The Springs Post-Acute

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 67) was assessed and monitored properly for the use of hand mittens (padded, mitt-shaped devices designed to prevent patients from pulling at tubes or self-injury). This deficient practice had the potential to place Resident 67 in unnecessary restraints.Findings:During an observation on 4/20/2026 at 10:12 a.m., Resident 67 was observed in bed with a hand mitten (soft, padded gloves worn over a patient's hands to prevent them from pulling out tubes or causing self-harm). on his left hand.During a review of Resident 67's admission Record, the admission Record indicated Resident 67 was admitted to the facility on [DATE] with diagnoses including gastrostomy tube (G-tube, a tube placed directly into the stomach for long-term feeding), hemiplegia (weakness to one side of the body) and hemiparesis (inability to move one side of the body) affecting right dominant hand, and anxiety disorder.During a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure one of five sampled residents (Resident 8) received non pharmacological interventions (evidence-based, non-invasive, non-drug treatments aimed at improving, maintaining, or modifying health conditions) prior to the administration of PRN (given as needed or requested) Ativan (a medication used to treat anxiety-feelings of fear, dread, or uneasiness).This deficient practice had the potential to result in resident's unnecessary consumption of medications and cause untoward adverse reactions for taking psychotropic (drug or other substance that affects how the brain works and causes changes in mood, awareness, thoughts, feelings, or behavior) medications.Findings:During a review of Resident 8's admission Record, the admission Record indicated Resident 8 was admitted to the facility on [DATE] with diagnoses including nontraumatic intracerebral (brain) hemorrhage (bleeding), acute and chronic respiratory failure (body can't get enough oxygen into 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 one resident (Resident 88) received daily activities appropriate to the resident's needs. The deficient practice had the potential to negatively affect the residents' physical and mental well-being. Findings:During a review of Resident 88's admission Record, the admission Record indicated Resident 88 was admitted to the facility on [DATE] with diagnoses including cerebral palsy (a group of permanent movement and posture disorders caused by abnormal brain development or damage before, during, or shortly after birth), muscle weakness, and contractures (a stiffening/shortening at any joint, that reduces the joint's range of motion) of the left and right knee.During a review of Resident 88's Minimum Data Set ([MDS] a resident assessment tool), dated 2/4/2026, the MDS indicated Resident 88's cognition (ability to think) was severely impaired. The MDS indicated Resident 10 was dependent on staff for all Activities of Daily Living (ADLs-…

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

Based on observation, interview, and record review, the facility failed to ensure one of six sampled residents (Resident 41) who was assessed as being at very high risk for pressure ulcer (a localized injury to the skin and/or underlying tissue usually over a bony prominence as a result of pressure, or pressure in combination with shear) development was provided a pressure relieving barrier to be placed between Resident 41's overlapping, contracted (loss of motion of a joint associated with stiffness and joint deformity) toes of the left foot as indicated per facility policy.This deficient practice had the potential to result in Resident 41 developing pressure ulcers on the left foot. Findings: During a review of Resident 41's admission Record, the admission Record indicated the facility initially admitted Resident 41 on 9/6/2024 with diagnoses including anoxic brain damage (injury to the brain caused by lack of oxygen), acute respiratory failure (condition that occurs when the lungs cannot get enough oxygen into the blood) with hypoxia (medical condition where the body's tissues…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure a resident with a physician order for a foley catheter (also called indwelling catheter, a thin, flexible tube that drains urine from the bladder into a bag outside the body) and had monitoring and care provided to prevent recurrent urinary tract infection ([UTI], a bacterial infection that affects the urinary tract, which includes the bladder, ureters, and kidneys) for one of two sampled residents (Resident 94).This deficient practice had the potential to result in Resident 94 acquiring recurrent UTIs when foley catheter was not monitored and care was not provided according to the physician's order.Findings:During a review of Resident 94's admission Records, the admission Records indicated Resident 94 was originally admitted to the facility on [DATE] with a readmission date on 12/30/2025 with diagnoses of chronic obstructive pulmonary disease ([COPD], lung disease that causes obstruction of airflow and can limit normal breathing),…

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 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 10) received HD on 1/27/2026.This deficient practice had the potential to result in fluid overload (a condition where excessive water and sodium accumulate in the body) weight gain, edema (swelling in legs/arms), and shortness of breath.Findings:During a review of Resident 10's admission Record, the admission Record indicated Resident 10 was recently re-admitted to the facility on [DATE] with diagnoses including chronic kidney disease (a serious, long-term condition where kidneys are damaged and cannot effectively filter blood, often leading to waste buildup) and dependence on renal dialysis.During a review of Resident 10's Minimum Data Set (MDS - a resident assessment tool), dated 2/5/2026, the MDS indicated Resident 10's cognition (ability to think) was severely impaired.…

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

Based on observation and interview, the facility failed to ensure a thermometer was placed in the dry storage food area. This deficient practice had the potential to result in food-borne illnesses (food poisoning) of the residents with symptoms including upset stomach, stomach cramps, nausea, vomiting, diarrhea and fever and can lead to other serious medical complications and hospitalization.During a concurrent observation and interview on 4/20/2025 at 9:08 a.m. with the Dietary Manager (DM), the DM verbalized the current storage room temperature is 72 degrees Fahrenheit ( F, temperature scale). The DM stated the facility did not need to have a thermometer in the dry storage room and indicated that when the room gets too hot, they will put the thermometer in the dry storage room and take the temperature. The DM stated nothing in the storage room would be affected by not having a thermometer since there is no produce. During an interview on 4/23/2025 at 3:03 p.m. with the Director of Nursing (DON), the DON stated a thermometer should be in the dry storage room so they can monitor the…

