La Paz Geropsychiatric Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure four of six sampled residents' psychotropic medication (a drug that changes brain function and results in alterations in perception, mood, consciousness or behavior) informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered), prior to starting medication. The facility failed to:1.Provide Resident 2, Resident 8, and Resident138 were provided with psychotropic medication informed consent, prior to starting medication. 2. Provide current documentation of an informed consent for Resident 90's Lexapro's ([generic name - escitalopram] a medication used to treat major depressive disorder [a mood disorder that causes a persistent feeling of sadness and loss of interest] and generalized anxiety disorder [a mental health condition characterized by excessive and uncontrollable worry about everyday things]) current dose of 10 milligrams ([mg] 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 the Notice of Proposed Transfer and Discharge was provided to the Ombudsman (resident advocate) at the time of discharge for three of three sampled residents (Resident 2, Resident 6 and Resident 154).This deficient practice had the potential to deny Resident 2, Resident 6 and Resident 154 protection from being inappropriately discharged and violated the residents' rights. Findings: A. During a review of Resident 2's admission Record (facesheet), dated 10/24/2025, the admission record indicated Resident 2 was admitted to the facility on [DATE] and readmitted on [DATE] with the diagnosis including schizoaffective disorder (schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), anxiety ( (emotion characterized by feelings of tension, worried thoughts) and insomnia (trouble falling asleep or staying asleep). During a review of Resident 2's History & Physical (H&P) dated 9/15/2025, the H&P indicated Resident 2 was…

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

Based on interview and record review, the facility failed to:1. Include signatures of two Licensed Vocational Nurses (LVNs) on the medication donation records titled Medication Destruction Record for 35 records on three out of three sampled pages in the donation log, as per facility's policy and procedure (P&P) titled, Donated Medications, dated 10/10/2024.2. Ensure the disposition or destruction records for controlled medications (medications that the use and possession of are controlled by the federal government) included signatures of a pharmacist in addition to a Registered Nurse (RN) or Director of Nursing (DON) on six of six sampled records, as per facility's P&P titled Accounting for Administered and Wasted Medications including Expired Medications, dated 6/11/2025. These deficient practices increased the risk for controlled medications diversion (the transfer of a controlled medication or other medication from a lawful to an unlawful channel of distribution or use), misuse, and the potential for accidental exposure to harmful medications to the facility staff and residents,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain and observe infection control practices by failing to:1.Ensure the laundry staff performed hand hygiene prior to handling clean linens.2.Ensure the laundry staff were keeping a log and monitoring the washing machine water temperatures and ensure the water heater was functioning prior to using the washing machines. 3. Perform proper hand hygiene procedures after checking Resident 140's blood glucose, and before and after administering insulin (medication that lowers blood sugar level), per facility's policy and procedure (P&P) titled, Hand Hygiene, dated 12/9/2024, affecting one of nine residents observed during medication administration.4.Follow facility's P&P on disinfecting blood glucose monitor after its use according to manufacturer guidelines and facility's P&P titled Cleaning of Non-critical, Reusable Equipment used by Persons Served (SNF), dated 8/11/2025, affecting one of nine residents observed during medication…

