Meadow Creek Post-Acute

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure nursing staff administered the correct medication dose as ordered for one of three sampled residents (Resident 41). Resident 41 had a physician's order for Zinc Sulfate (a dietary supplement to replenish an essential element, Zinc) 220 milligrams (mg, unit to measure dose), one tablet daily. Resident 41 was administered four tablets of Zinc 50 mg instead. (One tablet of Zinc Sulfate 220 mg contains 50 mg of elemental zinc.)This deficient practice created the potential for a medication error that could negatively impact the resident's health condition.Findings:During a review Resident 41's admission Record, the admission Record indicated Resident 41 was originally admitted to the facility on [DATE] and recently readmitted on [DATE]. Resident 41's admitting diagnoses included, but not limited to acute post-hemorrhagic (after an internal bleeding event) anemia (low of red blood cells), diabetes mellitus (DM-a disorder characterized by…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a Licensed Vocational Nurse (LVN 2) did not administer Norco (hydrocodone/acetaminophen, a narcotic pain medication) to one of one sampled residents (Resident 28) when the resident's assessed pain level was 3 out of 10 level on a pain scale rating from zero to ten (pain screening tool using numerical value to assess the level of pain ranging from 0 to 3-mild pain, from 4 to 6- moderate pain, and from 7 to 9-severe pain, and 10- the worse pain possible) and did not meet the criteria established in the pain medication order.This deficient practice had the potential for significant medication errors and/or medication overdose, which could worsen the resident's health condition. Findings:During a review of Resident 28's admission Record, the admission Record indicated Resident 28 was admitted to the facility on [DATE] with diagnoses, including but not limited to hemiplegia (paralysis of one side of the body) and hemiparesis (weakness of one side of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to store one of forty residents (Resident 66) frozen meals in a freezer set at zero (0) degrees Fahrenheit ( F-unit of measurement) or below and the facility failed to ensure food items in the residents' refrigerator were labeled with the residents' names and not expired.These failures had the potential to result deterioration of food quality changes in texture, and loss of nutrient. Using expired food items increases the risk of bacterial growth which can cause foodborne illness (illness cause by food contaminated with bacteria, viruses, parasites, or toxins) such as nausea, vomiting (throwing up), and diarrhea (loose stool).Findings: During a review of Resident 66's admission Record, the admission Record indicated Resident 66 was admitted to the facility on [DATE] with a diagnosis including end stage renal disease (ESRD - irreversible kidney damage), type 2 diabetes (disorder characterized by difficulty in blood sugar control and poor…

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 date food brought in from an outside source and placed in a refrigerator used to keep residents' food for one out of three residents (Resident 1). This deficient practice resulted in the inability to determine the date Resident 1's food was placed in the refrigerator had the potential to cause Resident 1 food borne illness (food poisoning: any illness resulting from the food spoilage of contaminated food, pathogenic bacteria, viruses, or parasites that contaminate food, as well as toxins).Findings: During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 1 had a diagnosis including metabolic encephalopathy (brain dysfunction resulting from a disruption in the body's chemical processes). During a review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool) dated 5/16/2026, the MDS indicated Resident 1…

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

Based on observation, interview and record review, the facility failed to ensure the door to the front entrance of the facility was secured after business hours (7:30 p.m. - 8 a.m.) This deficient practice resulted in the door to the front entrance of the facility being left open and unlocked by wedging a surgical mask between the door and the door frame, disabling the door's locking mechanism. This deficient practice placed residents' who resided in the facility at risk for acts of theft and harm by unauthorized individuals entering the facility and elopement (resident leaves facility without supervision).Findings: On 5/31/2026 at 6 a.m., upon entering the facility to conduct a complaint investigation, the front door to the entrance to the facility was observed with a surgical mask wedged between the door and the door frame, used to keep the door open by not allowing the locking mechanism to engage. There was no one observed monitoring the entrance to the facility. During a review of the facility's undated list of Residents Who Wander Around the Facility, the list of Residents Who…

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 ensure a physician for one of three sampled residents (Resident 1) responded to facility staff phone calls or contacted the facility's Medical Director when Resident 1 reported symptoms of pain and burning during urination As a result of this deficient practice, Resident 1's evaluation, diagnosis, and treatment were delayed. This deficient practice placed Resident 1 at risk for worsening symptoms/infections and had the potential to turn into sepsis (a life-threatening response to an infection).Findings: During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 1 had a diagnosis of a urinary tract infection ([UTI] an infection in the bladder/urinary tract). During a review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool) dated 5/16/2026, the MDS indicated Resident 1 had severe cognitive impairment (memory and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to administer medication as prescribed by a physician for one of three sampled residents (Resident 1). This deficient practice resulted in Resident 1 receiving medication prescribed for a 9 a.m., administration time, but it was not administered until 10:32 a.m. This deficient practice had the potential to cause a delayed therapeutic effect.Findings: During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE]. Resident 1 had diagnoses including cord compression (occurs when pressure is applied to the spinal cord [a long tube-like bundle of nerve tissue that extends from the brain stem down to the lower back], blocking the nerve signals between the brain and the rest of the body), cervical disc disorder (a group of conditions affecting the cushioning discs between the vertebrae [one of the bones that make up the spinal column] in the neck) with myelopathy (an injury,…