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

Based on observation, interview, and record review, the facility failed to ensure exterior waste disposal containers were fully closed and trash collection area was cleaned and free of black sticky residue.This failure had the potential to result in the attraction of pests and spread of pathogens due to unsanitary environment.Findings:During an observation on 4/20/2026 at 8:34 a.m. of the designated trash collection area located on the left side of the facility, two of three gray waste disposal containers and one blue waste container were not fully closed. The floor of the designated trash collection area had used pair of gloves and black sticky residue.During a concurrent observation and interview on 4/20/2026 at 9:10 a.m. with the Dietary Supervisor (DS), the DS stated the waste disposal containers were full and were not fully closed, a used pair of gloves was on the floor, and the floor had black sticky residue. The DS stated the importance of keeping the waste disposal containers fully closed and the designated waste disposal area clean was to ensure trash was contained and to…

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

Based on interview and record review, the facility failed to ensure the General Acute Care Hospital (GACH) Discharge Summary for one of six sampled residents (Resident 3) was in the medical record and readily accessible.This deficient practice had the potential to delay and negatively affect the delivery of necessary care and services.Findings:During a review of Resident 3's admission Record, the admission Record indicated the facility initially admitted Resident 3 on 12/26/2022 and re-admitted Resident 3 on 2/13/2025 with diagnoses including a left ulna (longer of the two bones in the forearm which stretches from the elbow to the wrist) fracture (broken bone), anoxic brain damage (injury to the brain caused by lack of oxygen), and osteoporosis (condition in which the bones become brittle) with pathological fracture (broken bone caused by an underlying disease or condition that weakens the bone structure). During a review of Resident 3's Minimum Data Set (MDS, resident assessment tool), dated 2/17/2026, the MDS indicated Resident 3 had severely impaired cognitive skills (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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of two hospice (compassionate care for people who are near the end of life) residents (Resident 13) home health aide ([HHA] trained professional who provides in-home personal care, basic health monitoring, and companionship to elderly, disabled, or chronically ill individuals) visits were made twice a week.The deficient practice had the potential to result in negative health outcomes. Findings:During a review of Resident 13's admission Record, the admission Record indicated Resident 13 was recently re-admitted to the facility on [DATE] with diagnoses including Severe Protein Calorie Malnutrition (life-threatening condition resulting from inadequate intake of protein and calories, causing significant muscle wasting, fat loss, and organ dysfunction.), dementia (a progressive state of decline in mental abilities), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), and Parkinson's disease (a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one out of four sampled residents (Resident 31) was screened appropriately prior to initiating antibiotic treatment. This deficient practice had the potential to increase antibiotic resistance and provide antibiotics without justification.During a review of Resident 31's admission Record, the admission Record indicated Resident 31 was admitted to the facility on [DATE] with diagnoses including tracheostomy (a tube placed into a surgically created hole through the front of the neck and into the windpipe-trachea), gastrostomy (G-tube, a tube placed directly into the stomach for long-term feeding), and acute and chronic respiratory failure. During a review of Resident 31's history and physical (H&P) dated 6/13/2025, the H&P indicated Resident 31 had fluctuating capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 3/31/2026, the MDS indicated Resident 31 had severe…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the Responsible Party (RP) 1 was notified when Resident 1 was started on Lantus ([insulin glargine] medication used to manage high blood sugar levels for people with diabetes mellitus [DM - a disorder characterized by difficulty in blood sugar control and poor wound healing]) for one of three sampled residents (Resident 1) on 12/8/2025.This deficient practice resulted in the violation of Resident 1's RP 1 rights to be informed and involved in treatment decisions which could lead to distrust toward the facility and its practices.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 diagnoses including cerebral infarction ([stroke] loss of blood flow to a part of the brain), metabolic encephalopathy (temporary or permanent damage to the brain due to lack of glucose, oxygen, or other metabolic agent, or organ dysfunction) and type 2 DM.During a review…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement infection control measures to prevent a scabies (a contagious skin condition caused by tiny insects called mites which infest and irritate the skin causing intense itching, red patches, and inflammation [the immune system's response to harmful stimuli]) outbreak (two or more clinically suspect or confirmed cases of scabies identified in patients/residents, healthcare workers, volunteers and/or visitors during a six week time period) for five of five sampled residents (Resident 1, 2, 3, 4, and 5) by failing to:1. Recognize a possible scabies outbreak when Residents' 1,2,3,4 and 5 with suspected scabies were treated prophylactically (a medication or action used to prevent disease or a recurrence of a condition) by the physician for scabies.These deficient practices placed residents, staff, and visitors at risk of acquiring and spreading scabies. Findings: A. During a review of Resident 1's admission Record (Face Sheet- front page…

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 notify the physician of a significant change in condition (COC sudden, clinical deviation from a resident's baseline in physical, cognitive, behavioral, or functional status) for one of three sampled residents (Resident 1) when the facility did not notify the physician when Resident 1 developed swelling and discoloration of the left fourth and fifth fingers.This failure had the potential to delay necessary medical evaluation and treatment, placing the resident at risk for worsening of the condition or other complications.Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility 11/27/2024 with diagnoses including Alzheimer's disease (a disease characterized by a progressive decline in mental abilities), schizophrenia (a mental illness that is characterized by disturbances in thought), and Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements). During a rereview of Resident…

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

Based on interview and record review, the facility failed to report a fracture (broken bone) of unknown origin for one of two sampled residents (Resident 1 ) to the California Department of Public Health (CDPH), law enforcement, or the Ombudsman. This deficient practice resulted in a delay in initiating an investigation and potentially increased the risk of abuse, neglect or mistreatment of other residents. of an investigation and potentially increased the risk of abuse, neglect, and mistreatment of other residents. Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility 11/27/2024 with diagnoses including Alzheimer's disease (a disease characterized by a progressive decline in mental abilities), schizophrenia (a mental illness that is characterized by disturbances in thought), and Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements). During a rereview of Resident 1'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.