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

Based on observation, interview, and record review, the facility failed to notify the physician for a change in condition for one of three sampled residents (Resident 117), when Resident 117 verbalized suicidal ideations.This deficient practice had the potential for delayed physician assessment and intervention, placing Resident 117 at risk for delayed behavioral health intervention, worsening psychiatric symptoms, and possible harm.During a review of Resident 117's admission Record, the admission Record indicated the facility admitted Resident 117 on 5/16/2019, with diagnoses including schizoaffective disorder bipolar type (mental illness that can affect thoughts, mood, and behavior), dementia (a progressive state of decline in mental abilities), diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), and hypertension (HTN-high blood pressure).During a review of Resident 117's History and Physical (H&P), dated 5/8/2025, the H&P indicated, Resident 117 had impaired judgement and insight.During a review of Resident 117's Minimum…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain a comfortable, homelike, and safe environment for one of six sampled residents (Resident 124). The facility failed to:1.Ensure adequate water flow during Resident 124's shower time.2.Maintain the physical environment by allowing the baseboard in a shared resident bathroom to peel off.This deficient practice had the potential to negatively impact Resident 124's well-being and posed a risk of accidents or injury to residents due to an unsafe and poorly maintained environment.Findings:During a review of Resident 124's admission Record, the admission Record indicated Resident 124 was admitted to the facility on [DATE] with diagnoses including schizophrenia(a mental illness that is characterized by disturbances in thought), diabetes mellitus(DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), unspecified cataract( clouding of the eyes' lens but the specific cause is undetermined) and mood…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that one of three sampled residents (Residents 63) were free from sexual abuse by another resident (Resident 146). The facility failed to: 1. Supervise Resident 146 with history of inappropriate sexual comments towards staff and residents, showing his private part, standing too close to staff and not giving enough boundaries. This failure had the potential to result in Resident 63 experiencing unwanted sexual contact, placing the resident at risk for emotional trauma, psychological harm, and a compromised sense of safety within the facility. Findings:During a review of Resident 63's admission Record, the admission Record indicated Resident 63 was admitted to the facility on [DATE] with diagnoses including schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), hyperlipidemia (abnormally high…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and record review the facility failed to ensure monitoring was done for psychotropic medications (medication used to treat mental health disorders) for two of six sampled residents (Resident 2 and Resident 8) when:1. Resident 2's target behaviors were not monitored.2. Resident 8's side effects were not monitored.These failures had the potential to cause harm to Resident 2 and Resident 8's quality of life and possible unwarranted use of psychotropic medications.Findings:A. During a review of Resident 2's admission Record (facesheet), dated 10/24/2025, the admission record indicated Resident 2 was admitted to the facility on [DATE] and readmitted on [DATE] with the diagnosis including schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), anxiety (emotion characterized by feelings of tension, worried thoughts) and insomnia (trouble falling asleep or staying asleep).During a review of Resident 2's History & Physical (H&P) dated 9/15/2025, the H&P indicated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to develop an individualized care plan with measurable objectives, time frame, and interventions to meet the residents' needs for two of three sampled residents (Resident 112 and Resident 117) by failing to:1. Develop an individualized care plan with goals and interventions for Resident 112's hip pain and refusal of care.2. Develop an individualized care plan with goals and interventions for Resident 117's suicidal ideation. These deficient practices had the potential to negatively affect the delivery of necessary care and services.Findings: 1.During a review of Resident 112's admission Record (facesheet), the admission Record indicated Resident 112 was admitted to the facility on [DATE] with diagnoses including schizophrenia (a mental illness that is characterized by disturbances in thought), anxiety (a common mental health condition characterized by excessive and persistent worry, fear, and nervousness that can interfere with daily life),…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide one of 18 sampled residents (Resident 88) with meaningful activities or regular room visits as part of an ongoing program designed to support the resident's individual choices and preferences for activities. This deficient practice had the potential to negatively impact the resident's sense of self-worth and psychosocial well-being, contributing to feelings of isolation, decreased self-respect, and diminished self-satisfaction.Findings:During review of Resident 88's admission Records, the admission Records indicated Resident 88 was admitted to the facility on [DATE] with diagnoses including anxiety (conditions that cause excessive and persistent feelings of fear or worry that can interfere with daily life), schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior ), muscle weakness (loss of muscle strength).During a review of Resident 88's Minimum Data Set (MDS a federally mandated 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 assess and provide treatment for constipation for one of three sampled residents (Resident 96), when Resident 96 did not have a bowel movement for four consecutive days on two separate occasions.This deficient practice resulted in delayed intervention and had the potential to cause abdominal discomfort, distention, and bowel obstruction.During a review of Resident 96's admission Record, the admission Record indicated the facility admitted Resident 96 on 6/27/2019, with diagnoses including major depressive disorder (a mood disorder that causes a persistent feelings of sadness and loss of interest), schizoaffective disorder (mental illness that can affect thoughts, mood, and behavior), and movement disorder (a neurological condition causing problems with movement either with too much, too little, or slow movement).During a review of Resident 96's Psychiatric Progress Notes, dated 10/15/2025, the Psychiatric Progress Notes indicated Resident 96 required frequent reorientation to reality.During a review of Resident 96'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 observation, interview, and record review, the facility failed to ensure that residents with or without limited range of motion (ROM-movement of joints) received appropriate treatment and services to maintain or improve mobility to ensure that one of four sampled residents (Resident 88), who had physician's orders for ROM exercises, received services as directed by the Restorative Nursing Assistant (RNA).This deficient practice had the potential to contribute to the development of contracture (conditions involving the shortening and hardening of muscles, tendons, or other tissues) and decreased functional ability in Resident 88's extremities.Findings:During review of Resident 88's admission Record, the admission Record indicated Resident 88 was admitted to the facility on [DATE] with diagnoses including anxiety (conditions that cause excessive and persistent feelings of fear or worry that can interfere with daily life), schizoaffective disorder( a mental illness that can affect thoughts, mood, and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to ensure the privacy curtain was secured to its curtain rack for one of one resident (Resident 138).This failure had the potential for Resident 138 to sustain an injury.Findings:During a review of Resident 138's admission Record, dated 10/24/2025, the admission record indicated Resident 138 was admitted to the facility on [DATE] with the diagnosis including schizophrenia (a mental illness that can affect thoughts, mood, and behavior), anxiety (emotion characterized by feelings of tension, worried thoughts) and insomnia (trouble falling asleep or staying asleep).During a review of Resident 138's History & Physical (H&P) dated 1/31/2025, the H&P indicated Resident 138 was alert and oriented.During a review of Resident 138's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 9/25/2025 the MDS indicated Resident 138's cognition was intact. The MDS also indicated Resident 138 was independent with activities of daily living ([ADL'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 observation, interview, and record review, the facility failed to ensure that one of two sampled residents (Resident 56) received effective pain management. The facility failed to:1.Ensure that Licensed Vocational Nurses (LVNs) administered appropriate pain medication based on Resident 56's assessed pain level.This deficient practice had the potential to result in inadequate and ineffective pain management for Resident 56, placing the resident at risk for unnecessary discomfort, and potential decline in physical and psychosocial well-being.Findings:During a review of Resident 56's admission Record, the admission Record indicated Resident 56 was admitted to the facility on [DATE] with diagnoses including schizophrenia (a mental illness that is characterized by disturbances in thought), anxiety disorder( mental health condition characterized by excessive and persistent worry, fear or nervousness), bilateral (both) osteoarthritis of knee(progressive disorder of the joints, caused by a gradual loss of…