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 Registered Nurse (RN) 1 accurately documented a prescribed treatment for one of three sampled residents (Resident 1) on the Medication Administration Record ([MAR] a daily documentation record used by a licensed nurse to document medications and treatments) when she irrigated (flush out medical device with fluid) Resident 1's indwelling catheter (thin, flexible, hollow tube inserted into the bladder to drain urine, typically into a collecting bag) with normal saline ([NS] a solution of salt and water) on 2/15/2026. This failure resulted in incomplete and inaccurate documentation for Resident 1, which prevented the facility from determining the amount of irrigating solution instilled through the indwelling catheter and verifying the corresponding drainage output relative to urine output. This failure had the potential to negatively impact Resident 1's health and non-continuity of care. Findings:During a review of Resident 1's admission Record…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident) hair was cut. This deficient practice resulted in Resident 1's hair being cut unevenly when the Beautician ([NAME]) 1 did not finish cutting Resident 1's hair. This deficient practice had the potential to negatively affect Resident 1's self-esteem and emotional wellbeing. Findings: During a review of Resident 1's admission Record (Face Sheet) the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] and readmitted [DATE]. Resident 1 had diagnoses including unspecified hypotension (low blood pressure), anemia (a condition where the body does not have enough healthy red blood cells), and schizoaffective disorder (a mental disorder that can affect thoughts, mood and behavior).During a review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool) dated 3/7/2026, the MDS indicated Resident 1's cognition (the mental action or process of acquiring knowledge and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop and implement a individualized care plan for one of three sampled residents (Resident 1) addressing Resident 1's safety from Resident 1's family member (FM) 2 who had history of non-compliant with the facility's rules and interrupted Resident 1's care. This deficient practice resulted in staff not having the necessary guidance and had the potential for interruption of medically necessary care and exposure to unsafe substances (alcohol).Findings:During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] and re-admitted to the facility on [DATE]. Resident 1's diagnoses included psychoactive substance abuse (the harmful or use of substances [alcohol, illicit drugs, prescription medications] that change how a person thinks, feels, or behaves), respiratory failure (when the lungs cannot adequately supply oxygen to the blood), chronic kidney disease (CKD- kidneys are permanently…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a resident (Resident 1), who had a known allergy (when the body's immune system overreacts to something that is normally harmless like food, medicine, pollen, or pests) to cortisone (medication that helps reduce swelling, redness, and allergic reactions in the body), licensed nurses verified the allergy prior to administering hydrocortisone (medication applied to the skin to reduce swelling, redness, itching, and irritation on the skin) for one of three sampled residents (Resident 1). These failures resulted in Resident 1 receiving five doses of hydrocortisone from 2/13/2025 to 2/15/2025, placing him at risk for an allergic reaction, including swelling, difficulty breathing, and other serious complications. Findings:During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE], with diagnoses including nontraumatic intracerebral (inside the brain tissue) hemorrhage…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a Care Plan was created for one of four sampled residents (Resident 1) who developed redness on his penile and scrotal area. This failure had the potential for Resident 1 to have further skin breakdown, increased risk of infection, pain, and diminished quality of life.Findings:During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE], with diagnoses including nontraumatic intracerebral (inside the brain tissue) hemorrhage (sudden bleed), acute respiratory failure (serious condition where a person cannot breathe on their own), quadriplegia (paralysis from the neck down, including legs and arms usually due to spinal cord injury) and type 2 diabetes ([DM] a disorder characterized by difficulty in blood sugar control and poor wound healing).During a review of Resident 2's Minimum Data Set ([MDS] a resident assessment tool), dated 11/24/2025, the MDS indicated Resident 1…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure one out of three sampled residents (Resident 1) did not receive Docusate Sodium (a stool softener) and Senna (a laxative medication [softens stool or stimulates the bowels to contract] used to treat constipation [bowel movements are infrequent, hard, or difficult to pass]) while Resident 1 was experiencing diarrhea (loose watery stools).This deficient practice placed Resident 1 at risk for emotional distress, burning and irritation of the skin, worsening moisture associated skin break down (MASD, umbrella term for skin inflammation and breakdown from prolonged exposure to moisture), and dehydration (the body loses more fluids than it is taking in).Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility 9/17/2025 and readmitted on [DATE] with diagnoses of dependence on renal dialysis (a person's kidneys have failed [End-Stage Renal Disease or ESRD] and they…

