Monterey Palms Health Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure there was a proper diagnosis and indication associated with the use of one psychotropic medication for one of five residents reviewed (Resident 114). This failure had the potential for the residents to receive unnecessary medication.On May 12, 2026, the medical record of Resident 114 was reviewed and the following was noted: Resident 114 was [AGE] years old, admitted to the facility on [DATE], with diagnoses that included dementia with psychotic disturbance, major depressive disorder, and anxiety disorder; Resident 114 had a physician order on May 4, 2026, for ramelteon 8 mg by mouth daily 30 minutes prior to bedtime without an indication or diagnosis, which was discontinued on May 7, 2026; Resident 114 had a physician order on May 7, 2026, for ramelteon 8 mg by mouth daily at bedtime for supplement; and The electronic medication administration record (eMAR) in Resident 114's medical record indicated Resident 114 received a dose of ramelteon 8…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 care and treatment for an injury/wound to prevent decline in skin integrity for a right second toe injury for one of 21 residents reviewed (Resident 3).This failure resulted in the wound going unmonitored, placing the resident at risk for infection and skin breakdown.Findings:On May 11, 2026, at 11:16 a.m., an observation and a concurrent interview was conducted with Resident 3. Resident was observed resting in bed without socks on. The right second toe was observed with a discolored area below the nailbed with a wound/injury present. The area was open to air, and no wound dressing was visualized. Resident stated his foot hit the door in his room a few days ago, possibly a week ago. Resident stated that the injury occurred during transport to the emergency room (ER) by paramedics. Resident was alert, oriented and able to self-report the incident. Resident denied pain and stated he did not report the injury to nursing…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 respiratory care and treatment for one resident (Resident 85) reviewed for oxygen (O2) use when the nasal cannula (NC - a tube used to deliver oxygen through the nose) was not dated when it was last replaced. This failure had the potential to result in deterioration of the nasal cannula, which would allow infectious organisms to grow, causing an infection. Findings: On May 11, 2026, at 12:05 p.m., Resident 85 was observed in bed, awake and alert. Resident 85 was using an NC for O2. The NC did not have a label to indicate the date when it was last changed. In a concurrent interview, Resident 85 stated she did not know when the NC was last changed. On May 11, 2026, at 12:09 p.m., a concurrent observation and interview was conducted with Licensed Vocational Nurse (LVN) 5. LVN 5 observed the NC for Resident 85 and confirmed the NC did not have a label with the date when it was last changed. LVN 5 stated without a date, there was no…

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

Based on observation, interview, and record and document review, the facility failed to ensure accurate and complete record of controlled substances (CSs), free of discrepancies when the remaining volume in the one pharmacy-labeled bottle containing hydromorphone (a federally scheduled II CS which has the highest potential for addiction and abuse) 5 mg/5 ml (5 milligram per 5 milliliter, unit of concentration of a liquid) oral solution did match the corresponding CS dispense log. This failure could lead to potential diversion of CS and residents not receiving medications needed for pain relief.On May 13. 2026, at 1:49 p.m., during a controlled substance (CS) audit in E Court Medication Cart 1 with Licensed Vocational Nurse (LVN) 1, the following was noted: There was a pharmacy-dispensed bottle labeled, hydromorphone 5 mg/5 ml solution for Resident 10 with the dispensed date of April 1, 2026;The bottle had approximately 100 ml of the solution;The dispense log for Resident 10's hydromorphone solution indicated 2-ml doses were logged out from April 12, 2026, with the last 2-ml dose…

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

Based on observation, interview, and record review, the facility failed to ensure one of two sampled residents (Resident 57) was provided with special adaptive equipment as ordered by physician for eating with meals.This failure had the potential to result in a burn accident while Resident 57 drinking hot beverage.On May 11, 2026, at 12:28 p.m., a concurrent observation and meal ticket (contains Resident name, room number, physician diet order, allergies, adaptive equipment, food like and dislike) review were conducted with Resident 57 at Assisted Feeding dining room. Resident 57's meal ticket indicated, 2 Handled cup (sippy cup). Resident 57 was observed being used regular cup serving beverage.On May 12, 2026, at 12:42 p.m., an observation was conducted with Resident 57 at Assisted Feeding dining room. Resident 57 was observed both of her hands were shaking intensely.On May 12, 2026, at 1:01 p.m., a concurrent observation, interview and meal ticket review were conducted with Resident 57 and Certified Nursing Assistant (CNA) 2 at Assisted Feeding dining room. CNA 2 reviewed Resident…