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

Based on interview and record review, the facility failed to ensure Licensed Vocational Nurse (LVN 4) received in-service training on physician notification, weight loss, nutrition, and hydration.This failure had the potential to result in residents not receiving appropriate nursing care and posed a risk of harm due to unmet healthcare needs.Findings:During an interview on 12/2/2025 at11:23 a.m. with LVN 4, LVN 4 stated she works on a per diem basis and had not received in-service training related to weight loss, nutrition, or hydration. LVN 4 stated she could not recall whether she had received training on physician notification procedures. During a concurrent interview and record review on 12/2/2025 at 3:35 p.m. with the Director of Staff Development (DSD), the In-Service Sign-In Sheets titled Notification of the Physician, dated 10/28/2025 and 10/29/2025, were reviewed. The documentation indicated that LVN 4 did not complete the required fields for employee name, signature, title, and department. Additionally, In-Service Sign-In Sheets titled Weight Loss, Nutrition, 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 actual hours worked was posted in an area visible to residents and the public. This failure had the potential to mislead residents and families about nursing staff and potentially affecting residents' care and safety.During an observation on 10/22/2025 at 10:28 a.m. the nurse staffing document titled Daily Schedule was posted by the entrance in between the staff restroom and living room near the nursing station. The Daily Schedule was updated with staff call offs and add on but did not indicate actual hours worked.During an observation on 10/23/2025 at 7:40 a.m. the nurse staffing titled Daily Schedule was posted by the entrance in between the staff restroom and living room near the nursing station. The Daily Schedule was updated with staff call offs and add on but did not indicate actual hours worked.During a concurrent interview and record review on 10/24/2025 at 10:06 a.m. with the Director of Nursing (DON), The DON stated the total nursing staff of 24 included the infection prevention nurse 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's Quality Assurance and Performance Improvement (QAPI data-driven plan of action to correct identified and potential problems) failed to maintain and develop action to correct identified and potential problems. The facility failed to:1.Provide effective oversight and ensure implementation of the plan of correction related to the deficient practice identified during the previous recertification survey regarding the prevention, identification, and reporting of abuse.2.Identify and monitor residents at risk for weight loss to ensure timely interventions and prevent further decline.These failures had the potential to negatively impact residents' quality of care and safety, and could result in abuse going unrecognized and uninvestigated, as well as unaddressed nutritional decline among vulnerable residents.Findings: 1.During a review of facility's Center of Medicare and Medicaid 2567 (CMS- survey report that documents and justifies a nursing home's compliance with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure Social Worker (SW) 2 received effective training on abuse reporting, related to identifying and reporting inappropriate sexual behavior of Resident 146 towards Resident 136 and 155.This deficient practice had the potential to result in incidents of abuse going unrecognized and unreported, placing residents at risk for harm.Findings:During a review of Resident 136's admission Record, the admission Record indicated Resident 136 was admitted to the facility on [DATE] with diagnoses including paranoid schizophrenia (a mental illness that is characterized by disturbances in thought), and anxiety (a common mental health condition characterized by excessive worry, fear, and nervousness that can interfere with daily life). During a review of Resident 136's Minimum Data Set (MDS-resident assessment tool) dated 9/16/2025, the MDS indicated Resident 136 had the ability to understand others with clear comprehension. The MDS indicated Resident 136 needed…

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 one sampled resident ' s (Resident 1) privacy when Resident 2 walked into the restroom while Resident 1 had her pants down while urinating. This failure resulted in Resident 1 feeling embarrassed, bad, and nasty. Findings: During a review of Resident 1's admission Record (Face Sheet), the admission Record indicated the facility admitted Resident 1 on 6/15/2024 with diagnoses including major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest) and schizophrenia (a mental illness that is characterized by disturbance in thought). During a review of Resident 1 ' s Minimum Data Set (MDS-a resident assessment tool) dated 3/28/2025, the MDS indicated Resident 1 was cognitively intact (ability to think and understand). During a review of Resident 2 ' s admission Record (Face Sheet), the admission Record indicated the facility admitted Resident 2 on 5/28/2022 with diagnoses including schizoaffective disorder (a mental health problem where you experience…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure one out of four sampled residents (Resident 1) was free from physical abuse (any intentional act causing injury or trauma to another person or animal by way of bodily contact) by Resident 2. As a result, Resident 2 entered Resident 1 ' s bathroom as Resident 1 was sitting on the toilet with her pants down around her ankles and Resident 2 punched Resident 1 on the right cheek, leaving a red mark on Resident 1 ' s right cheek. Resident 1 felt stated she felt mad, nasty, and embarrassed a man (Resident 2) was in her (Resident 1 ' s) female bathroom while her pants were down during the physical altercation. Findings: During a review of Resident 2 ' s admission Record, the admission Record indicated Resident 2 was admitted to the facility on [DATE] with diagnoses of schizoaffective disorder (a mental health problem where you experience psychosis as well as mood symptoms), benign prostatic hyperplasia (BPH, enlarged prostate [a small,…

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 supervision for one of one male resident (Resident 2) with history of wandering from entering an occupied female ' s restroom (Resident 1). This failure resulted in Resident 1 being exposed with her pants down and punched in the right cheek. Findings: During a review of Resident 1's admission Record (Face Sheet), the admission Record indicated the facility admitted Resident 1 on 6/15/2024 with diagnoses including major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest) and schizophrenia (a mental illness that is characterized by disturbance in thought). During a review of Resident 1 ' s Minimum Data Set (MDS-a resident assessment tool) dated 3/28/2025, the MDS indicated Resident 1 was cognitively intact (ability to think and understand). During a review of Resident 2 ' s admission Record (Face Sheet), the admission Record indicated the facility admitted Resident 2 on 5/28/2022 with diagnoses including schizoaffective disorder (a mental health problem…