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 certified nursing assistant (CNA) 3 and licensed vocational nurses (LVN) 4 were competent in caring for and reporting episodes of diarrhea (loose/ watery stool) for one out of three sampled residents (Resident 1).This deficient practice resulted in Resident 1 continuing to receive medications to induce bowel movements, during the time she was having loose stools which had the potential for emotional distress, burning and irritation of the skin, worsening moisture associated skin break down (MASD, umbrella term for skin inflammation and breakdown from prolonged exposure to moisture), and dehydration (the body loses more fluids than it is taking in).(Cross reference: F760) Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including dependence on renal dialysis (a person's kidneys have failed [End-Stage…

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 interview, and record review, the facility failed to ensure that one of three residents (Resident 1), who was a ventilator (a machine used in healthcare to assist or perform breathing for a patient who cannot breathe adequately) dependent received personal hygiene care, including regularly scheduled showers and bed baths, to prevent maggots (a baby fly that looks like a small, white, worm without legs) infestation around tracheostomy and a Stage III pressure injury (a full-thickness skin loss that extends into the subcutaneous tissue [fat layer]) to the left lateral (relating to or situated on the side) side of the resident's neck. The facility failed to: 1. Ensure Resident 1 was provided with regularly scheduled showers and bed baths to promote the resident's cleanliness in accordance with the facility's policy and procedure (P&P) titled, Bath, Shower/Tub, dated 2018, which indicated, The purposes of this procedure are to promote cleanliness, provide comfort to the resident and to observe the condition of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the immediate reporting of an incident involving neglect for one of three sampled residents (Resident 1). Resident 1, who is ventilator (a machine used in healthcare to assist or perform breathing for a patient who cannot breathe adequately) dependent, was found with maggots (a baby fly that looks like a small, white, worm without legs) present around the tracheostomy site (a surgically created opening in the neck to assist with breathing ).The facility failed to:1.Promptly report the incident to the California Department of Public Health (CDPH) as required by state regulations.2.Notify the resident's representative, who was designated to act on behalf of the resident in decision-making and to receive important health-related information.This deficient practice resulted in a delay in regulatory oversight and in informing the residents' representative, thereby impeding timely intervention. The failure to report and notify CDPH had the potential…

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 maintain complete and accurate clinical records for one of three sampled residents (Resident 1). The facility failed to: 1. Document on Resident 1's Electronic Health Record (EHR-a digital system used to document and manage a resident's health information ) the discovery of maggots around Resident 1's tracheostomy site (a surgically created opening in the neck to assist with breathing) on 10/22/2025.2.Document a change in condition, the SBAR Situation, Background, Assessment, Recommendation (SBAR) communication tool to inform or escalate the issue to appropriate clinical staff.These deficient practices had the potential to compromise the continuity of care, delay necessary medical intervention, and negatively impact the resident's health and safety.Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including acute…

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 staff followed proper infection prevention and control practices while providing tracheostomy care for one of three sampled residents (Resident 3). The facility failed to:1. Ensure staff adhered to infection control protocols during tracheostomy (a surgical procedure that creates an opening in the trachea (windpipe) in the front of the neck) care (procedure involving the routine cleaning and management of a tracheostomy tube and surrounding skin to maintain airway patency and prevent infection).2.Ensure Respiratory therapist (RT) 3 was not wearing artificial (acrylic) nails while providing tracheostomy care to Resident 3 on 10/24/2025.This failure placed ventilator (a machine that delivers oxygen to the lungs to assist with breathing) dependent residents at risk for cross-contamination (the transfer of bacteria, viruses, microorganisms, or other harmful substances from one surface to another through improper or unsanitary…

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 immediately, or no later than 24 hours, an injury of unknown origin for one of three sampled residents (Resident 1). Resident 1 was found with swelling to his left elbow and an X-Ray (a procedure that takes pictures of the inside of the body to diagnose broken bones and other injuries) taken on 9/4/2025 confirmed Resident 1 had a left shoulder dislocation (an injury where the ends of bones at a joint are forced out of their normal position). Resident 1 was transferred to a General Acute Care Hospital (GACH) for further evaluation. This deficient practice resulted in the inability of the California Department of Public Health (CDPH) to investigate the injury of unknown injury in a timely manner and had the potential for facts related to Resident 1's injury to be lost and/or forgotten. Findings: During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was initially admitted to the facility on [DATE] and…