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

Based on observation, interview and record review, the facility failed to dispose of garbage and refuse properly when trash were found outside surrounding the dumpsters. And the lids of the dumpsters did not close properly due to overflowing.This failure had the potential to attract pests and rodents.On May 11, 2026, at 9:39 a.m., a concurrent observation and interview were conducted with the Dietary Supervisor (DS) outside back kitchen at dumpster area. There was three dumpsters, one for recycle and another two for trash. The lids of the two trash dumpsters were unable to fully close due to overflowing with trash. Trash was found on floor surrounding the trash dumpster area. One of the recycled dumpster's lid was widely opened. The DS stated surrounding dumpsters should not have trash and dumpsters' lids should close properly to prevent attract pests.On May 11, 2026, at 9:45 a.m., an interview was conducted with the Registered Dietitian (RD). The RD stated it was infection control, and environment hazard issue with trash surrounding dumpsters and lids of the dumpsters not close…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 residents (Resident 1) was treated with dignity and respect when a staff member called the resident a liar after the resident alleged the staff member had purposely hit his elbow away while providing resident care.This failure resulted in Resident 1 becoming upset and angry. Findings:On January 29, 2026, at 4:20 p.m., an interview was conducted with Resident 1, who stated he could not remember the exact date, but Certified Nursing Assistant (CNA) 1 was providing perineal (area of skin between the anus and genitals) care for him when he asked CNA 1 if CNA 1 would hand him a wipe. When he (Resident 1) reached for the wipe CNA 1 Hit his elbow out of the way. Resident 1 stated it was more than a push. Resident 1 stated he told CNA 1, You hit my elbow, and CNA 1 responded by yelling You're a liar. Resident stated (CNA 1) Got mad at me, and it was upsetting, it made me mad. Resident 1 stated he was not sure of the exact date but he…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 pharmacy services were provided to meet the needs of residents when two of four sampled residents' (Resident 3 and Resident 7) medications were not administered in accordance with the physician orders. This failure has the potential to negatively impact the effectiveness of the medication which could lead to worsening of Residents 3 and 7's health condition. Findings: On April 29, 2025, at 1:20 p.m., Resident 3 was interviewed. Resident 3 was alert and oriented. Resident 3 stated he would at times receive his antibiotic late or early. A review of Resident 3's admission record indicated the resident was admitted to the facility on [DATE], with diagnoses which included bacteremia (bacteria in blood), diabetes (high blood sugar), hypertension (high blood pressure). A review of the physician order dated April 11, 2025, indicated, cefazolin 2 (grams) gm/(milliliter) mL (gm/mL measure of metric) administer intravenous (in the vein) every 8 hours at…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 medical records were maintained in accordance with the accepted professional standards and practices when three of four sampled residents' (Resident 3, Resident 5, and Resident 6) medication administrations were not accurately documented. This failure increased the risk for medication errors which could negatively impact Residents 3, 5, and 6's health condition. Findings: On April 29, 2025, at 1:20 p.m., Resident 3 was interviewed. Resident 3 was alert and oriented. Resident 3 stated he would at times receive his antibiotic late or early. A review of Resident 3's admission record indicated the resident was admitted to the facility on [DATE], with diagnoses which included bacteremia (bacteria in blood), diabetes (high blood sugar), and hypertension (high blood pressure). A review of the physician order dated April 11, 2025, indicated, cefazolin 2 (grams) gm/(milliliter) mL (gm/mL measure of metric) administer intravenous (in the vein) every 8…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 dietetic service observations, dietary staff interviews and dietary document reviews the facility failed to ensure that dietary staff safely and effectively carried out the functions of food and nutrition services when: 1. Dietary Aide (DA) 2 did not follow manufacture's guideline time length for testing the Quaternary (Quat) sanitizer (sanitizing solution used for sanitizing food contact surfaces); 2. [NAME] 2 did not follow the proper steps to clean the Prep counter after preparing raw chicken on January 28, 2025, (Cross reference to 812); and 3. [NAME] 1 was unable to demonstrate proper Cooling Food (an essential process used in food production to prevent foodborne illness. Bacteria grow best in food in the temperature range 135°F (°F - a unit of measurement) to 41°F, also referred to as the temperature danger zone. Food must be cooled quickly to minimize bacterial growth. If left out to cool, cooked food can become unsafe to eat in a matter of hours). These failures had the potential to cause foodborne illness for 89 out of 89 sampled residents who received food 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.