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 members failed to notify the physician when Tamiflu (medication used to prevent and treat infections caused by the flu virus) was not available immediately when residents were symptomatic for two of seven sampled residents (Resident 5 and 4). This deficient practice had the potential to delay medical interventions. Findings: a. During a review of Resident 5's admission Record (Face Sheet), the Face Sheet indicated Resident 5 was originally admitted to the facility on [DATE] with diagnoses including respiratory syncytial virus (a virus that causes infections of the respiratory tract), acute lower respiratory infection (a sudden infection that affects the lower airways of the lungs), and hypertension (high blood pressure). During a review of Resident 5's Minimum Data Set (MDSresident assessment, dated 11/11/2024, the MDS indicated Resident 5's cognitive skills (the mental action or process of acquiring knowledge and understanding through thought, experience,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement their careplan for four of seven residents (Resident 5, 4, and 3) and did not monitor the vital signs every four hours as indicated. This deficient practice had the potential to compromise other resident's wellbeing. Findings: a. During a review of Resident 5's admission Record (Face Sheet) the Face Sheet indicated Resident 5 was originally admitted to the facility on [DATE] with diagnoses including respiratory syncytial virus (a virus that causes infections of the respiratory tract), acute lower respiratory infection (a sudden infection that affects the lower airways of the lungs), and hypertension (high blood pressure). During a review of Resident 5's Minimum Data Set [(MDS) a standardized assessment and care screening tool], dated 11/11/2024, the MDS indicated Resident 5's cognitive skills (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) were mildly impaired. The MDS…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to ensure Tamiflu (Oseltamivir Phosphate: prevents and treats infections caused by the flu virus) medications was administered to meet the needs for two of seven sampled residents (Resident 5 and Resident 4). This deficient practice had the potential to result in a delay in administration of necessary medication for the residents. Findings: a. During a review of Resident 5's admission Record (Face Sheet), the Face Sheet indicated Resident 5 was originally admitted to the facility on [DATE] with diagnoses including respiratory syncytial virus (a virus that causes infections of the respiratory tract), acute lower respiratory infection (a sudden infection that affects the lower airways of the lungs), and hypertension (high blood pressure). During a review of Resident 5's Minimum Data Set (MDS- a resident assessment), dated 11/11/2024, the MDS indicated Resident 5's cognitive skills (the mental action or process of acquiring knowledge and understanding…

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 enforce its own policy related to Influenza (contagious respiratory illness caused by the influenza virus) outbreak by not retesting contaminated samples collected on 12/27/2024 and reordering test kits on a timely manner for two out of 12 residents (Resident 5 and Resident 4) that were symptomatic. These deficient practices had placed all residents, staff, vendors, visitors, and the surrounding community at risk for spread of the influenza virus. Finding: a. During a review of Resident 5's admission Record (Face Sheet), the Face Sheet indicated Resident 5 was originally admitted to the facility on [DATE] with diagnoses including respiratory syncytial virus (a virus that causes infections of the respiratory tract), acute lower respiratory infection (a sudden infection that affects the lower airways of the lungs), and hypertension (high blood pressure). During a review of Resident 5's Minimum Data Set [(MDS) a standardized assessment and care screening…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure 9 out of 62 residents (Resident 3, Resident 7, Resident 14, Resident 15, Resident 16, Resident 21, Resident 81, Resident 107, and Resident 128) who were a smokers continue to smoke in an area that maintains the quality of life for these residents. The facility failed to: 1. Follow facility's policy and procedure (P&P) titled Smoking Policy for Skilled Nursing Facilities approved on 1/31/2024, which indicated Smoking is recognized as a privilege and the facility will adhere to all city, state, and federal regulations. If the facility changes its policy to prohibit smoking, the facility will allow current residents who smoked to continue smoking in an area that maintains the quality of life for these residents. These failures resulted in not honoring residents' choice and disregard to Resident 3, Resident 7, Resident 14, Resident 15, Resident 16, Resident 21, Resident 81, Resident 107, and Resident 128's resident rights and affect residents'…

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

Based on observation interview and record review the facility failed to: a. Ensure expired bagels were removed from shelfs. b. Ensure the floor in the kitchen all along the walls and in the corners was free from food crumbs and dirt build up. c.Ensure the drain face plate used for multiple kitchen equipment (ice machine, freezer, and coffee machine) was clean and free from blackish greenish slimy substance. These failures had the potential to expose residents to food-borne illnesses (any illness resulting from ingestion of food contaminated with bacteria, viruses, or parasites) and put residents at risk for cross contamination (unintentional transfer of harmful bacteria from one object to another). Findings: a. During a concurrent observation and interview on 10/15/24 at 8:26 a.m., with Dietary Supervisor (DS), DS stated that he had checked the bread rack this morning after they received the bread delivery and did not see the expired bag of bagels. DS stated that expired food should never be served to residents. DS stated serving expired foods to the residents has the potential 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's Quality Assurance Performance Improvement (QAPI, a data driven proactive approach to improvement used to ensure services are meeting quality standards) failed to maintain and develop an effective plan of action to correct an identified and potential problems by failing: 1. To provide an effective oversight of the facility and implementation of the facility's plan of correction (POC) of the deficient practice regarding abuse reporting and call lights accessibility for residents from the previous recertification survey. 2. To identify and address problems with the implementation of no smoking among the residents who are smokers. These failures had the potential to violate residents' rights and resulted into repeated deficiencies which could lead to abuse not being identified or investigated and individualized needs of residents not being met. Findings: 1.During a review of facility's Center of Medicare and Medicaid 2567 (CMS-survey report that documents and justifies a nursing home's compliance with federal health requirements)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility staff failed to ensure call light was within reach for three of three sampled residents (Resident 132, 140 and Resident 141). This deficient practice had the potential for Resident 132, 140 and 141 not to receive necessary assistance when needed, and experienced loss of self-esteem. Findings: During a review of Resident 132's admission Order, the admission Record indicated Resident 132 was admitted to the facility on [DATE], with diagnoses including schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), essential hypertension (high blood pressure) and hyperlipidemia (an excess of fats in your blood). During a review of Resident 132's Minimum Data Sheet (MDS - a federally mandated resident assessment tool) dated 07/19/2024 indicated Resident 132 had no cognitive (ability to think, understand, learn, and remember) impairment and requires assistance for some activities of daily living. During an observation on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to notify resident physician for two of six sampled residents (Resident 14 and Resident 108) who were manifesting tremors (involuntary , rhythmic shaking and trembling of one or more parts of the body) on their hands and arms that affected their activities of daily (ADL- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). This failure had the potential to affect Resident 14 and Resident 108 daily functioning and quality of life. This failure had the potential for Resident 14 and 108 to feel frustrated and helpless. Findings: During a review of Resident 14's admission Record, the admission Record indicated Resident 14 was admitted to the facility on [DATE] with diagnoses including schizophrenia(a mental illness that is characterized by disturbances in thought), extrapyramidal and movement disorder( EPS-involuntary movement and are caused by certain medicines especially antipsychotic…

