of CNA 2 ' s Employee Performance Review, the Employee Performance Review indicated CNA 2 was evaluated on 3/29/2022. During a review of CNA 3 ' s employment file, the employment file indicated employee performance review was not done. During a review of CNA 4 ' s Employee Evaluation, the Employee Evaluation indicated CNA 4 was evaluated on 10/21/2011 and was not signed by CNA 4. During a subsequent interview and record review on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of two sampled residents (Resident 2) did not receive Seroquel (a psychotropic medication [drug that affects brain activities associated with mental processes and behavior] used for mental and mood disorders) without a diagnosis and indication of used. These failures resulted in Resident 2 to received Seroquel without diagnosis from Resident 2 ' s physician and had the potential for increased risk for Residents 2 to experienced serious adverse effects (unwanted, uncomfortable, or dangerous effects that a drug may have) of Seroquel including dizziness, drowsiness and irregular heartbeat, that can lead to an overall negative impact on their physical, mental, and psychosocial well-being. Findings: During a review of Resident 2 ' s admission Record (Face Sheet), the Face Sheet indicated, Resident 2 was originally admitted to the facility on [DATE] and readmitted to the facility on [DATE] with a diagnoses including dementia (loss of memory,…

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 pharmaceutical services to meet the residents needs for two of three sampled residents (Resident 1 and 2) when: a. The facility failed to ensure Registered Nurse (RN) 1 did not document in Resident 1 ' s Medication Administration Record (MAR) that Methadone (strong medicine used to treat heroin [an illegal substance] dependence) was administered on 7/27/2024 to Resident 1 because it was not given to Resident 1. b. The facility failed to ensure Resident 1 ' s physician order for Methadone on 7/17/2024 at 12:29 p.m. indicated the medication should not be administered on the day Resident 1 will visit the methadone clinic on Mondays. c. The facility failed to ensure Licensed Vocational Nurse (LVN) 6 and 7 documented the administration of Norco (a combination medication of Hydromorphone and Acetaminophen used to manage moderate to severe pain) in Resident 1 and 2 ' s MAR. The deficient practice of Resident 1 ' s missed dose of Methadone on 7/27/2024…

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 ensure one of three sampled residents (Resident 1) was free from significant medication error when: a. The facility failed to ensure Resident 1 received Methadone (strong medicine used to treat heroin [an illegal substance] dependence) 55 milligrams on 7/27/2024 at 9 a.m. as ordered. b. The facility failed to ensure Resident 1 ' s physician order for Methadone on 7/17/2024 at 12:29 p.m. indicated the medication should not be administered on the day Resident 1 will visit the methadone clinic on Mondays because Resident 1 will receive a dose in the clinic. The deficient practice of not receiving the methadone on 7/27/2024 placed Resident 1 at risk for drug withdrawals (negative physical and mental symptoms that occur after stopping or reducing intake of a drug). The deficient practice of the physician order not indicating to not give Resident 1 ' s Methadone dose on Mondays when Resident 1 goes to the Methadone clinic resulted in Resident 1 receiving 55…

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 foods were dated, properly sealed, refrigerated after opening per manufacturer's recommendation, and discarded before the used by date (expiration dates) for 91 out 93 total residents. This failure placed residents at risk for developing foodborne illness (food poisoning: any illness resulting from the food spoilage from contaminated food with germs) which can cause symptoms including upset stomach, stomach cramps, nausea, vomiting, diarrhea, and fever, and can lead to other serious medical complications and hospitalization. Findings: During a concurrent observation and interview on 7/23/2024, at 8:22 a.m., with Dietary Manager (DM), in dry storage room [ROOM NUMBER], there were food items that were not dated, properly sealed, refrigerated after opening per manufacturer's recommendation, and discarded before the used by date as follows: a. Opened and used lemon juice in a plastic bottle with Receiving Date (RD- the day of delivery)…