Based on dietary observation, dietary staff interview and record review, the facility failed to ensure the menus, recipes, Cooks spreadsheet were followed and resident nutritional needs were met when: 1. [NAME] 1 and [NAME] 2 did not follow the Cooks spreadsheet (the menu document used to guide dietary staff on food items, portions, texture of foods and therapeutic diet) to serve the portion size of pureed food items during the noon meal on 1/27/2025 and 1/28/2025; 2. [NAME] 1 did not follow recipe to make pureed cauliflower during the noon meal on January 27, 2025; 3. [NAME] 2 did not follow recipe to make Buttered corn during the noon meal on January 28, 2025 (Cross reference 804); 4. Dietary Aide 1 did not follow the Cooks spreadsheet served the right dessert for Low fat low cholesterol diet and Cardiac diet during the noon meal on January 28, 2025; and 5. The Dietary Manager served salad dressing without measuring during noon meal on January 27, 2025. These failures had the potential for 89 out of 89 sampled residents receiving food prepared in the kitchen to not meet their…

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

Based on observation, interview, and record review, the facility failed to follow its policy and procedure to provide appetizing and palatable (refers to the taste and/or flavor of the food) food at appropriate temperatures according to residents' preferences, for seven out of 89 sample residents, Residents 23, 43, 47, 82, 84, 96 and 99. This failure placed residents at risk for decreased nutritional intake and had the potential to affect the resident's nutritional status. Findings: (Cross reference 803) On January 27, 2025, at 9:27 a.m., during an interview, Resident 96 stated the food was cold most of the time. On January 27, 2025, at 10:59 a.m., during an interview, Resident 43 stated dinner needs to be warm and served on time. On January 27, 2025, at 10:59 a.m., during an interview, Resident 47 stated they did not like the taste of the food. On January 27, 2025, at 11:27 a.m., during an interview, Resident 82 stated the food was terrible and cold. On January 27, 2025, at 11:56 a.m., during an interview, Resident 84 stated the food was terrible, and eggs were cold. On January 28,…