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 four sampled residents (Resident 65 and Resident 89) was free from physical abuse by failing to: 1. To protect Resident 65 from Resident 37 who hit a staff member on the way to their room, and then hit Resident 65 with a table who was her roommate. This failure resulted Resident 65 getting hit by the table sustaining a small cut to right forehead. Findings: During a review of Resident 65's admission Record, the admission Record indicated the resident was admitted on [DATE] to the facility with diagnoses that included paranoid schizophrenia (mental illness characterized by a pattern of behavior where a person feels distrustful and suspicious of other people and surroundings) and unspecified dementia (a progressive stated of decline in mental abilities) without behavioral disturbance. During a review of Resident 65's Minimum Data Set (MDS- a federally mandated resident assessment tool) dated 8/30/2024, the MDS indicated 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 individualized activities that meets the interest of the resident's for three of three sampled residents, (Resident 3, 21 and 104). This failure had the potential to impact the mental and psychosocial wellbeing of Resident 3, 21 and 104, exacerbating feelings of depression that could impact residents' quality of life. Findings: During a review of Resident 3's admission Record, the admission Record indicated Resident 3 was admitted to the facility on [DATE] with diagnoses including paranoid schizophrenia (a mental illness that is characterized by disturbances in thought), type II diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) and essential hypertension (high blood pressure). During a review of Resident 3's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 9/5/2024, the MDS indicated Resident 3 had no cognitive (ability to think, understand,…

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 the facility failed to ensure 3 out of 3 Certified Nursing Assists (CNA) had completed their facility assigned mandatory on-line continuing education requirements with facility on-line continuing education program. Facility failed to: 1. Ensure Certified Nursing Assistant (CNA) 1, CNA 2 and CNA 3 had yearly mandatory dementia (loss of memory, language, problem-solving and other thinking abilities) training 2.Ensure CNA 2 and CNA 3 had completed one hour of mandatory yearly sexual harassment training. This failure had the potential to put the resident's safety at risk when training requirements were not completed. Findings: During a concurrent interview and record review on 10/18/24 at 9:16 a.m. with the Director of Staff Development (DSD plan, directs, or coordinates the training for staff (DSD), DSD was asked to retrieve data on the yearly mandatory in-services for CNA 1, CNA 2, and CNA 3. DSD stated CNA 1 CNA 2 and CNA 3 were missing four out of five hours of the required yearly dementia training. CNA 2 and CNA 3 were also missing one hour of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure one of 33 sampled residents (Resident 139) had a comprehensive care plan developed and implemented for diagnosis of schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior). This failure had the potential to result in a delay of the delivery of care and services. Findings: During a review of Resident 139's admission Record, the admission Record indicated, Resident 139 was admitted to the facility on [DATE] with diagnoses including schizoaffective disorder, anxiety (intense, excessive, and persistent worry and fear about everyday situations), and major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities). During a review of Resident 139's Minimum Data Set (MDS- federally mandated resident assessment tool), dated 9/13/2024, the MDS indicated, Resident 139 had the ability to understand and express ideas and wants. The MDS indicated Resident 139…

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 care plan for vision was revised and updated for one of 33 sampled residents (Resident 108). This failure had the potential to put Resident 108 at risk for not receiving the care and services needed to meet her individualized needs. Findings: During a review of Resident 108's admission Record, the admission Record indicated Resident 108 was admitted to the facility on [DATE] with diagnoses including bipolar disorder (a mental health condition that causes extreme mood swings that include emotional highs [mania] and lows[depression] that make it difficult to carry out day-to-day tasks and activities),tremor (involuntary rhythmic shaking or twitching of one or more body parts) pre glaucoma ( also called glaucoma suspect where a person had elevated pressure within the eyes but no detectable visual damage), and age related bilateral nuclear cataract (opacity or clouding that develops in the center of the eyes which is related to aging). 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.