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 all facility staff were provided with five hours of dementia (diseases that affect memory and thinking) training annually. This failure had the potential to result in residents with dementia being neglected and not provided with resident centered, comprehensive care. Findings: During a concurrent interview and record review on 7/26/2024 at 11:54 a.m. with the Director of Staff Development (DSD), the DSD stated, all facility staff are to be in-serviced on dementia training two hours upon hire and six hours annually to prevent residents with dementia from being neglected or abused. During an interview on 7/26/2024 at 3:24 p.m. with the Director of Nursing (DON), the DON stated it was important to provide dementia training to all facility staff to prevent nurse burnout and to educate staff on how to care for residents who are at a higher risk of being started on unnecessary medications. During a review of the facility's policy and procedure (P&P) titled Dementia Care revised on October 2017, indicated, all…

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 nursing staff member failed to provide reasonable accommodation to meet the resident's needs for five of five sampled residents (Resident 442, Resident 19, Resident 441, Resident 32, and Resident 192 by: A. Failing to adjust the side rails as resident requested on 3/2024 for Resident 442. B. Failing to place call light within reach for Resident 442, 19, 32 and 192. These failures had the potential to resulted in residents not being able to summon staff for assistance with care, and negatively impacting the psychosocial well-being of the residents or result in delayed provision of services. Findings: A. During a review of Resident 442's admission Record, the admission Record indicated, Resident 442 was initially admitted to the facility on [DATE] and last readmission was on 4/25/2024 with diagnosis including paraplegia (an impairment in motor or sensory function of the lower extremities), muscle weakness, and wedge compression fracture of lumbar vertebra…

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 the care plan interventions for two of three sampled residents (Resident 293 and Resident 193). The facility failed to: 1.Implement interventions for smoking for Resident 293. 2.Treat and provide pain medication for Resident 193. These deficient practices had the potential for delayed provision of necessary care and services. a. During a review of the Resident 293's Face Sheet (admission Record), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including osteomyelitis (inflammation or swelling in the bone) of the right ankle and foot, type 2 diabetes mellitus (a condition in which the body fails to metabolize (process) glucose (sugar) correctly with foot ulcer (open sore or lesion that has difficulty healing), difficulty in walking, peripheral vascular disease ([PVD] circulatory condition that is caused by the narrowing of the blood vessels) and hypertension (high blood pressure). 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 reviews, the facility failed to ensure effective pain management for two of five sampled resident (Resident 441 and Resident 193), by failing to: a. Obtain a physician order for pain medication for moderate pain (pain scale rating from zero to ten [pain screening tool using numerical value to assess the level of pain ranging from 0 to 3-mild pain, from 4 to 6- moderate pain, and from 7 to 9-severe pain, and 10- the worse pain possible]). This deficient practice had the potential to result in insomnia (a sleep disorder with trouble falling asleep, staying asleep, or getting good quality sleep) for Resident 441 b. Administer pain medication in a timely manner as ordered by Resident 193 physician. This failure resulted in Resident 193's to experience unnecessary pain. Findings: During a review of Resident 441's admission Record, the admission Record indicated, Resident 441` was admitted to the facility on [DATE] with diagnoses including displaced fracture (broken bone) 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 of one sampled resident (Resident 391) received treatment in accordance with the physician`s order. This deficient practice has the potential for Resident 391 not be free from infection. Findings: During a review of Resident 391's Face Sheet (admission record), the Face Sheet indicated Resident 391 was admitted to the facility on [DATE] with diagnoses including osteomyelitis (inflammation that occurs in the bone) of vertebra (irregular bone that make up the column or spine), endocarditis (inflammation of the inner lining of the heart's chambers and valves), opioid dependence (feeling withdrawal symptoms when not taking the medication). During a review of Resident 391's Minimum Data Set [(MDS) a standardized assessment and care screening tool], dated 7/22/2024, the MDS indicated Resident 391's cognitive skills (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) were intact. The…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure feeding tube formula, tubing, administration syringe, and water flush bags were changed within 24 hours for one of three sampled residents (Resident 85). This failure had the potential to result in Resident 85's Gastrostomy tube ([G-tube] - tube that is placed directly into the stomach through an abdominal wall incision for administration of food, fluids, and medications) getting clogged and placed Resident 85 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. Findings: During a review of Resident 85's admission Record, the admission Record indicated, Resident 85 was initially admitted to the facility on [DATE] and last re-admission was on 7/16/2024 with diagnosis including gastrostomy malfunction (Obstructed G-tube not responding to traditional unclogging…