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

The facility failed to maintain a sanitary environment, prepare, and serve food in accordance with the professional standards for food service and safety when: 1. Kitchen equipment was stored wet; 2. Dust was found on several locations in the kitchen; 3. Build-up on kitchen equipment: on storage shelves in walk in freezer, on the blender machine, ice machine and hot waterspout; 4. Two opened tortillas exposed to the air in walk in refrigerator; 5. Ground beef was placed in walk in refrigerator for defrosting without a label; 6. Strainer had brown spots on the sieve (mesh in the strainer frame); 7. Two cracked tiles and one broken tile found in dishwashing area; 8. Four jackets found on the rack in storage area number 2; 9. One cutting board was marred found in kitchen; and 10. Cook 2 did not follow proper steps to clean the prep counter after preparing raw chicken. (Cross reference 802) These failures had the potential to cause foodborne illnesses (stomach illness acquired from ingesting contaminated food) in a medically vulnerable population of 89 of 89 residents who received food…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 person-centered care plan was developed and implemented for a resident with a new diagnosis of pulmonary emboli (a condition in which one or more arteries in the lungs become blocked by a blood clot) and on anticoagulant (medication used to prevent blood clots from forming or growing larger) treatment. This failure had the potential to delay the necessary care and services which could place Resident 24 at risk for another life-threatening blood clot or other complications that could develop related to the treatment with an anticoagulant. Findings: On January 27, 2025, at 1:40 p.m., Resident 24 was observed awake, alert, lying on bed. Resident 24 was asked if he was hospitalized recently. Resident 24 could not recall. On January 28, 2025, Resident 24's record was reviewed. Resident 24 was admitted to the facility on [DATE], and was re-admitted on [DATE], with diagnoses which included heart failure (a chronic condition in which the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide the necessary care and services to maintain cleanliness and proper hygiene of resident's fingernails for one of 19 residents reviewed (Resident 29). This failure had the potential to negatively impact the physiological and psychological well being of Resident 29. In addition this failure had the potential to result in cross contamination of bacteria underneath the dirty fingernails to Resident 29's food during meals. Findings: On January 27, 2025, at 2:30 p.m., an Enhanced Barrier Precaution (EBP - a type of infection control practices that use personal protective equipment to reduce the spread of multidrug resistant organism) sign was observed outside Resident 29's room. Resident 29 was observed asleep. A review of Resident 29's record, on January 28, 2025, indicated Resident 29 was admitted to the facility on [DATE], and had a latest readmission on [DATE], with diagnoses which included cerebral infarction (a condition that…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 medications and biologicals were properly stored when: 1. One of 36 residents reviewed (Resident 47) had a bottle of medication from an outside pharmacy by her bedside, readily available for use; 2. Three expired Daptomycin antibiotic (medications used to treat infections) intravenous piggyback (IVPB - a method of administering IV antibiotics by piggybacking it to a primary IV fluids) were stored in the F Court medication room refrigerator for Resident 68, readily available for use. These failures had the potential for the residents to self-administer a medication without licensed nurse monitoring and to receive expired or ineffective medications. Findings: 1. On January 27, 2025, at 11:25 a.m., an observation and concurrent interview was conducted with Resident 47. Resident 47 was observed in her wheelchair by the bedside. Resident 47 was alert, oriented with some confusion noted. An orange medication bottle from (name of outside…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 resident's food preference was honored for one of three sampled residents (Resident 50), when a turkey sandwich was on Resident 50's lunch plate and the meal ticket (lists resident's current diet, likes and dislikes for the current day and mealtime) indicated she disliked turkey and liked cottage cheese. This failure had the potential to result in decreased food intake, and could lead to unplanned weight loss, further compromising Resident 50's nutritional and medical status. Findings: On January 27, 2025, at 1:16 p.m., during a concurrent observation, interview and review of meal ticket was conducted with Resident 50 in the small dining hall. Resident 50's meal ticket that designated her food preferences and dislikes, was reviewed. The meal ticket listed 4 oz Cottage Cheese under preferences and Turkey under dislikes. Observed Resident 50 eating a turkey sandwich and the meal ticket indicated dislikes turkey and prefers cottage cheese to be served daily. Resident 50 stated she did not like turkey…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 dispose of garbage and refuse properly when trash was found outside on the floor surrounding the dumpsters, and the lids of the dumpsters did not close properly. This failure had the potential to attract pests and cause infection control issues. Findings: On January 27, 2025, at 8:41 a.m., an observation was conducted outside back kitchen at dumpster area. There ware three dumpsters, a white color recycle dumpster and another two black color dumpsters for trash. The recycle dumpster's lid and one of the trash dumpster's lids were not close. Trash (used gloves, used fork, napkins, opened cut boxes) was found on floor surrounding the dumpster area. On January 27, 2025, at 9:43 a.m., a concurrent observation and interview was conducted with the Dietary Services Supervisor (DSS) outside back kitchen at the dumpster area. The DSS acknowledged trash was found on floor surrounding the dumpster area. The DSS stated dumpsters' lids needed to close properly all the time otherwise would attract pests and cause infection…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 infection control measures for one of 19 residents reviewed for infection (Resident 507) who required contact isolation precautions (method to prevent the spread of serious illnesses that can be transmitted by direct or indirect contact), when multiple staff members were observed entering and exiting the resident's room without following contact isolation precautions. This failure had the potential to result in spreading infection to a vulnerable resident population. Findings: On January 29, 2025, at 2:22 p.m., Certified Nursing Assistant (CNA) 2 was observed entering Resident 507's room answering a call light and providing Resident 507 with water. CNA 2 did not wear appropriate PPE (Personal Protective Equipment - gown, gloves, mask) while in the room of Resident 507. On January 29, 2025, at 3:32 p.m., CNA 3 was observed entering Resident 507's room to perform vital sign monitoring. CNA 3 did not use a disposable blood pressure…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 basic accommodations of needs were provided when one of three residents, (Resident 3)'s call light was not within reach. This failure resulted in Resident 3 to be unable to call for assistance. Findings: On July 2, 2024, at 11:58 a.m., an unannounced visit to the facility for a complaint investigation was initiated. On July 2, 2024, at 1:42 p.m., observed Resident 3 sitting in a wheelchair at the foot of her bed. Resident 3's call light was wrapped around the right siderail. On July 2, 2024, at 1:42 p.m., an interview was conducted with Resident 3. Resident 3 stated she was unable to reach her call light and could not call for help. On July 2, 2024, at 1:57 p.m., an interview was conducted with the Certified Nursing Assistant, (CNA). The CNA stated that when residents are sitting in wheelchairs their call lights should be within reach. The CNA observed Resident 3's call light and stated that Resident 3's call light was not within…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 call lights (devices that emit a tone and light up indicating the location of the call, used by the residents to signal a need for assistance from facility staff), were answered timely, when two out of five residents (Residents 1 and 5), who required assistance from staff with activities of daily living (ADLs), verbalized their concerns of facility staff not answering their call lights and/or attending to their needs in a timely manner. This failure had the potential for delayed medical management and unmet care needs. Findings: On April 19, 2024, at 11:09 a.m., an unannounced visit was conducted at the facility for a quality-of-care complaint. On April 19, 2024, at 11:24 a.m., Resident 1 was observed lying in bed. During a concurrent interview, Resident 1 stated she was able to get up to the bathroom with staff assistance. Resident 1 stated she would press the call light to get assistance from staff. Resident 1 stated…