Based on interview and record review the facility failed to ensure the Director of Staff Development (DSD- plans, directs, or coordinates the training for staff) was competent in obtaining report of facility staff's annual mandatory training with the use online education program. This failure had the potential for the facility not be able to assess the skills necessary to provide nursing services to assure resident safety. Findings: During a concurrent interview and record review on 10/18/24 at 9:16 a.m. with the DSD, reviewed on-line education program. The DSD stated the facility uses an online education program and was responsible for operating and maintaining the system. The DSD stated upon hire, the DSD assigns staff to the online learning program. The program automatically sends staff emails regarding what training needs to be completed and when. When asked to retrieve a report on mandatory in-services for participation and competency, the DSD was unable to provide the requested data. The DSD stated that she had never received training on how to generate reports to verify staff…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement their protocol for Antibiotic Stewardship (refers to a set of commitments and actions designed to optimize the treatment of infections while reducing the adverse events associated with antibiotic use) for one of 33 sampled residents (Resident 139) by obtaining culture ( a laboratory test that analyzes a sample of body fluid or tissue to identify harmful bacteria, fungus, or viruses that may be causing an infection ) or blood tests prior to prescribing antibiotic medication (a substance used to kill bacteria and to treat infections) after being screened for cellulitis (bacterial skin infection that may appear as a red, swollen area, feeling hot and tender to the touch). This failure had the potential for Resident 139 to develop antibiotic resistance (not effective to treat infection) from inappropriate antibiotic use. Findings: During a review of Resident 139's admission Record, the admission Record indicated, Resident 139 was admitted to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to protect the resident rights to be free from physical abuse for one of two sampled residents (Resident 1) by a resident. This failure resulted in Resident 2 stabbed Resident 1 on his right index finger repeatedly with a pen. Resident 1 sustained a one inch cut on the right index finger. Findings: During a review of Resident 1 ' s admission Record (Face Sheet), the admission Record indicated, Resident 1 was admitted to the facility on [DATE], with diagnoses including schizophrenia (a mental condition characterized by abnormal thought processes and unstable mood), anxiety (emotion characterized by feelings of tension, worried thoughts) andhypertension (high blood pressure). During a review of Resident 1 ' s History and Physical (H&P) dated 7/2/2024 the H&P indicated Resident 1 was alert and oriented to name only. During a review of Resident 1 ' s Minimum Data Set (MDS- a standardized assessment and care screening tool) dated 7/10/2024, the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to protect the residents' right to be free from physical abuse by another resident for two of four sampled residents (Resident 2 and 4). The facility failed to: a. Ensure Resident 1's physician was informed when he was exhibiting behaviors such as auditory hallucination ([AH] hear voices or noises that are not there), paranoid delusion ([PD] a type of serious mental illness where patient cannot tell what is real from what is imagined.), and visual hallucination([VH] perception of an external visual stimulus where none exists). b. Ensure Resident 3's physician was informed when he was exhibiting behaviors such as agitation ([AG] manifested by striking out), anxiety ([AX] persistent and excessive worry) and mood swings ([MS] extreme of sudden change of mood). These failures resulted in Resident 1 going to Resident 2's room and hit him in the face on 6/24/2024. Resident 3 hit Resident 4 in the face while she was sitting in the wheelchair on 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, interviews, and record review, the facility failed to ensure the resident, who had a history of physical aggressive behavior towards staff and resident did not physically abuse another resident and facility staff for one of two residents sampled residents (Resident 1). The facility failed to: 1. Ensure Resident 1 was assessed and supervised for aggressive behavior towards staff and residents to prevent the resident from physically attacking Resident 1 and Registered Nurse Supervisor (RNS) 1 on 2/17/2024. 2. Inform Resident 1 ' s psychiatrist (a specialist who specializes in the study of mind and behavior or in the treatment of mental, emotional, and behavioral disorders) of Resident 2 ' s increasing agitation, threatening spitting at towards staff on 2/8/2024, refusing care, and refusing medications per facility ' s P&P titled, Change in a Resident ' s Condition or Status. These failures resulted in Resident 2 chasing Resident 1 and kicked Resident 1 in the face when he fell on the floor…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement infection control practices to prevent the development and transmission of communicable diseases and infections. The facility failed to: 1. Monitor and document the vital signs (clinical measurements, specifically pulse rate, temperature, respiration rate, and blood pressure, that indicate the state of a patient's essential body functions) for five of five sampled residents (Resident 4, 5, 6,7, and 8) who were tested positive of COVID-19 infection (a highly contagious infection, caused by a virus that can easily spread from person to person). 2. Ensure three of five sampled residents (Resident 4,7, and 8) received Paxlovid (a medication to treat Covid 19 infection) within five days of symptom onset and documenting a reason for contraindication if it was not given. 3. Initiate or update (as needed), a care plan for Covid 19 positive residents and document a Post Event Assessment (same as Change of Condition) when the residents were tested…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to assess the residents for eligibility and failed to ensure residents were offered the pneumonia (an infection of the lungs) vaccination (medication to prevent a particular disease) and influenza (contagious respiratory disease that can cause mild to severe illness) vaccination for one of five sampled residents (Resident 5). This failure had the potential to result in Resident 5 being at a higher risk of acquiring and transmitting pneumonia and influenza to other vulnerable and immunocompromised residents in the facility. Findings: During a review of Resident 5 ' s admission record, the admission record indicated Resident 5 was admitted to the facility on [DATE]. Resident 5 ' s diagnoses included schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves), Covid-19 infection on 11/9/2022, and hyperlipidemia (abnormally high levels of fats in the blood). During a review of Resident 5 ' s History and Physical (H&P), dated…

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

Based on observation, interview, and record review the facility failed to: a.Ensure open plastic package of liquid eggs waswith open dates and expiration dates. b.Ensure employees' rotisserie chickens were not stored in the residents' refrigerator. c.Ensure the cook performed hand washing after removal of gloves during lunch food plating and preparation. These failure had the potential to place residents at risk for food borne illness (any illness resulting from ingestion of food contaminated with bacteria, viruses, or parasites). Findings: a.During an observation on 10/17/2023, at 8:20 a.m. a plastic package of liquid eggs that was open and half full was not labeled with the date when it was opened and date of expiry. During a subsequent interview on 10/17/2023, at 8:20 a.m. and on 10/19/2023, at 8:50 a.m. with Director of Food and Nutrition Services (DFNS), DFNS stated the liquid eggs were used for breakfast in the morning and the kitchen staff forgot to label it. DFNS stated liquid eggs should be labeled with open date and by use date to prevent food borne illness among…