Based on interview and record review the facility failed to protect one of three residents' (Resident 1) right to be treated with respect, kindness, and dignity when Certified Nurse Assistant (CNA)1 entered Resident 1's room, even after being banned from providing care to Resident 1.The deficient practice violated residents' rights and had the potential to result in negative psychological outcomes.Findings:During a review of Resident 1's admission Record, the admission record indicated the facility originally admitted the resident on 4/3/2024 with a diagnosis including hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body), hemiparesis condition characterized by weakness on one side of the body, affecting the arm, leg, hand, and/or face), acute respiratory failure (occurs when the air sacs of the lungs cannot release enough oxygen into the blood), diabetes mellitus(DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), asthma (chronic lung disease), and Post traumatic stress disorder (PTSD - a disorder in which 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 supervise one of six sampled residents (Resident 1), who was assessed as a high risk for falls by: a. Ensuring staff familiarity with Resident 1 ' s routine when Resident 1 was moved to a new room with a new set of care givers. b. Implement Resident 1 ' s Interdisciplinary Team ([IDT]- refers to a team of different healthcare professionals who work together to create a personalized care plan for a patient)-Fall Progress Notes interventions that indicated: b.1.Not to leave Resident 1 in the wheelchair unattended. b.2.When Resident 1was up in a wheelchair, activity staff or nursing staff would either escort Resident 1 to the activity room or return Resident 1 to bed. b.3.If Resident 1 was in his wheelchair in his room, or the hallway activity staff would endorse to nursing staff. c. Appropriately re-assesses Resident 1 each time he falls to monitor effectiveness on the interventions. This deficient practice resulted for Resident 1…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure three of four sampled residents (Residents 34, 45, and 82) call lights (device that allows residents to request assistance from nursing staff) were answered in a timely manner. This deficient practice resulted in a delay of care and services. Findings: During a review of Resident 34's admission Record, the admission Record indicated Resident 34 was admitted to the facility on [DATE] with diagnoses including polyneuropathy (malfunction of nerves in the body), muscle weakness, and paraplegia (inability to voluntarily move the lower parts of the body). During a review of Resident 34's Minimum data Set (MDS), a resident assessment tool, dated 2/3/2024, the MDS indicated Resident 34's cognition was intact. The MDS indicated Resident 34 needed partial assistance (helper does less than half the effort) with eating, oral hygiene, needed substantial assist (helper does more than half the effort) with personal hygiene, and was dependent…

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 protect one of three sampled residents (Resident 50) from physical and verbal abuse, by not separating Resident 50 from Resident 197 after a verbal altercation and Resident 197 threw a box of tissues at Resident 50. This deficient practice placed Resident 50 at risk for further abuse and had the potential to cause feelings of intimidation, neglect and not feeling safe in the facility which was considered the Residents' home. Findings: During a review of Resident 50's admission Record , the admission Record indicated Resident 50 was admitted to the facility on [DATE], with diagnoses including cerebral infarction unspecified (a condition in which blood flow to the brain is interrupted, causing brain tissue to die without a specified identifiable cause), muscle weakness generalized, and legal blindness (a very limited visual field). During a review of Resident 50's History and Physical (H&P), dated 4/17/2024, the H&P indicated, Resident 50 had 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 three of three resident's (Resident 80, 86, 296) Minimum data Set (MDS - a resident assessment tool), Section P - Restraints (any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body) and alarms, indicated Residents 80, 86, and 296 had restraints. This deficient practice resulted an inaccurate depiction of Resident 80, 86, and 296's current health status. Findings: a) During a review of Resident 80's admission Record, the admission Record indicated Resident 80 was originally admitted to the facility on [DATE] with diagnoses including metabolic encephalopathy (brain problem), seizures (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness), and Resident 80 had a gastrostomy (a surgical…

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

Based on observation, interview, and record review, the facility failed to ensure food containers that are opened were labeled with an open date and use by date. This deficient practice had the potential to result in pathogen (germ) exposure to residents and placed residents at risk for developing foodborne illness (food poisoning) with symptoms including upset stomach, stomach cramps, nausea, vomiting, diarrhea and fever and can lead to other serious medical complications and hospitalization. Findings: During an observation on initial tour of the kitchen on 2/4/2025 at 08:18 a.m., with the Dietary Aide 1 (DA 1), there were several items in refrigerator that had no preparation dates or use by date. Those items found in the refrigerator were 8 wrapped turkey sandwiches, 1 large jar of pickle relish, 2 prepared fruit cups and 2 prepared salads. During a concurrent interview and observation on 2/4/2024 at 12:47 p.m. with Dietary Aide 1 (DA 1), DA 1 observed the sandwiches, fruit cup jar of pickles and salad had no prepared dates on them . DA1 stated staff are responsible for dating 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 identify unresolved quality deficiencies, some of which had been cited on previous surveys, and ensure actions were developed and implemented to attempt to correct the deficiencies through the quality assessment and assurance (QAA) process as evidenced by the severity and number of deficiencies cited involving assessment, monitoring, and documentation of physical restraints(any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body), and accurate resident assessment with documentation. This failure had potential to result in the residents residing in the facility not receiving services and care they need. Findings: During a review of Resident 86's admission Record, the admission Record indicated, Resident 86 was admitted to the facility on [DATE] with traumatic subarachnoid hemorrhage…