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 resident, who used a ventilator (a machine used in healthcare to assist or perform breathing for a patient who cannot breathe adequately on their own), had a functional limitation in range of motion ([ROM] the direction a joint can move to its full potential) to both her upper and lower extremities (arms and legs) and required a two person physical assist with bed mobility, including turning and repositioning, did not sustain a facial injury for one of three sampled residents (Resident 2). The facility failed to: 1. Ensure Certified Nurse Assistant (CNA) 2 did not turn and reposition Resident 2 by herself, without assistance, placing Resident 2 on the tubing of a ventilator circuit (a system of tubes connecting a ventilator). 2. Ensure CNA 2 followed the facility's Policy and Procedure (P/P) titled, Repositioning revised on 5/2013, which indicated .use two people while tuning or moving the resident in bed. 3. Ensure CNA 2 followed 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 to ensure ten of ten sampled residents (Resident's 4, 5, 10, 11, 12, 13, 14, 15, 16, and 17) were provided showers on their scheduled shower day. This deficient practice resulted in incomplete personal hygiene care provided to Resident's 4, 5, 10, 11, 12, 13, 14, 15, 16, and 17, and had the potential to result in a negative impact on their quality of life and self-esteem. Findings:a. During a review of Resident 4's admission Record (Face sheet), the Face Sheet indicated Resident 4 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including respiratory failure (a serious condition that makes it hard to breathe) with tracheostomy (a surgical procedure that creates an opening through the neck into the windpipe that provides an air passage to help you breathe when the usual route for breathing is obstructed or impaired) and end stage renal disease ([ESRD] when the kidneys are no longer able to work at a level needed for…

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

Based on interview and record review the facility failed to ensure one of two sampled residents (Resident 2) received oral care. This deficient practice placed Resident 2 at risk for poor dental hygiene and increased the risk for oral infections. Findings: During a review of Resident 2 ' s admission record, the admission record indicated the facility initially admitted Resident 2 on 1/17/2023, with diagnoses including muscle weakness, abnormalities of gait and mobility, and dementia (a progressive state of decline in mental abilities). During a review of Resident 2 ' s Minimum Data Set (MDS), a resident assessment tool, dated 1/19/2025, the MDS indicated moderately impaired cognition of Resident 2. The MDS indicated Resident required supervision (helper provides verbal cues and touching assistance) with oral hygiene and personal hygiene. During an interview and record review on 5/20/2025 at 9:15 a.m., with Licensed Vocational Nurse (LVN) 2, Resident 2 ' s Point of Care Response History, Task :oral care was reviewed. The history indicated to provide Resident 2 with oral care every…

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 wound treatments were administered for three out of six sampled residents ( Resident 7,8,9) with pressure ulcers (localized damage to the skin and/or underlying tissue usually over a bony prominence) on 5/4/2025. This deficient practices had the potential to result in poor wound healing. Findings: During a review of Resident 7 ' s admission record, the admission record indicated the facility initially admitted Resident 7 on 4/9/2025, with diagnoses including Metabolic encephalopathy (brain disorder), attention to gastrostomy (G- tube - a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems). During a review of Resident 7 ' s Minimum Data Set (MDS), a resident assessment tool, dated 5/7/2025, the MDS indicated intact cognition of Resident 7. The MDS indicated Resident 7 was dependent (staff does all the effort to complete task) on staff for oral hygiene,…