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 C.During a concurrent observation and interview on 10/19/2023, at 4:08 p.m. with Housekeeping and Laundry Supervisor (HLS), dryer number 1 and 2 had digital readings of 180 degrees Fahrenheit ([F] unit of measurement) but dryer number 3 had no temperature reading visible on the dryer machine. HLS stated the facility did not have a log of dryers' temperature. During an interview on 10/19/2023, at 4:22 p.m. with Facilities Manager (FM), FM stated the facility did not track or maintain a log of temperatures for the dryers. FM stated the laundry staff members would touch the glass lid of the dryers to ensure the dryer was drying the clothes properly. FM stated if the glass lids are cold, it would mean the dryers are not drying the residents' clothes completely and he would be called to check or troubleshoot the dryer machines. During an interview on 10/19/2023, at 4:26 p.m. with Laundry Aide (LA 1), LA 1 stated they did not track and maintain a temperature logs for the dryers. LA 1 stated they would call FM to check…

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 four of eight sampled residents (Residents 43, 73, 98, and 115) received treatment and services to prevent a decline in range of motion (ROM, full movement potential of a joint) and mobility by failing to: 1.Ensure Resident 43's Restorative Nursing Aide (RNA, nursing aide program that helps residents maintain their function and joint mobility) order dated 6/15/2023 included the distance to walk to maintain the distance of 400 feet of ambulation (walking ability) after discharge from Physical therapy (PT, profession aimed in the restoration, maintenance, and promotion of optimal physical function) on 1/3/2023 2. Ensure the RNA order included the specific type of exercises for RNA to perform during RNA treatment to maintain mobility and ROM for Resident 73. 3.Ensure the RNA order included the specific type of exercises for RNA to perform during RNA treatment to maintain mobility and range of motion (ROM- extent or limit to 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 address significant (resident loses five percent [%] of total weight in one month, or 7.5% in three months, or 10% in 6 months) weight loss for two of 31 sampled residents with weight loss (Resident 5 and Resident 120). The facility failed to: 1. Ensure the cause of Resident 5's decreased food intake and 25 lbs weight loss in six months was evaluated and interventions implemented to prevent the resident's further weight loss by assessing the resident's food likes and dislikes, honoring Resident 5's food preferences, and/or offering alternative food items. 2. Ensure nursing staff evaluated, monitored, and had interventions in place to prevent Resident 120's weight loss of 23 pounds (lbs), in 6 months. 3. Ensure the registered dietitian ([RD]- health professional who has special training in diet and nutrition) assessed Resident 5's and Resident 120's weight loss and made dietary recommendations for necessary nutritional supplements and diet…

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 light device was within reach for one of eight sampled residents (Resident 68). This failure had the potential to prevent Resident 68 from receiving necessary care and services. Findings: During a review of Resident 68's admission record indicated the Resident 68 was originally admitted to the facility on [DATE] with diagnoses including paranoid schizophrenia (mental health disorder with characteristics such as delusions [false belief] and hallucinations {perception of something not present}), muscle weakness, and unspecified vision loss. During a review of Resident 68's Minimum Data Set (MDS, a comprehensive assessment and care-screening tool) dated 9/16/2023 indicated Resident 68 was able to make decisions for daily life tasks and had severely impaired vision. The MDS indicated Resident 68 required two-person extensive assistance for bed mobility (moving in bed to and from different positions such as side to side),…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to report an allegation of suspected resident to resident altercation in a timely manner for one of three residents (Resident 105) after the allegation was reported to the Administrator (ADM)by the California Department of Public Health (DPH works to protect the public's health in California) on 10/17/2023. This failure had the potential to result in psychosocial and emotional harm on Resident 105. Findings: During a review of Resident 105's admission Record (facesheet), indicated Resident 105 was admitted to the facility on [DATE] with diagnoses including schizophrenia( disorder that affects a person's ability to think, feel and behave clearly, hypertension (high blood pressure) and muscle weakness. During a review of Resident 105's Minimum Data Set ([MDS] standardized screening tool) dated 7/1/2023, the MDS indicated resident has an intact cognition(thought process) and was independent with bed mobility, transfer, toilet use and personal hygiene. During…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to develop and implement a resident-centered care plan with measurable objectives, timeframes, and interventions for one of five sampled residents (Resident 22) who was admitted to the facility with pressure ulcer (injuries to skin and underlying tissue resulting from prolonged pressure on the skin). This deficient practice had the potential to negatively affect the delivery of necessary care and services for Resident 22. Findings: During a record review of Resident 22's admission Record (face sheet), the face sheet indicated, Resident 22 was originally admitted on [DATE] and re-admitted on [DATE] to the facility with diagnoses including schizophrenia (serious mental disorder in which people interpret reality abnormally), type 2 diabetes mellitus (a condition that happens because of a problem in the way the body regulates and uses sugar as a fuel), and Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements, such as…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of eight sampled residents (Resident 68) received the services to maintain or improve the ability to perform activities of daily living (ADLs, basic activities such as eating, dressing, toileting) This deficient practice had the potential to place Resident 68 at high risk for further ADL decline, generalized deconditioning (decline in physical function of the body because of physical inactivity), decreased joint mobility (movement around a joint), and decreased quality of life. Findings: During a review of Resident 68's admission Record (face sheet) indicated Resident 68 was originally admitted to the facility on [DATE] with diagnoses including paranoid schizophrenia (mental health disorder with characteristics such as delusions [false belief] and hallucinations {perception of something not present}), muscle weakness, and unspecified vision loss. During a review of Resident 68's Minimum Data Set (MDS, a comprehensive assessment…