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

Based on interview and record review, the facility failed to provide documented evidence of all employees screening, education, offering, and current Corona virus disease, COVID-19 (contagious infectious disease), vaccination (medications used to prevent diseases usually given by injection or by mouth) status. This failure had the potential to place staff and residents at risk for serious outcomes such as being hospitalized due to COVID-19. Findings: During an interview and record review on 2/6/2025 at 11:15 a.m., with the Infection Prevention Nurse (IPN), the facility's employee records of COVID-19 status 2024 to 2025 and the physicians, and consultants COVID-19 immunization status were unknown. The IPN stated she did not know she had to get the physicians and consultants Covid-19 immunization status. During an interview on 2/7/2025 at 5 p.m. with the Director of Nursing (DON), the DON stated all staff include board members, licensed practitioners, lab, and hospice (a type of care that focuses on improving the quality of life for people who are terminally ill and nearing the end of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review: a) The facility failed to ensure one of one resident (Resident 80) had a call light the resident could use. b) The facility failed to ensure one of three sampled residents (Resident 30) had a working call light. This deficient practice resulted in a delay of care and services. Findings: a) During a review of Resident 80's admission Record, the admission Record indicated Resident 80 was originally admitted to the facility on [DATE] with diagnoses including metabolic encephalopathy (brain problem), seizures (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness), and Resident 80 had a gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems)tube. During a review of Resident 80's Minimum data Set (MDS- a resident assessment tool), dated 11/20/2024, the MDS indicated Resident 80 had…

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 assess, monitor, and document the use of hand mittens (soft gloves that are designed to restrict the movement of one or both hands, and are used with patients who have removed essential lines or tubes on more than one occasion.) to prevent the residents from pulling out his gastrostomy tube ([G-tube]- a tube inserted through the abdomen that brings nutrition directly to the stomach) for one of six sampled residents (Resident 86). This failure had the potential to result in entrapment, skin injury, and compromised circulation for Resident 86's hands. Findings: During a review of Resident 86's admission Record, the admission Record indicated, Resident 86 was admitted to the facility on [DATE] with traumatic (physical injury of sudden onset) subarachnoid (tissue layer that protects the brain) hemorrhage (bleeding), hemiplegia of right side (total paralysis of the arm, leg, and trunk on the same side of the body), and generalized muscle…

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 three sampled resident's (Resident 11 and 33) Preadmission Screening and Resident Review (PASARR - a federal assessment requirement to help ensure that individuals who have a mental disorder -MD- are placed in facilities that can provide the appropriate care) screening was accurate. This deficient practice had the potential to result in inappropriate placement and unidentified specialized services for Resident 11 and 33. Findings: a) During a review of Resident 11's admission Record, the admission Record indicated Resident 11 was admitted to the facility on [DATE] with diagnoses including schizophrenia, unspecified a mental illness that can affect thoughts, mood, and behavior), type 2 diabetes mellitus ( a long -term condition in which the body has trouble controlling blood sugar and using it for energy) and essential hypertension ( high blood pressure). During a review of Resident 11's Minimum Data Set (MDS - a resident assessment tool),…

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 a comprehensive care plan for one of two sampled residents (Resident 296) who had bilateral (both) hand mittens. This deficient practice had the potential to negatively affect the quality of life and wellbeing for Resident 296 to prevent him from achieving his highest practical well-being. Findings: During a review of Resident 296's admission Record, the admission Record indicated Resident 296 was admitted to the facility on [DATE] with diagnoses including chronic respiratory failure with hypoxia (inadequate levels of oxygen [life sustaining element of air] in the body), tracheostomy (a surgical procedure that creates an opening in the trachea (windpipe) to provide an airway when the natural airway is blocked or compromised), and gastrostomy (a surgical procedure that creates an opening in the abdomen and inserts a tube directly into the stomach). During a review of Resident 296's history and physical (H/P) dated 10/25/2024, 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.

Based on observation, interview, and record review, the facility failed to provide services to one of 13 sampled residents (Resident 76) with limited range of motion [(ROM) full movement potential of a joint (where two bones meet)] and mobility (ability to move) by failing to transfer Resident 76 out of the bed daily. This failure had the potential to result in Resident 76's decreased activity tolerance and to experience limited social interaction, affecting Resident 53's quality of life. Findings: During a review of Resident 76's General Acute Care Hospital (GACH) Documents Review Report, the GACH Documents Review Report indicted Resident 76 was admitted to the GACH on 3/27/2024 and found to have a meningioma (brain tumor). The GACH Documents Review Report indicated Resident 76 underwent surgical removal of the meningioma on 4/2/2024, partial removal of the skull on 4/3/2024, and placement of a tracheostomy tube (hole made through the front of the neck and into the windpipe [trachea]) for breathing on 4/13/2024. During a review of Resident 76's General Acute Care Hospital (GACH)…