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 physician responded to the consultant pharmacist's recommendation from 6/4/24 to obtain a valproic acid level (a lab value used to ensure certain medications are used safely and effectively) related to the use of divalproex sodium (a medication used to treat seizures) in one of five sampled residents (Resident 5.) The deficient practice of failing to ensure the physician evaluated and responded to medication irregularities (potential issues with a resident's medication regimen) identified by the consultant pharmacist during the Medication Regimen Review (MRR - a monthly report from the consultant pharmacist identifying any medication irregularities in a resident's current medication regimen) increased the risk that Resident 5 could have experienced adverse effects (unwanted, uncomfortable, or dangerous effects that a drug may have) related to their medication therapy possibly leading to impairment or decline in their mental or physical…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to monitor valproic acid levels (a laboratory test used to ensure medications used to treat seizures are present at a safe and effect level in the blood) related to the use of divalproex sodium (a medication used to treat seizures) in one of five residents sampled for unnecessary medications (Resident 5.) The deficient practices of failing to monitor valproic acid levels related to the use of divalproex increased the risk that Resident 5 could have experienced adverse effects (unwanted, uncomfortable, or dangerous effects that a drug may have) or seizures related to valproic acid levels being too high or too low leading to medical complications possibly resulting in hospitalization. Findings: During a review of Resident 5's admission Record (a document containing diagnostic and demographic information), dated 6/6/24, indicated she was admitted to the facility on [DATE] and most recently readmitted on [DATE] with diagnoses including psychosis (a mental…

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 discard and replace one expired fluticasone/salmeterol inhaler (a medication used to treat breathing problems) affecting Resident 22 in one of two inspected medication carts (East Medication Cart.) The deficient practice of failing to remove expired medications from the medication carts increased the risk that Resident 22 could have received medication that had become ineffective or toxic due to improper storage possibly leading to health complications resulting in hospitalization or death. Findings: During a concurrent observation and interview on 7/24/24 at 12:56 AM of East Medication Cart with the licensed vocational nurse (LVN 6), the following medications were found either expired, stored in a manner contrary to their respective manufacturer's requirements, or not labeled with an open date as required by their respective manufacturer's specifications: 1. One opened fluticasone/salmeterol inhaler for Resident 22 was found labeled with an open date of 5/4/24. According to the manufacturer's product…

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 assess mental capacity (ability to make decisions) and provide information to one of three sampled residents (Resident 85) and their responsible parties before signing arbitration agreement (a way of resolving a dispute without filing a lawsuit and going to court). This failure had the potential to result in Resident 85 not fully understanding their right to limit opportunity to initiate judicial proceedings that challenge unfavorable decisions. Findings: During a review of Resident 85's admission Record, the admission Record indicated, Resident 85 was originally admitted to the facility on [DATE] and was readmitted on [DATE] with diagnosis including gastrostomy (surgical opening made into the stomach to introduce food), dementia (progressive loss of memory), bilateral age-related cataract (cloudy area in the lens (the clear part of the eye that helps to focus light) of your eye, and altered mental status. During a review of Resident 85's History 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 interview and record review, the facility failed to supervise two of seven sampled residents (Resident 1 and Resident 6). A. The facility failed to ensure Resident 1 did not leave the facility premises unsupervised and without the staff knowledge and this failure had the potential for Resident 1 to be exposed to elements of extreme weather conditions, traffic accident, safety/ fall incident and/or be subjected to any forms assault (physical attack) which could be detrimental to her health and well-being. B. The facility failed to ensure Resident 6 was assisted to use the toilet in a timely manner. This failure left Resident 6 feeling frustrated because she had to crawl her way to the toilet to prevent herself from having an incontinence in her bed. Findings: A. During a review of Resident 1's admission record (Face sheet), the Face sheet indicated Resident 1 was admitted at the facility on 4/13/2023 with a diagnosis including diabetes mellitus (a disease that occurs when the blood glucose, also known as…