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

Based on observation, interview, and record review, the facility failed to ensure that two of three trash dumpster lids were securely closed. This failure had the potential to attract pests, insects, and vermin (animals that are believed to carry diseases such as rodents [rats/mice]) which could create an unsanitary environment for the vulnerable residents residing in the facility. Findings: On March 21, 2024, at 10:50 a.m., an unannounced visit was conducted at the facility for an environmental complaint. On March 21, 2024, at 11:05 a.m., an observation was conducted with the Administrator (Adm) and the Director of Nursing (DON) of the three facility trash dumpsters. One trash dumpster located at the back of the facility, near the kitchen, was observed with the lid open. The trash dumpster had two bags of trash and there were flies flying in and out. The second trash dumpster located across the driveway, near the facility property line by a brick wall, was observed with lid open was for recyclables. The dumpster was observed to be full of broken-down cardboard. During a concurrent…

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

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 abuse when his arm was held down by a Certified Nurse Aide's (CNA) knee while attempting to dress him. This failure resulted in Resident 1 being subjected to physical abuse, which had the potential to result in physical injury, emotional and psychological distress. Findings: On December 11, 2023, at 8:54 a.m., an unannounced visit was conducted at the facility to investigate a facility reported incident involving Resident 1. A review of Resident 1's admission record indicated he was admitted to the facility on [DATE], with diagnoses including hemiplegia (paralysis of one side of the body) and hemiparesis (one-sided muscle weakness), history of falling, cerebral infarction (stroke) and expressive language disorder (a problem with language communication). The MDS (Minimum Data Set, an assessment tool), dated October 1, 2023, indicated Resident 1 had severe cognitive impairment and unclear…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 assess, and monitor neuro-checks (a neurologic function assessment tool used to assess and monitor a resident's level of consciousness) on one of four residents (Resident 1), after an unwitnessed fall. This failure had the potential to result in an unassessed altered level of consciousness (ALOC- state of decreased awareness and/or arousability), and delay of treatment for Resident 1. Findings: On August 24, 2023, at 11:10 a.m., an unannounced visit was made to the facility to investigate a quality-of-care issue. A record review of Resident 1's medical records indicated the resident was admitted to the facility on [DATE], at 6:42 p.m., with diagnoses which included history of falls; syncope (Fainting) and collapse; delirium (Mental state of confusion). Resident 1 had a brief stay, of less than 24 hours at the facility, as she was discharged to the General Acute Care Hospital (GACH) on August 9, 2023, at 3:29 p.m., for re-evaluation of ALOC,…