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 cleanse and change the gastrostomy ( G- tube - a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems) site dressing on 5/4/2025 for three out of siix sampled residents (Residents 7, 8, 9). This deficient practices had the potential to result in G-tube site infections. Findings: During a review of Resident 7 ' s admission record, the admission record indicated the facility initially admitted Resident 7 on 4/9/2025, with diagnoses including Metabolic encephalopathy (brain disorder) and attention to gastrostomy. During a review of Resident 7 ' s Minimum Data Set (MDS), a resident assessment tool, dated 5/7/2025, the MDS indicated intact cognition of Resident 7. The MDS indicated Resident 7 was dependent (staff does all the effort to complete task) on staff for oral hygiene, toileting hygiene, and showering. During a review of Resident 7 ' s Treatment Administration…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure three out of three sampled residents (Residents 67,75 and 347) self- determination was not violated when a monitoring system (contactless cardiorespiratory monitor with cloud service) with microphone and speaker was turned on without giving consent. This failure violated the rights of Residents 67,75 and 347. Findings: During a review of Resident 67 admission Record dated 4/25/25, the admission record indicated Resident 67 was admitted on [DATE] and readmitted [DATE] with diagnosis including anxiety ( feelings of worry, nervousness or fear), depression ( persistent feelings of sadness, hopelessness, loss of interest) diabetes mellitus type two (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 67's History and Physical (H&P) dated 12/18/24, the H&P indicated Resident 28 had the capacity to understand and make decisions. During a review of Resident 67's Minimum Data…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility accurately assesses and documented on the Minimum Data Set (MDS- a resident assessment tool) reflective of the residents' status at the time of assessment on two of five sampled residents (Resident 29 and Resident 78) by failing to: 1.Ensure Resident 29 used bilateral (both) hand mittens was accurately assessed in the MDS as a restraint (any manual method, physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement). 2.Ensure Restorative Nursing Assistant Services (RNA services performed to restore and maintain physical function of a resident as directed by their established care plan) performed for Resident 78 was documented and assessed in the MDS. These failures had the potential of not identifying Resident 29 and Resident 78's relevant care needs and developing a plan of care that will meet Resident 29 and 78's needs. Findings:…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that a preadmission screening assessment ([PASRR] a federal requirement that evaluates individuals seeking admission to Medicaid-certified nursing facilities to ensure they are not inappropriately placed for long-term care) level II was done for two of 19 residents (Resident 31 and Resident 4) who was diagnosed with a mental illness schizophrenia ( a chronic mental disorder characterized by disruptions in thought processes, perceptions, emotions, and social interactions). This deficient practice had the potential for Resident 31 and Resident 4 not receiving the necessary and appropriate psychiatric level of treatment and evaluation in the facility. Findings: During a review of Resident 31's admission Record, the admission Record indicated Resident 31 was admitted to the facility on [DATE], with diagnoses including schizophrenia, epilepsy (brief episodes of abnormal electrical activity in the brain). During a review of Resident 31's History and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to provide the necessary care and services to prevent development or worsening of pressure injury (injury to skin and underlying tissue resulting from prolonged pressure on the skin) for two of four sampled residents (Resident 53 and Resident 83). The facility failed to 1. Ensure Resident 53's skin assessment was done during shower days on Wednesdays and Saturdays and other remaining days when Resident 53 received a bed bath. 2.Ensure facility followed Resident 53's care plan titled Risk for Skin Breakdown dated 9/2023 with interventions included to turn and reposition resident at least every two hours, reassess skin daily by Certified Nursing Assistant (CNA) and weekly by licensed nurses or treatment nurse. 3. Monitor and assess Resident 83's right leg for skin breakdown. These deficient practices had the potential for Resident 53 and 83's pressure injury to progress and developed new pressure injury. Findings: 1.During a review of Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that medication error rate was less than five percent (%). 14 medication errors out of 30 total opportunities contributed to an overall medication error rate of 46.67 percent ( %) for one of three residents (Resident 3) observed during medication administration (MedPass). The deficient practice of failing to administer medications in accordance with the physician orders increased the risk that Residents 3 may experience adverse reactions, complications, that could lead to a decline in the residents' condition, harm, or hospitalization. Findings: During a review of Resident 3's admission Record, the admission Record indicated, Resident 3 was originally admitted to the facility on [DATE] with diagnoses including chronic kidney disease (a condition where the kidney gradually lose their ability to function properly, typically over several months or years), hypertension (HTN-high blood pressure), diabetes mellitus (DM-a disorder…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure two of two sampled residents (Resident 60 and Resident 75) were aware of their rights. This failure had the potential l to violate the resident rights and had the potential to not allow the opportunity for residents to exercise their right. Findings: During a review of Resident 60's admission Record (Face Sheet) , the Face Sheet indicated, Resident 60 was admitted to the facility on [DATE] with diagnoses of but not limited to respiratory failure occurs when the lungs can not properly exchange gases, causing abnormal levels of carbon dioxide and/or oxygen in the arteries), osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage), and atrial fibrillation (a rapid heart rate). During a review of Resident 60's History and Physical (H&P), dated 2/20/2025, the H&P indicated Resident 60 had the capacity to understand and make decisions. During a review of Resident 60's Minimum Data Set (MDS) , dated 3/8/2025, the MDS…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow and implement its policy and procedure (P&P) regarding the use of restraints (any manual method physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement) for one of five sampled residents (Resident 29) by failing to: 1.Ensure physician order had the specific reason for the use of restraint that will benefit the resident's medical symptom. 2.Monitor and assess Resident 29's tolerance while Peek-A-Boo mittens (specialized, padded mittens used to prevent residents from pulling or interfering with medical devices) when removed. These failures had the potential to put Resident 29 at risk for unnecessary prolonged use of restraint that could lead to decline in mobility and injury. Findings: 1.During a review of Resident 29's admission Record, the admission Record indicated Resident 29 was originally admitted to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a Preadmission Screening and Resident Review (PASARR- a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care) was accurately documented for one of four reviewed residents (Residents 28). This deficient practice had the potential to result in an inappropriate placement and delay of needed services for Resident 28. Findings: During a review of Resident 28's admission Record, the admission Record indicated Resident 28 was admitted to the facility on [DATE] with diagnoses including anxiety( feelings of worry, nervousness or fear), depression ( persistent feelings of sadness, hopelessness, loss of interest) and post-traumatic stress disorder (PTSD- a health condition that develops after a person experiences or witnesses a traumatic event). During a review of Resident 28's History and Physical (H&P) dated 12/18/2024, the H&P indicated Resident 28 had the capacity to understand and make…