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 seven sampled residents (Resident 1 and Resident 6) were provided psychological (emotional and mental state) assessment and follow-up when: a. Resident 1 left the facility unnoticed and was found by facility staff under a tree with bare minimum clothes and no shoes, and b. Resident 6 crawled on the floor to use the toilet when there was no supervision provided for Resident 6. This failure had the potential to result in the residents' unmet psychosocial needs and concerns which could potentially affect their quality of life. Findings: A. During a review of Resident 1's admission record (Face sheet), the Face sheet indicated Resident 1 was admitted at the facility on 4/13/2023 with a diagnosis including diabetes mellitus (a disease that occurs when the blood glucose, also known as the blood sugar, is too high), osteoporosis (a disease in which the bones become fragile and more likely to break), hypertension (a condition of a high or raised…

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

Based on observation, interview and record review, the facility failed to ensure the alarm system located at the rear entrance/exit door of the building was functioning properly. This failure has resulted in the elopement (resident leaving premises without knowledge of staff) of one of seven sampled residents (Resident 1) which could have negatively caused Resident 1 her safety and well-being. Findings: During a review of Resident 1's admission record (Face sheet), the Face sheet indicated Resident 1 was admitted at the facility on 4/13/2023 with a diagnosis including diabetes mellitus (a disease that occurs when the blood glucose, also known as the blood sugar, is too high), osteoporosis (a disease in which the bones become fragile and more likely to break), hypertension (a condition of a high or raised blood pressure when the blood is pumping with more force than normal through the arteries) and dementia (the loss of cognitive functioning such as thinking, remembering, and reasoning to such extent that it interferes with a person's daily life and activities). 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.

Based on interview and record review, the facility failed to ensure one of seven sampled residents (Resident 6) was treated with dignity and respect by assisting Resident 6 to use the toilet in a timely manner. This failure left Resident 6 feeling frustrated because she had to crawl her way to the toilet to prevent herself from having an incontinence in her bed. Findings: During a review of Resident 6's admission Record (Face sheet), the Face sheet indicated Resident 6 was admitted at the facility on 3/26/2024 with a diagnosis including asthma (a condition in which the airways narrow and swell, produce extra mucus that can result to difficulty in breathing/ shortness of breath, trigger coughing and a wheezing or whistling sound during breathing out), diabetes mellitus (a serious condition when the blood glucose, also known as blood sugar is too high) and morbid obesity (a condition in which a person's weight is higher than what is healthy for their height and can increase the risk of the person's risk for many health problems). During a review of Resident 6's Minimum Data Set ([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 observation, interview, and record review, the facility failed to Identify and to intervene for one of three sampled residents (Resident 1) with a history of trauma and triggers which may cause re-traumatization. This failure resulted in Resident 1 feeling anxious and re-traumatized by Resident 2 during smoking breaks at the smoking patio. 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 last admission was 1/24/2024. Resident 1 ' s diagnosis included paranoid schizophrenia (a pattern of behavior where a person feels distrustful and suspicious of other people and acts accordingly. Delusions and hallucinations are the two symptoms that can involve paranoia), anxiety disorder (disorder involves persistent and excessive worry that interferes with daily activities), osteoarthritis (a chronic disease causing the deterioration of the cartilage within a joint), and epilepsy (A disorder in which nerve cell…