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 obtain a podiatry (foot doctor) consult after one of three sampled resident (Resident 8) was noted with a thickened toenail of the left hallux (big toe). This deficient practice resulted in a delay of needed foot care services and had the potential to contribute to a negative physical and psychosocial wellbeing of Resident 8. Findings: During a review of Resident 8's admission record, the admission record indicated Resident 8 was admitted on [DATE] with diagnoses including downs syndrome (a condition that can affect how he brain and body develops causing mental and physical challenges), chronic kidney disease (a long-term condition where the kidneys gradually lose their ability to filter waste products from the blood), attention to gastrostomy, (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems) and reduced mobility. During a review of Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to monitor, assess, document and discontinue a peripheral intravenous (IV) hep lock (is an intravenous catheter that is threaded into a peripheral vein, flushed with saline, and capped off for later use) site when IV therapy was completed for one of three sampled residents (Resident 42). This failure had the potential to result in Resident 42's IV hep lock site to develop an infection. Findings: During a review of Resident 42's admission Record, the admission Record indicated, Resident 42 was initially admitted to the facility on [DATE] and last re-admission was on 1/31/2025 with right foot open wound, sepsis (a life-threatening blood infection), and diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 42's History and Physical (H&P) , dated 1/12/2025, the H&P indicated, Resident 42 had the capacity (ability) to understand and make decision. During a review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure one of three sampled ventilator (a medical device to help support or replace breathing) dependent resident (Resident 40)'s Heat and Moisture Exchanger (HME - way to provide humidification to adult tracheostomy [a surgical procedure that creates an opening in the trachea or windpipe to provide an airway when the natural airway is blocked or compromised]residents) portion of the ventilator circuit (tubing that connects the ventilator to the resident) was changed as scheduled. The failure had the potential to result in harboring of microorganisms (germs) in the respiratory equipment which can cause infection. Findings: During a review of Resident 40's admission Record, the admission Record indicated Resident 40 was readmitted to the facility on [DATE] with diagnoses including anoxic brain damage (a condition where the brain is deprived of oxygen for a prolonged period, leading to cell death and damage), dependence on ventilator,…

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

Based on observation, interview, and record review, the facility failed to provide Speech Therapy (SLP, profession aimed in the prevention, assessment, and treatment of speech, language, communicative, and swallowing disorders) services to one of 13 sampled residents (Resident 76) with limited range of motion ([ROM] full movement potential of a joint [where two bones meet]) and mobility (ability to move) by failing to: 1. Provide SLP services to Resident 76 in accordance with the SLP Evaluation recommendations, dated 8/6/2024. 2. Provide a SLP Evaluation in accordance with Resident 76's physician orders, dated 1/23/2025. These failures had the potential to prevent Resident 76 from improving speech, cognition, and the ability to eat by mouth. Findings: During a review of Resident 76's General Acute Care Hospital (GACH) Documents Review Report, the GACH Documents Review Report indicted Resident 76 was admitted to the GACH on 3/27/2024 and found to have a meningioma (brain tumor). The GACH Documents Review Report indicated Resident 76 underwent surgical removal of the meningioma 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 observation, interview, and record review, the facility failed to ensure one of two Physical Therapists (PT 1) had a current and active license to provide Physical Therapy ([PT] profession aimed in the restoration, maintenance, and promotion of optimal physical function) treatment at the facility. This deficient practice resulted in PT 1 providing intervention to Resident 90 and had the potential for PT 1 to provide intervention to other residents requiring PT treatment with an invalid PT license. Findings: During a review of Resident 90's admission Record, the admission Record indicated the facility admitted Resident 90 on [DATE] with diagnoses including displaced fracture (break in bone) of the medial condyle (middle upper bone bump) of the left tibia (larger of the two bones located in the leg between the knee and ankle), right foot drop (a condition that makes it difficult to lift the front of the right foot), difficulty in walking, and muscle weakness. During a review of Resident 90's Minimum Data…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on, interview, and record review, the facility failed to ensure one of five sampled residents (Resident 29) was offered the pneumococcal vaccine (a vaccination that protects against pneumococcal bacteria, which can cause serious infections such as pneumonia, meningitis, and sepsis) upon admission to the facility. This deficient practice had the potential to increase the risk of Resident 29 acquiring, transmitting, or experiencing complications from the pneumococcal disease. Findings: During a review of Resident 29's admission Record, the admission Record indicated Resident 54 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including chronic respiratory failure with hypoxia (a condition in which the lungs are unable to adequately exchange oxygen and carbon dioxide over a prolonged period), , traumatic brain injury (TBI-a disruption in the normal function of the brain that can be caused by a bump, blow, or jolt to the head), and seizures (a sudden, uncontrolled electrical…

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 staff failed to ensure funds were returned to social security after a resident was discharged from the facility for one of three sampled residents (Resident 1). This deficient practice resulted in the Business Office Manager (BOM) not refunding social security funds back within three business days as indicated per the facility ' s Policy and Procedure (P&P) titled, Links Healthcare Resident Trust Policy. 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] and readmitted on [DATE] with diagnoses including metabolic encephalopathy (temporary or permanent damage to the brain due to lack of glucose, oxygen or other metabolic agent, or organ dysfunction), chronic obstructive pulmonary disease ([COPD] a chronic lung disease causing difficulty in breathing), and type 2 diabetes mellitus ([DM] a disorder characterized by difficulty in blood sugar control and poor wound…