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 an attempt was made to find the identity for one of one sampled resident (Resident 192) since being admitted to the facility on [DATE]. This failure had a potential to result in Resident 192 being known as John Doe not receiving adequate care and services to prevent a decline in physical, mental, and psychosocial well-being. Findings: During a review of Resident 192's admission Record (Face Sheet) , the Face sheet indicated, Resident 192 was admitted to the facility on [DATE] with diagnoses of but not limited to hemiplegia(total paralysis of the arm, leg, and trunk on the same side of the body), acute respiratory failure (a serious condition where the lungs struggle to adequately transfer oxygen into the blood or remove carbon dioxide, leading to a potentially life-threatening deficiency in oxygen or a buildup of carbon dioxide), encephalopathy (a group of conditions that cause brain dysfunction) and sepsis ((a life-threatening blood 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 ensure one of the one sampled, Resident 4 was treated for candidiasis (a fungal infection typically on the skin or mucous membranes caused by candida). This failure resulted in Resident 4 having an untreated oral fungal infection since 3/29/2025. Findings: During a review of Resident 4 s admission Record (Face Sheet), the Face Sheet indicated Resident 4 was originally admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses of but not limited to candidiasis, acute respiratory failure (a serious condition where the lungs struggle to adequately transfer oxygen into the blood or remove carbon dioxide, leading to a potentially life-threatening deficiency in oxygen or a buildup of carbon dioxide) and cardia arrest (when the heart stops beating suddenly). During a review of Resident 4's History and Physical (H&P), dated 3/31/2025, the H&P indicated, Resident 4 did not have the capacity to understand and make…

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 resident, who had a history of pneumonia and pleural effusion and verbalized shortness of breath (SOB)/difficulty breathing at rest on 3/23/2025 at 2:13 a.m., blood pressure of 98/57 millimeters of mercury [mmHg] is unit of measurement) on 3/25/2025 at 9:48 a.m. and yellow sputum (mucus cough up from the respiratory tract) , cough, congestion (buildup of mucus in the airways, leading to difficulty breathing), lethargy ( a condition marked by drowsiness and an unusual lack of energy and mental alertness) and SOB on 3/25/2025 at 11:00 p.m. was assessed and monitored for one of four sampled residents (Resident 294). The facility failed to 1. Ensure Licensed Vocational Nurse (LVN unknown) informed Resident 294's medical doctor (MD) when Resident 294's had shortness of breath (SOB)/difficulty breathing at rest on 3/23/2025 at 2:13 a.m. 2. Ensure LVN (unknown) informed Resident 294's MD of Resident 294's systolic blood pressure (SBP- the force of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to implement the necessary services and care on one of four sampled residents (Resident 78) by failing to: 1.Ensure the Restorative Nursing Services ( nursing interventions that promote the residents' ability to adapt and adjust to living independently and safely) Order was being implemented and followed by restorative nursing assistant (RNA- healthcare professional who focuses on helping patients regain and maintain their physical and functional abilities after an illness or injury). 2. Ensure RNA informed licensed nurse of Resident 78 unable to perform active assisted range of motion( AAROM-type of exercises where a resident uses their muscles to move a body part but the resident receive assistance from an external force like a therapist, a device or even gravity) to bilateral lower extremities and bilateral upper extremities while sitting at the edge of the bed everyday three times a week as tolerated one time a day every Monday, Wednesday…

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 oral care and oral suctioning were provided to one of four sampled residents (Resident 57) when Resident 57 had dried secretions on the mouth. This failure had the potential to put Resident 57 at risk for airway obstruction (a blockage in the airway that prevents air from moving in and out of the lungs), and respiratory infection. Findings: During a review of Resident 57's admission Record, the admission Record indicated Resident 57 was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses that included tracheostomy (medical procedure where a hole is created in the neck to allow access to the windpipe for breathing), gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems), dependence on respirator( patient is unable to breathe independently requiring continuous use of mechanical device to support…

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 Nurse Assistant Training Program was renewed under the California department of Public Health (CDPH) licensing and certification program (L&C) denied application on [DATE]. This failure had the potential to put the residents' safety at risk when not ensuring the facility had an approved Nurse Assistant Training Program. Findings: During a concurrent interview on [DATE] at 9:30 a.m. with the Director of Staff Development (DSD), and record review of the facility's Nurse Assistant Training Program Notice dated [DATE]. The nurse assistant training program notice indicated communication notices were sent on [DATE] and [DATE] outlining the documents or revisions required to complete the application. A Resume with verifiable qualification, one year of verifiable experience in teaching adults or completion of a course of teaching adults was needed. The DSD stated that she was aware that the facility's Nurse Assistant Training Program had expired 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.