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 the facility ' s Coronavirus disease Covid-19(respiratory infection) policy by: a. failing to report the COVID-19 outbreak (At least one laboratory confirmed case of COVID-19 resident who has resided in the skilled nursing facility for at least 7 days,)to the California Department of Public Health (CDPH), with one out of three sampled residents (Resident 2) positive for Covid-19 on 10/9/2023, b. failing to document 159 out of 159 facility staff COVID testing from (10/18/2023 -10/25/2023). This deficient practice potentially increased the risk of further spreading Covid-19 to other residents and staff. Findings: During a review of Resident 2s admission Record, the admission record indicated Resident 2 was admitted to the facility on [DATE] with a diagnosis including congestive heart failure (heart cannot pump blood well enough to meet the body ' s needs). During a review of Resident 2 ' s Minimum Data Set ([MDS]- a standardized assessment 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 interview and record review, the facility failed to report an allegation of abuse for one of one resident (Resident 1), when Resident 1 filed a grievance (a complaint that may or may not be justified) on 7/12/2023 with the Social Services Director (SSD) alleging Certified Nursing Assistant (CNA)1 inappropriately touched her (Resident 1). This deficient practice delayed California Department of Public Health (CDPH) investigation and had the potential to result in further abuse to go unreported. Findings During a review of Resident 1 ' s admission Record, the admission record indicated Resident 1 was admitted on [DATE] with the diagnoses including diabetes (high blood sugar in the blood) and morbid obesity (more than 80 to 100 pounds above their ideal body weight). During a review of Resident 1 ' s Minimum Data Set ([MDS]- a standardized assessment and care screening tool) dated 7/24/2023, the MDS indicated Resident 1 was cognitively (thinking) intact and required extensive assistance from two staff…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to follow professional standards of practice when Licensed Vocational Nurse 1 (LVN 1) administered one of one resident (Resident 1) Docusate Sodium 100 mg (milligrams) tablet (medication to soften bowel movements) without a physician ' s order. This deficient practice resulted in Resident 1 receiving medication without a physician order and had a potential for Resident 1 to experience allergic reactions or medication interactions. Findings During a review of Resident 1 ' s admission record (AR), the AR indicated Resident 1 was admitted on [DATE] with the diagnoses including diabetes (high blood sugar) and osteomyelitis (infection of the bone) of the lower leg. During a review of Resident 1 ' s Minimum Data Set ([MDS]- a standardized assessment tool that measures health status in nursing home residents) dated 9/12/2023, the MDS indicated Resident 1 ' s cognition (thinking and reasoning) was moderately impaired and Resident 1 required two staff…

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 written abuse prevention policy and procedure (P/P) by not reporting an allegation of physical abuse within two hours of the incident for one of four sampled residents (Resident 1) to the State Survey Agency (SSA) after the Responsible Party 1 (RP1) of Resident 1 reported to the nursing staff that a certified nursing assistant (CNA) pushed Resident 1 onto Resident 1's wheelchair on 8/16/2023 at approximately 4:30 p.m. The abuse was reported to the SSA on 8/17/2023 at 11:10 a.m. This deficient practice delayed the SSA's investigation of the alleged physical abuse, which potentially placed Resident 1 at risk for further abuse and violation of resident rights. 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], with a diagnosis that included orthopedic aftercare (care for a healing fracture [a break in the bone]), left hip injury, 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 implement its abuse prevention policy and procedure (P/P) by not reporting the results of the facility's investigation of an allegation of abuse for one of four residents (Resident 1) to the local law enforcement, local Ombudsman, and the State Survey Agency (SSA) within five days after the alleged abuse occurred on 8/16/2023. The facility submitted the conclusion report on 8/24/2023. This deficient practice potentially placed Resident 1 at risk for further abuse and violation of resident rights. 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], with a diagnosis that included orthopedic aftercare (care for a healing fracture [a break in the bone]), left hip injury, history of falling and dementia (a condition that affects the function of the brain such as thinking, remembering, and reasoning to interferes with a person's daily life and activities). During…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure two sampled residents (Residents 29 and 39) were treated with dignity and respect by: 1. Failing to provide Resident 29 with privacy after being left naked and exposed in bed while waiting for care to be provided. 2. Failing to ensure staff did not stand over Resident 39 while assisting with meals. These deficient practices had the potential for Residents 29 and 39 to experience embarrassment due to a loss of dignity. Findings: a. During a review of Resident 29's admission Record (face sheet), the admission Record indicated Resident 29 was admitted to the facility on [DATE], and re-admitted on [DATE]. Resident 29's diagnoses included Type 2 diabetes mellitus (high blood sugar), Alzheimer's disease (progressive disease that destroys memory and other important mental functions), gastrostomy dependent (tube inserted into the stomach for nutrition, hydration, and medication), left hand contracture (gradual thickening and tightening 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 resolve the following resident grievances in a timely manner for three of nine sampled residents (Residents 33, 61, and 68): 1. Residents 61 and 68 missing clothing items from the laundry room. 2. Resident 33's missing backpack. This deficient practice was violation of the facility's policy to make every effort to have a home-like environment. Findings: a. During a review of Resident 33's admission Record (face sheet), the admission Record indicated Resident 33 was admitted to the facility on [DATE]. Resident 33's diagnoses included muscle weakness, contracture (condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints) of the right and left ankle, and heart failure (chronic, progressive condition in which the heart muscle is unable to pump enough blood to meet the body's needs for blood). During a review of Resident 33's Minimum Data Set (MDS), a standardized assessment 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: 1. Recognize Resident 31's non-verbal cues for pain and to ensure the resident's pain assessment was accurate. 2. Ensure Resident 31's care plan interventions for pain management were implemented. 3. Ensure Resident 31 received appropriate hospice (care to provide comfort, relieve pain, and offer support for persons near the end of life and their families) services. These deficient practices resulted in inadequate relief from pain for Resident 31 and placed Resident 31 at risk of not receiving the care necessary to prevent pain, discomfort and distress. Findings: During a review of Resident 31's admission Record, the admission Record indicated the resident was admitted to the facility on [DATE], and readmitted on [DATE]. Resident 31's diagnoses included Alzheimer's disease (a disease that causes problem with memory, thinking and behavior), chronic kidney disease (gradual loss of kidney function), dysphagia (difficulty swallowing),…