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 six sampled resident ' s (Resident 2) care plans were revised after Resident 2 fell on 2/10/2024, and 7/14/2024. This deficient practice resulted in Resident 2 ' s continued falls and subsequent skin tear and discoloration to the left temporal (the area behind the temples and ears) area of her head following a third fall on 11/15/2024. Findings: During a review of Resident 2 ' s admission Record (Face sheet), the Face Sheet indicated Resident 2 was admitted to the facility on [DATE] with a diagnosis including metabolic encephalopathy (a condition of the brain that can causes confusion, memory loss or loss of consciousness), unspecified dementia (a condition of loss of mental functioning such as thinking, remembering and reasoning that interferes with a person ' s daily life and activities) and end stage renal disease ([ESRD] a condition in which the kidneys stop working and are not able to remove wastes and extra water from…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure two of six sampled residents (Resident 1 and Resident 5) were provided incontinence care in a timely manner. This deficient practice resulted in Residents 1 and 5 sitting in a wet and soiled diaper for 55 minutes after they requested assistance and this deficient practice had the potential to cause break down in Resident 1 and 5 ' s skin and cause them to feel uncomfortable, undignified and embarrassed. Findings: a. During a review of Resident 1 ' s admission Record (Face sheet), the Face Sheet indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included a cerebral infarction ([stroke] a serious condition that occurs when the blood flow to the brain is blocked, causing the brain tissue to and hypertension ([HTN]. During a review of Resident 1 ' s Minimum Data Set ([MDS] a resident assessment tool) dated 12/20/2024, the MDS indicated Resident 1 was able to make decisions…

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 six sampled resident ' s (Resident 2) did not fall an sustain an injury when her care plans were revised after Resident 2 ' s falls on 2/10/2024, and 7/14/2024. This deficient practice resulted in Resident 2 sustaining a skin tear and discoloration to the left temporal (the area behind the temples and ears) area of her head following a third fall on 11/15/2024. Findings: During a review of Resident 2 ' s admission Record (Face sheet), the Face Sheet indicated Resident 2 was admitted to the facility on [DATE] with a diagnosis including metabolic encephalopathy (a condition of the brain that can causes confusion, memory loss or loss of consciousness), unspecified dementia (a condition of loss of mental functioning such as thinking, remembering and reasoning that interferes with a person ' s daily life and activities) and end stage renal disease ([ESRD] a condition in which the kidneys stop working and are not able to remove wastes and extra…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a Certified Nursing Assistant (CNA 1) did not turn and reposition a resident (Resident 1) who required a two-person physical assist with bed mobility, by himself, without the assistance of another staff for one of three sampled residents (Resident 1). This deficient practice resulted in Resident 1 ' s left hand scratching his right forearm which resulted in a scratch measuring 0.2 centimeters (cm- unit of measurement) by 2 cm. Findings: During a review of Resident 1 ' s admission Record (Face Sheet), the Face sheet indicated Resident 1 was admitted on [DATE] with the diagnoses of hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (weakness of one side of the body) the following cerebral infarction (a blood clot which blocks an artery that supplies blood to the brain) affecting the left side. During a review of Resident 1 ' s Minimum Data Set (MDS – a federally mandated resident assessment tool)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of four sampled residents (Resident 1) was treated with dignity and respect when the Assistant Director of Nursing (ADON) mentioned to Resident 1 that peace can be found six feet below the ground. This deficient practice resulted Resident 1's feeling sad and depressed. Findings: During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was originally admitted to the facility on [DATE] with diagnoses including acute and chronic respiratory failure (a condition where there's not enough oxygen [element that supports life] or too much carbon dioxide [important part of air] in your body) and schizoaffective disorder (a mental health disorder affecting how resident interprets reality). During a review of Resident 1's Minimum Data Set ([MDS]), a standardized assessment and care screening tool), dated 7/29/2024, the MDS indicated Resident 1's cognition was moderately impaired. During a review of Resident 1's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to report family member 2's (FM 2) allegation of abuse, involving one of four sampled residents (Resident 1), to the California Department of Public Health (CDPH), State Long Term Care Ombudsman (an agency that assist residents in long-term care facilities with issues related to day-to-day care, health, safety, and personal preferences), and local police within the regulated time frame of two hours. This deficient practice resulted in CDPH's inability to investigate the allegation of abuse timely and had the potential for other allegations of abuse to go unreported. Findings: During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was originally admitted to the facility on [DATE] with diagnoses including acute and chronic respiratory failure (a condition where there's not enough oxygen [element that supports life] or too much carbon dioxide [important part of air] in your body) and schizoaffective disorder (a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to prevent further potential abuse for one of four sampled residents (Resident 1) after family member 2's (FM 2) reported allegations of abuse by failing to: a. Immediately assess Resident 1's physical and psychosocial status and evaluation of whether the alleged victim felt safe. b. Immediately notify Resident 1's physician. c. Remove access of the Assistant Director of Nursing (ADON) to Resident 1 and other residents after the allegation was reported on 7/19/2024. d. Notify the California Department of Public Health (CDPH), State Long Term Care Ombudsman (an agency that assist residents in long-term care facilities with issues related to day-to-day care, health, safety, and personal preferences), and local police; and e. Provide the five-day conclusion of facility investigation to the CDPH. These deficient practices resulted in the inability of CDPH to determine if FM 2's allegation of abuse was true and failure to protect Resident 1 and other…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to report an injury of unknown origin (the cause of injury was not observed by any person or could not be explained by the resident) to California Department of Public Health (CDPH) for one of three sampled residents (Resident1) when Resident 1 had swelling on the right knee on with a right femur fracture (break in the thigh bone) on 5/29/2024. This failure had the potential to result into a delayed investigation to rule out abuse and neglect. Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including anoxic brain damage( irreversible damage to the brain caused by lack of oxygen) cardiac arrest ( abrupt loss of heart function), tracheostomy(opening surgically created in the neck into the windpipe to allow air to fill the lungs) and gastrostomy tube ( G-tube inserted through the wall of the abdomen into the stomach used to give medicines…