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

Based on interview and record review the facility failed to maintain a comfortable environment for residents residing in one of the facility's nursing stations (F court nursing station) when temperatures were measured greater than 81 degrees Fahrenheit. This failure had the potential to result in uncomfortable temperatures for residents residing in F court nursing station. Findings: On July 25, 2023, at 10:37 a.m., during a concurrent observation and interview with Resident 1, she stated her room was warm a couple of days ago. On July 25, 2023, at 10:40 a.m., during an interview with the Administrator (ADM), he stated the facility's air conditioning system began to not blow cool enough air last week. He stated the facility's air conditioning units were overworked. On July 25, 2023, at 11:00 a.m., during a concurrent observation and interview with Resident 2, the resident noted to be sitting up at the side of his bed dressed and groomed. He stated the air conditioning went out about a week ago. He stated, It got a little warm. On July 25, 2023, at 11:35 a.m., during an interview with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure stored medical supplies were current when expired intravenous (within the vein) medication tubing was found in the facility's medication storage room. This failure had the potential to cause all of the facility's four residents receiving intravenous therapy to be exposed to expired intravenous equipment. Findings: On [DATE], at 10:39 a.m., during a concurrent observation and interview with Registered Nurse (RN)1, in station F court's medication storage room, 20 packets of CareFusion MaxPlus intravenous extension sets with expiration dates of [DATE], was observed. RN 1 stated the extension sets were expired and should have been thrown away. On [DATE], at 10:47 a.m., during a concurrent observation and interview with the Director of Nursing (DON), she reviewed the package of CareFusion MaxPlus intravenous extension set with an expiration date of [DATE], stored in the facility's F court medication storage room. The DON stated 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 the over-the-counter (OTC) medication, hydrogen peroxide (an antiseptic solution) brought by the resident's family member was stored properly and was ordered by the physician for one of 20 residents reviewed (Resident 14). In addition, the facility failed to provide care and services in accordance to their policy and procedure and in accordance with professional standard of practice. This failure had the potential for the hydrogen peroxide to cause irritation of Resident 14's mouth and cause side effects to the resident's teeth and may cause breathing problems if not properly used. Findings: On February 28, 2023, at 11:45 a.m., a concurrent observation and interview was conducted with Resident 14. Resident 14 was observed awake, lying in bed, and able to verbalize her needs. One bottle of 3% (percent - a unit of measurement) hydrogen peroxide was observed on the top of Resident 14's bedside cabinet readily available for use.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 an indwelling urinary catheter (a plastic flexible tube inserted into the bladder to collect urine) was monitored and assessed for the presence of sediment (particles or mucus) in the urine for one of two residents reviewed for catheters (Resident 16). This failure had the potential to delay the identification and treatment of a possible urinary tract infection for Resident 16. Findings: On March 1, 2023, at 11:58 a.m., a concurrent observation and interview was conducted with Resident 16, in his room. Resident 16 was observed lying in bed awake, alert, and able to verbalize his needs. Resident 16 was observed with an indwelling urinary catheter attached to the side of his bed. The indwelling urinary catheter tubing was observed with a moderate amount of sediment. Resident 16 stated his catheter had not been changed for a while. On March 1, 2023, at 12 p.m., a concurrent observation and interview was conducted with…

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

Based on observation, interview, and record review, the facility failed to ensure sanitary food preparation and storage practices were followed when: 1. One box of Tricolor Penne Pasta was left open to air; and 2. Gravy stored in a metal container was readily available for use after the use-by-date had already passed. These failures had the potential to expose residents to foodborne illness. Findings: 1. On March 1, 2023, at 9:30 a.m., an observation in the dry storage area was done. One box of Tricolor Penne Pasta was observed open to air. On March 1, 2023, at 9:44 a.m., an interview was conducted with the Dietary Manager (DM). The DM stated staff should have closed the box properly or thrown the box away. 2. On March 1, 2023, at 10:10 a.m., an observation in the kitchen's refrigerator was conducted. A metal container of gravy with a preparation date of February 26, 2023, and a use-by-date of February 29, 2023 was stored in the refrigerator, readily available for use. On March 1, 2023, at 10:12 a.m., an interview was conducted with the DM. The DM confirmed that the metal container…

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