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 pain medication for one of five sampled residents (Resident 31) prior to wound treatment. This deficient practice resulted in Resident 31 experiencing unnecessary pain. Findings: During a review of Resident 31's admission Record, the admission Record indicated the resident was admitted to the facility on [DATE], and readmitted on [DATE]. Resident 31's diagnoses included Alzheimer's disease (disease that causes problems with memory, thinking and behavior), chronic kidney disease, dysphagia (difficulty swallowing), contractures of the muscles of the right and left shoulder (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints), presence of gastrostomy tube ([GT] a tube that is placed directly into the stomach through an abdominal wall incision for administration of food, fluids, and medication), transient cerebral ischemic attack (brief episode during which…

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 nursing staff administered a medication with meals and food, per physician's order, for one of three residents (Resident 61) observed during the morning medication administration (med pass). 2. Ensure a resident (Resident 285) was assessed and received a physician's order for the self-administration of medications, and the medications left at the bedside were labeled and checked for drug interactions from the facility's contracted pharmacy. These deficient practices had the potential for harm to Residents 61 and 285 due to potential adverse effects of the medications and medication duplication. Findings: a. During an observation on 7/13/21 from 8:40 a.m. to 9:02 a.m., at the [NAME] Station Medication Cart 1 for Resident 61's medication administration (med pass), Licensed Vocational Nurse 7 (LVN 7) prepared the following medications: Ibuprofen (Motrin, a non-steroidal anti-inflammatory [NSAID] used for pain relief) 600…

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 medication error rate of less than five (5) percent, due to two (2) medication administration errors involving one out of three residents (Resident 61) observed during medication administration (med pass). This deficient practice of a medication administration error rate of six and six one hundredths percent (6.06 %) exceeded the five (5) percent threshold. Findings: During an observation on 7/13/21 from 8:40 a.m. to 9:02 a.m., at the [NAME] Station Medication Cart 1 for Resident 61's medication administration (med pass), Licensed Vocational Nurse (LVN 7) prepared the following medications: Ibuprofen (Motrin, a non-steroidal anti-inflammatory used for pain relief) 600 mg (strength in milligram units) tablet, Buspirone (Buspar, used to treat anxiety) HCl 10 mg tablet, Gabapentin (Neurontin, used to treat seizures) 600 mg tablet, Nifedipine ER (Procardia XL, used to treat high blood pressure and chest pain) 30 mg tablet, Escitalopram (Lexapro, used to treat depression and anxiety) 20 mg tablet,…

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 one (1) bottle of an over-the-counter medication was not expired, located in one (1) medication storage room, out of three (3) total medication storage rooms at the facility. This deficient practice had the potential for harm to residents due to the potential loss of strength of the medication, and the potential for the residents to receive ineffective medication dosages due to expired medication. 2. Ensure the refrigerator temperature monitoring records did not have an incorrect printed temperature range, located in two (2) medication storage rooms, out of three (3) total medication storage rooms at the facility. This deficient practice had the potential for harm to residents due to the potential loss of strength of the medications, and the potential for the residents to receive ineffective medication dosages due to potential undetected excursions outside of the correct temperature range. Findings: 1. During an observation on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the following for one sampled resident (Resident 44) receiving hospice (type of healthcare that focuses on the care, comfort, and quality of life of a person with a serious illness who is approaching the end of life) care: a. Ensure there was a signed agreement between the facility and the Hospice agency. b. Ensure Resident 44's diagnoses qualified the resident to be placed under hospice care. c. Ensure Informed consent and treatment authorization of the Hospice program was completed and signed. d. Implement the facility's Hospice program policy and procedures. e. File weekly assessment nursing progress notes in the Hospice binder or in Resident 44's medical records. These deficient practices had the potential to result in Resident 44 not receiving appropriate hospice care and services or placed under hospice program against her will. Findings: During a review of Resident 44's admission Record, the admission Record indicated the resident was…