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), who was prescribed with Percocet (medication used to help relieve moderate to severe pain that contains combination of acetaminophen and oxycodone) were reassessed and monitored for its continued used. This failure had the potential for Resident 1 to receive unnecessary medication and at risk for adverse drug effects (unwanted undesirable effects that are possibly related to a drug) of Percocet. Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including anoxic brain damage( irreversible damage to the brain caused by lack of oxygen) cardiac arrest ( abrupt loss of heart function), tracheostomy(opening surgically created in the neck into the windpipe to allow air to fill the lungs) and gastrostomy tube ( G-tube inserted through the wall of the abdomen into the stomach used to give medicines 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 ensure one of three sampled residents (Resident 1), who was transferred from the facility ([DATE]) to a General Acute Care Hospital (GACH) for evaluation and treatment after being found lethargic (a condition marked by drowsiness and an unusual lack of energy and mental alertness) and hypotensive (low blood pressure), was readmitted to the facility after Resident 1 was treated and stabilized at the GACH ([DATE]). This deficient practice resulted in Resident 1 remaining at the GACH for approximately 43-47 days after Resident 1 was deemed appropriate for discharge back to the facility ([DATE] - [DATE]) but was denied readmission by the facility. Resident 1 was subsequently transferred to a different facility placing the resident at risk for confusion, disorientation and psychosocial harm related to dislocation from a place that was considered Resident 1's home. Findings: During a review of Resident 1's admission Record (Face Sheet) the Face Sheet…

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 six out of six sampled residents (Resident 38, Resident 78, Resident 237, Resident 81, Resident 80, and Resident 20) had a completed acknowledgement of advance directives and Physician Orders for Life-Sustaining Treatment ([POLST]- a medical order that helps give people with serious illness more control over their care during a medical emergency) in their medical records. These failures had the potential for delay of care and treatment and/ or inadvertently missed health care wishes/ decisions of the residents during emergency, changes in condition and end of life. Findings: A. During a review of Resident 38's admission Record, the admission Record indicated, Resident 38 was admitted to the facility on [DATE] with diagnoses including metabolic encephalopathy (a condition in which brain function is disturbed either temporarily or permanently due to different diseases or toxins in the body), end stage renal disease (a medical condition in which 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 ensure one of 2 sampled residents (Resident 80) was treated with respect and dignity by failing to provide clean and dry adult incontinence briefs and bed sheets for Resident 80. Resident 80 was observed sitting in saturated adult briefs and wet bed sheets, and urine was leaking from the adult briefs onto the bed sheets. This deficient practice violated the rights of Resident 80's for dignity. Findings: During a review of Resident 80's admission Record, the admission Record indicated Resident 80 was admitted on [DATE] with diagnoses of cerebral infarction (refers to damage to tissues in the brain due to a loss of oxygen to the area), hyperlipidemia (unhealthy levels of fats in the blood), and urinary tract infection (infections that happen when organisms enter the tube through which urine leaves the body causing inflammation). During a review of Resident 80's History and Physical (H/P), the H/P indicated, Resident 80 has the capacity to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of two sampled resident (Resident 20) hand mittens (soft gloves that are designed to restrict the movement of one or both hands, and are used with patients that have removed essential lines or tubes on more than one occasion) restraints (any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or restricts normal access to one's body), were assessed, monitored per physician's order dated 2/1/2024 and Resident 20's untitled care plan for restraints initiated on 1/11/2024. These deficient practices had potential to result in skin injury, and compromised circulation of the right hand. Findings: During a review of Resident 20's admission Record, the admission Record indicated Resident 20 was admitted to the facility on [DATE] with diagnoses including sepsis (an infection that is spread…

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 38) was left unsupervised, while attempting to go to the bathroom. This failure put Resident 38 at an increased risk for fall and injury. Findings: During a review of Resident 38's admission Record, the admission Record indicated, Resident 38 was admitted to the facility on [DATE] with diagnoses including metabolic encephalopathy (a condition in which brain function is disturbed either temporarily or permanently due to different diseases or toxins in the body), end stage renal disease (a medical condition in which a person's body fails to filter toxins out of the body) on hemodialysis (a mechanical treatment to filter toxins from the body) dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), and cataract (a clouding of the lens of the eye obstructing vision). During a review of Resident 38'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.