Based on interview and record review the facility failed to ensure an annual performance review was conducted for two of two sampled Certified Nursing Assistants (CNA 1 and CNA 2). This deficient practice had the potential for the facility not to be able to assess areas of weakness identified in performance reviews and skills necessary to provide nursing services to assure resident safety. Findings: During a concurrent interview and record review on 4/23/2025 at 11:03 a.m. with the Director of Staff Development Consultant (DSDC), reviewed CNA 1 and CNA 2's employee files. The DSDC stated that she could not find any performance evaluations for CNA 1 and CNA 2. The DSDC stated that CNA's performance evaluations should be done annually. The DSDC stated staff were in-serviced based on the outcomes of their performance evaluations. The DSDC stated we need to educate our staff to assist residents needs and to prevent any negative outcomes to the residents. During a concurrent interview and record review on 4/23/2025 at 11:03 a.m. with the Administrator (ADM). Reviewed CNA 1 and CNA 2'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 The facility failed to ensure the Narcotic and Hypnotic Record have a prefilled licensed nurse signature in a designated signature box for narcotics reconciliation for one of seven facility medication carts (a mobile storage unit used in healthcare settings to safely and efficiently transport and store medications and medical supplies). This deficient practice had the potential for loss of accountability, which affected the controls against drug loss, diversion, or theft. Findings: During a review of Resident 20's admission Record, the admission Record indicated Resident 20 was admitted to the facility on [DATE], with diagnoses including heart failure (the heart cannot pump enough blood to meet the body's needs) and respiratory failure (the lungs cannot adequately provide oxygen to the blood or eliminate carbon dioxide). During a review of Resident 20's Minimum Data Set ([MDS], resident assessment tool), dated 3/18/25, the MDS indicated, Resident 20 was dependent (helper does all the effort. Resident does none…

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 the sampled residents (Resident 82) did not receive unnecessary psychotropic medication as needed for longer than 14 days and a new prescription required every 14 days after the resident had been evaluated. This failure had the potential to place Resident 82 at risk for adverse reactions associated with the use of psychotropic drugs. Findings: During a review of Resident 82's admission Record (Face Sheet), the Face Sheet indicated, Resident 82 was originally admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses of but not limited to heart failure (the heart is unable to pump blood around the body properly), and diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 82's History and Physical (H&P) dated 1/16/2025, the H&P indicated, Resident 82 can make needs known but cannot make medical decisions. During a review of…

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

Based on observation, interview, and record review the facility failed to ensure fresh fruits were stored properly when an open container with a cantaloupe, and honeydew melon, dated fresh fruit 3/29/25 expires on 4/5/2025. This failure had the potential to expose residents to food-borne illnesses (any illness resulting from ingestion of food contaminated with bacteria, viruses, or parasites). Findings: During a concurrent observation in the walk-in refrigerator on 4/22/25 at 8:16 am and interview with the Cook, it was observed an open container with a half of a cantaloupe with a date of 4/8/25 on the skin of the fruit and a half of a honeydew melon in a plastic bag dated 4/18/25 the container was dated fresh fruit 3/29/25, expires on 4/18/25. The cook stated that each fruit should have an open date and a use by date to ensure the food is fresh. The cook stated there is a potential for stomach issues if food is served out of date. During an interview on 4/25/25 at 9:11a.m., with the dietary supervisor (DS), The DS stated that they are now using labels with open and best buy dates.…