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

Based on observation, interview, and record review, the facility failed to ensure appropriate infection control practices were implemented, by not: a. Ensuring a resident (Resident 3), who was positive and on contact isolation for Clostridium difficile ([C-diff] infectious germ that causes severe diarrhea, watery stool and inflammation of the colon transmitted from person to person by spores) did not share a room with other residents. b. Ensuring staff wore proper personal protective equipment ([PPE] protective clothing, gloves, masks designed to protect from the spread of infection or illness) while handling soiled linen hampers and trash. c. Ensuring kitchen staff used gloves while handling food. These deficient practices had the potential to result in cross contamination, foodborne illnesses and spread of infection among residents and other staff members. Findings: a. During the initial tour of the facility and concurrent interview with Licensed Vocational Nurse 2 (LVN 2) on 7/12/21 at 10:46 a. m., Resident 3 was observed in contact isolation (intended to prevent transmission of…

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

Based on observation, interview, and record review, the facility failed to inform one sampled resident (Resident 33) during the admission process whether a electric wheelchair for mobility was allowed in the facility. This deficient practice denied the resident of her right to be informed. Findings: During a review of Resident 33's admission Record (face sheet), dated 5/13/21, the admission Record indicated Resident 33's diagnoses included muscle weakness, contracture (condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints) of the right and left ankle, and heart failure. During a review of Resident 33's Minimum Data Set (MDS), a standardized assessment and care-screening tool, dated 5/20/21, the MDS indicated Resident 33's cognition had the ability to make decisions of daily living. The MDS indicated Resident 33 required extensive assistance of a two-person physical assist with activity of daily livings ([ADLs] daily self-care activities, such as dressing, eating, personal hygiene and grooming), transferring 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 interview and record review, the facility failed to implement a care plan to prevent one sampled resident (Resident 70) from the recurrence of developing a urinary tract infection ([UTI] infection of the bladder). This deficient practice placed Resident 70 at increased risk for recurrent UTIs. Findings: During a review of Resident 70's admission Record, dated 7/15/21, the admission Record indicated Resident 70 was initially admitted to the facility on [DATE], and last admitted to the facility on [DATE]. Resident 70's diagnoses included metabolic encephalopathy (dysfunction in the brain that can cause temporary confusion and abnormal behaviors), gastronomy status (tube surgically inserted into the stomach to provide nutrition, hydration, and medications) and acute kidney failure (condition in which the kidneys suddenly can not filter waste from the blood, develops rapidly over a few hours or days). During a review of Resident 70's History and Physical (H/P) dated 10/23/2020, the H/P indicated Resident 70…

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 five sampled residents (Resident 49) was provided with a smoking apron (protective fabric designed to protect smokers from cigarette burns) during smoke breaks. This deficient practice placed Resident 49 at risk for injury and bodily harm. Findings: During a review of Resident 49's admission Record, the admission Record indicated Resident 49 was admitted to the facility on [DATE]. Resident 49's diagnoses included hemiplgia (inability to move one side of the body) affecting the right side, lack of coordination, and chronic obstructive pulmonary disease ([COPD] progressive lung disease causing obstructed air flow from the lungs). During a review of Resident 49's Minimum Data Set (MDS), a standardized resident assessment and care-screening tool, dated 11/30/2020, the MDS indicated Resident 49's cognition (ability to think and reason) was moderately impaired for daily decision-making skills. The MDS indicated Resident 49…