Based on observation, interview and record review, the facility failed to ensure one of four sampled residents (Resident) 12's medication regimen was free from significant medication errors. This deficient practice jeopardized Resident 12's health and safety by the failure to administer the medication via Gastrostomy ([G-tube] a tube inserted through the wall of the abdomen directly into the stomach to deliver nutrition and medication) in accordance with the physician order and/or manufacturer's specification. The failure had the potential for Resident 12 to experience adverse reactions (undesired effect of a drug (medication)) that included but not limited to, severe stomach pains, stomach irritation, or G-tube clogging (an obstruction which makes movement or flow of feeding or medication difficult or impossible). Findings: During a review of Resident 12's admission Record, the admission Record indicated the facility admitted Resident 12 on 5/7/2022 with diagnoses that included encounter for attention to Gastrostomy (G-tube), Gastroesophageal reflux disease ([GERD], is the backward…

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

Based on observation, interview and record review, the facility failed to ensure one of four sampled residents (Resident) 12's medication regimen was free from significant medication errors. This deficient practice jeopardized Resident 12's health and safety by the failure to administer the medication via Gastrostomy ([G-tube] a tube inserted through the wall of the abdomen directly into the stomach to deliver nutrition and medication) in accordance with the physician order and/or manufacturer's specification. The failure had the potential for Resident 12 to experience adverse reactions (undesired effect of a drug (medication)) that included but not limited to, severe stomach pains, stomach irritation, or G-tube clogging (an obstruction which makes movement or flow of feeding or medication difficult or impossible). Findings: During a review of Resident 12's admission Record, the admission Record indicated the facility admitted Resident 12 on 5/7/2022 with diagnoses that included encounter for attention to Gastrostomy (G-tube), Gastroesophageal reflux disease ([GERD], is the backward…

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 proper use of personal protective equipment (PPE- garments, gear or equipment designed to protect from injury or infection) in the kitchen by one of three dietary aides (DA), DA 1. This failure had the potential for DA 1's hair shedding into residents' food he is preparing. Findings: During a tray line observation on 2/20/2024 at 11:45 a.m., DA 1 was not wearing a beard guard (a latex-free net used to prevent hair from falling into food) while placing trays in the food warmer. During a concurrent observation and interview on 2/20/2024 at 12:30 p.m., with the Dietary Manager (DM), the DM stated DA 1 was not wearing a beard guard and stated DA 1 should be wearing a beard guard while in the kitchen. During an interview on 2/22/2024 at 1:28 p.m., with the Registered Dietician (RD), the RD stated the required attire in the kitchen included beard guards and DA 1 should have been wearing one. The RD stated it was important to wear a beard guard to prevent hair from getting in the resident's food. A review…

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

Based on interview and record review, the facility failed to ensure the Binding Arbitration Agreement (signed agreement to settle issues with a neutral party instead of going to court) was explained to, and acknowledged by one of the 2 sampled residents (Resident 76). This failure posed the risk for the resident to make uninformed decisions regarding the right to file an appeal if there was any allegations of medical malpractice. Findings: During a review of the Arbitration agreement on 01/22/2024 at 4 p.m., facility provided the list of residents who entered into arbitration agreement (42 residents). the two sampled residents were Resident 76 and Resident 58. During a review of Resident 76's admission Record, the admission Record indicated the facility admitted Resident 76 on 12/27/2023 with diagnoses that included hemiplegia (extreme weakness of one side of the body) and hemiparesis (weakness of one side of the body), diabetes mellitus (a diseases that affect how the body uses blood sugar and results in high blood sugar) and slurred speech. During a review of Resident 76's History…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to protect one of four sampled resident's (Resident 1) right to personal privacy and confidentiality when Certified Nurse Assistant (CNA) 1 photographed Resident 1's Restorative nursing assistant (RNA [provides rehabilitative care to individuals recovering from illnesses or injuries]) notes using her personal cell phone. This deficient practice resulted in the violation of Resident 1's right to privacy and confidentiality and had the potential to negatively affect Resident 1's psychosocial well-being. Findings: During a review of Resident 1' admission Record (Face sheet), the Face sheet indicated Resident 1 was admitted to the facility on [DATE] with the diagnoses including cerebral infarction (disruption of blood to the cells of the brain) affecting left non-dominant side, leukemia (cancer of blood), angina pectoris (chest pain), legal blindness and opioid (pain medication) dependence. During a review of Resident 1 's Minimum Data Set…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to screen two of three sampled residents (Resident 2 and Resident 3) for Candida auris ([C. auris] a yeast type of fungus that causes severe infections]) immediately after being informed on 8/19/2023 of possible exposure from Resident 1 (roommate of Resident 2 and 3). This failure had the potential to spread infectious microorganism (organism that cause infection) from person to person or objects and equipment throughout the facility and increase the risk of infection for the residents and staff causing fever, chills, and low blood pressure. Findings: During an observation on 8/23/2023, at 12:33 p.m. observed Resident 2 and Resident 3 were on contact isolation (when a patient has an infectious disease that may be spread by touching either the patient or objects the patient has handled) for C. auris. During a review of Resident 1 ' s admission Record (AR), indicated Resident 1 was originally admitted to the facility on [DATE] with diagnoses…

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 readmit one of three sampled residents, (Resident 1) from the general acute care hospital (GACH) after Resident 1 was cleared by GACH to return to the facility on [DATE]. This deficient practice resulted in the denial of Resident 1 ' s right to return to the facility. Findings: During an observation on [DATE] at 1:00 p.m. in the facility ' s sub-acute unit (inpatient care unit for patients with complex health problems) there were two empty beds available in the facility to admit Resident 1. During a review of Resident 1 ' s admission Record (AR), indicated Resident 1 was originally admitted to the facility on [DATE] with diagnoses that included cardiac arrest (occurs when the heart suddenly and unexpectedly stops pumping), anoxic brain damage (caused by a complete lack of oxygen to the brain which results in death of the brain cells), respiratory failure ( difficulty breathing on your own), tracheostomy (an incision in the throat to…

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