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

Based on interview, and record review, the facility failed to ensure resident that has visual impairment was assisted to get new eyeglasses for one of 5 sampled residents, (Resident 73). This deficient practice has a potential for Resident 73 to have a decrease in preferred activities of daily living (ADLS [ability to care for yourself without assistance]) and had the potential for injury, falls and decrease in overall quality of life. Findings: During a review of Resident 73's initial admission record (AR) dated 11/27/2019, the AR indicated Resident 73 was admitted to the facility with diagnoses of schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves), unspecified visual loss right eye ( Blindness and low vision), cataract in the left eye (a clouding of the lens of the eye, which is typically clear ) and optic atrophy (damage to your optic nerve, which carries impulses from your eye). During a review of Resident 73's Minimum Data Set (MDS [a standardized assessment and care screening tool]) dated 7/10/2023, MDS Section B indicated 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: 1.Assessed and provide intervention when Resident 65's persistent complained of pain to right and left hip and does not want to get out of bed and attend social activities outside her room. 2. Informed Resident 65's physician of her complained of right and left hip pain with pain level of 10/10 (a numerical tool to measure the severity of pain, with 0- as no pain and 10 represents the most severe or worst pain you have ever experienced). 3. Implement Resident 65's care plan (CP) goal to be free from pain and interventions including observe and report pain to the physician and will be able to maintain her activities of daily living. These deficient practices had the potential for Resident 65 to continuously suffer from right and left hip pain, prefers to stay in bed, doesn't want to participate in activities of daily living (ADL's) and walks sideways if she gets up from bed. Findings: A. During an observation the on 10/17/2023 at 10:15…

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: 1.to follow physician order for administering pain medication for moderate pain (pain level of 4-7)for one of five sampled resident (Resident 70). 2.to administer Naprosyn( used to relieve pain and reduces inflammation) every twelve hours for a pain level of zero (indicating no pain). These deficient practices had the potential to place Resident 70 at risk for a heart attack, stomach ulcers (bleeding in your stomach) and stroke (when blood flow to the brain is blocked or there is sudden bleeding in the brain) that could lead to death. Findings: During a review of Resident 70's admission record (AR) dated 6/4/2021, the AR indicated Resident 70 was admitted to the facility with diagnoses of schizophrenia (a mental disorder marked by hallucinations, delusions, and disintegration of the thought processes), low back pain and gastritis (redness and swelling [inflammation] of the stomach lining.) During a review of Resident 70's Minimum Data Set (MDS- a comprehensive assessment and screening tool) dated 9/13/2023, the MDS…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to monitor the side effects (undesirable effect of medication ) of Depakote (medication used to treat conditions that affect the brain) and properly monitor the extrapyramidal symptoms (EPS-movement disorders that can occur as a side effect of antipsychotic medications (class of drugs used to treat various mental health conditions) of olanzapine (antipsychotic medication) , benztropine (medication used to treat tremors or stiffness), and amantadine (medication used to treat tremors, shaking ) for one of 31 sampled Residents (Resident 85) This deficient practice resulted in the misidentification of side effects and extrapyramidal symptoms of Resident 85. Findings: During a review of Resident 85's admission Record (face sheet), indicated Resident 85 was admitted to the facility on [DATE] with diagnoses including schizophrenia (a serious mental disorder that affects how a person thinks, feels, and behaves), dementia (a decline in cognitive…

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 obtain laboratory testing per physician order and report an abnormal laboratory result to Resident 85's physician. This deficient practice had the potential for Resident 85 to receive inadequate medications and delayed treatment. Findings: During a review of Resident 85's admission Record (face sheet), indicated Resident 85 was admitted to the facility on [DATE] with diagnoses including schizophrenia (a serious mental disorder that affects how a person thinks, feels, and behaves), dementia (a decline in cognitive abilities that impact a person's ability to perform everyday activities) with anxiety (feeling of unease, worry, or fear) bipolar (a mental health condition that causes extreme mood swings that include emotional highs and lows) and diabetes (high blood sugar levels). During a review of Resident 85's annual History and Physical (H&P), dated 9/19/2023, indicated, Resident 85 was alert and oriented to name and place and had limited judgement and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to follow up necessary dental services for one of two sampled residents (Resident 43). This deficient practice had the potential to cause a delay in treatment and place Resident 43 at risk for infection. Findings: During a review of Resident 43's admission Record (facesheet), indicated the Resident 43 was admitted to the facility on [DATE] with diagnoses including paranoid schizophrenia (characterized by hallucinations, delusions and disturbances in thoughts, perception and behavior),diabetes mellitus ( high blood sugar), and anemia (not enough red blood cell to carry oxygen to the body's organs). During a review of Resident 43's Minimum Data Set ([MDS] standardized screening tool) dated 4/14/2023, the MDS indicated Resident 4 had moderately impaired cognition( when a person has trouble remembering, learning new things, concentrating, or making decisions that affect everyday life) and was independent with bed mobility, transfer , toilet 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 interview and record review, the facility failed to offer and administer pneumococcal vaccine (vaccine which helps prevent infection by Streptococcus [bacterium that causes one of the most common and severe forms of pneumonia (infection of the lungs)]) upon admission and with 30 days of admission to the facility for one of five sampled residents (Resident 126). This deficient practice had the potential on increased risk for Resident 126 of acquiring and transmitting pneumonia to other resident and staff in the facility. Findings: During a record review of Resident 126's admission Record (face sheet), indicated Resident 126 was admitted to the facility on [DATE] with diagnoses including schizophrenia (serious mental disorder in which people interpret reality abnormally), latent tuberculosis (when a person is infected with tuberculosis [infectious disease caused by Mycobacterium tuberculosis {bacterium that causes tuberculosis}], but does not have symptoms), hepatitis C (infectious disease caused by 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.