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 therapeutic diet (meal plan that controls the intake of certain foods or nutrients/compounds in foods often followed as part of the treatment of a medical condition, and is most times done temporarily to heal and/or to prevent health conditions) prescribed by the physician was followed and food preferences were honored for one sampled resident (Resident 84). This deficient practice had the potential for Resident 84 to experience stomach cramps, pain and diarrhea. Findings: During an interview on 07/12/21 at 11:15 a.m. with Resident 84, Resident 84 stated he was blind and had surgery. Resident 84 stated his vision was extremely limited. During a concurrent observation and interview on 7/12/21 at 12:34 p.m. with the Social Services Designee (SSD), Resident 84 was observed in his room eating lunch. Items observed on Resident 84's meal tray included a sandwich, eight ounces of coffee, four ounces of cranberry juice, and a cup of vanilla ice cream. Resident 84 stated he was allergic to milk and was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed implement a resident's Minimum Data Set ([MDS] a resident assessment and care-screening tool) assessment to assist in directing care to one of 18 sampled residents (Resident 44) who required a two-person physical assist, by failing to: 1. Implement its policy and procedure (P/P) which indicated a care plan would be initiated according to identified risk factors. 2. Ensure staff were trained how to use the assessment Resident Special Needs List tool. These deficient practices resulted in Resident 44 falling and sustaining a scrape (injury to the skin) to the left knee and soreness to the left hip, and the potential for a fracture (broken bone) or severe injury. Findings: During a review of Resident 44's admission Record (face sheet), the admission Record indicated the resident was admitted to the facility on [DATE]. Resident 44's diagnoses included metabolic encephalopathy (condition in which brain function is disturbed either temporarily or permanently…

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

Based on interview and record review, the facility failed to ensure one sampled resident (Resident 39) was free of unnecessary medications. This deficient practice placed Resident 39 at increased risk for adverse drug side effects due to the resident taking multiple medications in the same drug category. Findings: During a review of Resident 39's admission Record (face sheet), dated 7/15/21, the admission Record indicated Resident 39 was re-admitted to facility on 5/21/21. Resident 39's diagnoses included muscle weakness and oral phase dysphagia (inability to coordinate chewing and swallowing). During a review of Resident 39's Minimum Data Set (MDS), a comprehensive assessment and care-screening tool, dated 4/20/21, the MDS indicated Resident 39 had severe cognitive (ability to think and reason) function. The MDS indicated Resident 39 required extensive assistance with toileting and was incontinent of bowel and bladder (unable to voluntary control urine and feces). During an interview on 7/16/21 at 1:43 p.m. with Licensed Vocational Nurse 3 (LVN 3), LVN 3 stated, The order for senna…

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 document a reason for not attempting a gradual dose reduction (GDR) for the use of an antidepressant (medication used for the treatment of mood disorders) for one resident sampled (Resident 39). This deficient practice had the potential to result in Resident 39 receiving more medication than was necessary. Findings: During a review of Resident 39's admission Record (face sheet), dated 7/15/21, the admission Record indicated Resident 39 was re-admitted to facility on 5/21/21. Resident 39's diagnoses included schizophrenia (long-term mental disorder of a type involving a breakdown in the relation between thought, emotion, and behavior, leading to faulty perception, inappropriate actions and feelings, withdrawal from reality and personal relationships into fantasy and delusion, and a sense of mental fragmentation) and major depressive disorder (disorder characterized by periods of sadness and feelings of hopelessness). During a review of Resident's 39's Minimum Data Set (MDS), a comprehensive resident assessment and…

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

Based on observation, interview, and record review, the facility failed to: 1. Correctly label and date food items in the kitchen. 2. Ensure the ice-maker machine was locked and the interior was free from dirt. These deficient practices placed the residents receiving food and ice from the kitchen at risk for food-bourne illnesses. Findings: During an initial kitchen tour observation on 7/12/2021 at 9:03 a.m. the following was observed: 1. One opened beef based can with no open date indicated. 2. One box of Quaker oats with no receive date indicated on the box. 3. One bean pot vegetarian can with no receive date indicated on the can. 4. Four bags of corn inside the freezer with no receive date indicated on the bag. 5. Watermelons and pineapples with no receive date indicated on the counter where the fruits were being stored. During an observation inside the staff lounge area on 7/12/21 at 9:20 a.m., the ice machine maker was unlocked. During an interview on 7/12/21 at 9:21 a.m. with the Dietary Supervisor (DS), the DS stated the ice machine must always be locked. During an…

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