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 to correct identified and potential problems by failing to: 1.To provide an effective oversight of the facility and implementation of the facility's plan of correction (POC- specific corrective actions the facility will take to address the deficiencies and the timeline for completion) of the deficient practice regarding pressure injury (localized damage to the skin and/or underlying tissue usually over a bony prominence) and quality of care ( providing the best possible healthcare to residents focusing on safety, effectiveness, and desired health outcomes). These failures had the potential to negatively impact on the care of the residents and individualized needs of the residents not being met. Findings: During a review of facility's CMS 2567 (survey report that documents and justifies a nursing home's compliance with federal health…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to observe infection control practices by failing to: a. Assess and monitor Resident 78's midline catheter (a long, thin , flexible tube inserted into a large vein in the upper arm with the tip just below the armpit used to provide venous access for medications, fluids and blood products) dressing . Resident 78's midline dressing was soiled and soaked with blood. These failures had the potential to result in the spread of diseases and infection to the facility staff, residents, and visitors. Findings: a. During a review of Resident 78's admission Record, the admission Record indicated Resident 78 was originally admitted to the facility on [DATE] and readmitted on [DATE] to the facility with diagnoses that included pneumonia (an infection/inflammation in the lungs), candidiasis ( fungal infection caused by an imbalance of healthy bacteria and yeast in the body), dependence on respirator ( a person requires a mechanical breathing machine to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement their protocol for Antibiotic Stewardship for one of one sampled resident (Resident 84). Resident 84 was prescribed an antibiotic drug without meeting the McGeer Criteria (a set of clinical definitions used for surveillance in long-term care facilities (LTCF) These McGeer criteria require more diagnostic information, such as positive laboratory tests, to meet the criteria for definitive infection.), after being screened for a urinary tract infection (UTI- an infection in the bladder/urinary tract). This failure had the potential to result in Resident 84 developing antibiotic resistance (not effective to treat infection) from unnecessary or inappropriate antibiotic use. Findings: During a review of Resident 84's admission Record (Face Sheet) , the Face Sheet indicated, Resident 84 was admitted to the facility on [DATE] with diagnoses of but not limited to nontraumatic intracranial hemorrhage 9bleeding within the brain not caused by trauma or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure that the facility's Certified Nursing Assistants (CNAs) were provided with approved training when their nurse assistant training program expired on [DATE]. This failure had the potential to affect the residents' quality of life due to lack of knowledge. Findings: During a concurrent interview on [DATE] at 9:30 a.m. with the Director of Staff Development (DSD), and record review of the facility's Nurse Assistant Training Program Notice dated [DATE]. The nurse assistant training program notice indicated communication notices were sent on [DATE] and [DATE] outlining the documents or revisions required to complete the application. A Resume with verifiable qualification, one year of verifiable experience in teaching adults or completion of a course of teaching adults was needed. The DSD stated that she was aware that the facility's Nurse Assistant Training Program had expired on [DATE] and that she had just sent in a new application on [DATE] and was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure nursing staff notified the physician in a timely manner when one out of three residents (Resident 1) had blood pressure and temperature readings below the baseline, possibly leading to hypotension (low blood pressure) and/or hypothermia (abnormally low body temperature). This deficient practice had the potential of a delay in services for Resident 1 who was being monitored for sepsis prevention. Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including acute respiratory failure (a life-threatening condition where the lungs cannot adequately exchange oxygen and carbon dioxide, leading to low blood oxygen levels),), gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems), tracheostomy (a surgical procedure that creates an opening in the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one out of three sampled residents (Resident 1) received consultation care for his suprapubic catheter (a thin, flexible tube that is inserted through a small incision in the lower abdomen (pubic area) into the bladder). This deficient practice had the potential for Resident 1 to become septic because of recurrent urinary tract infections ([UTI], an infection of the urinary tract, which includes the kidneys, bladder, ureters, and urethra). Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including acute respiratory failure (a life-threatening condition where the lungs cannot adequately exchange oxygen and carbon dioxide, leading to low blood oxygen levels), quadriplegia (paralysis from the neck down, including legs, and arms, usually due to a spinal cord injury), gastrostomy (a surgical opening fitted with a device to allow feedings to be…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure one of three sample residents (Resident 1) who had a suprapubic catheter: A. did not touch the floor while hanging on the side of the bed. B. was changed often in a timely manner. These failures had the potential to result in the transmission of infectious microorganisms to the suprapubic bag and increase risk of infection for Resident 1 who was on antibiotics for urinary tract infection ([UTI], an infection of the urinary tract, which includes the bladder, urethra, kidneys, and ureters). Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including acute respiratory failure (a life-threatening condition where the lungs cannot adequately exchange oxygen and carbon dioxide, leading to low blood oxygen levels), quadriplegia (paralysis from the neck down, including legs, and arms, usually due to a spinal cord injury), gastrostomy (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 turn and reposition every two hours, more often as needed, one of one dependent (helper does all the effort) resident (Resident 1) who was assessed at a very high risk for developing a pressure injury (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence). This deficient practice increased Resident 1 ' s risk for developing a facility-acquired, Stage II (Partial-thickness loss of skin, presenting as a shallow open sore or wound) pressure injury on the right posterior lower leg area measuring 2 centimeters [(cm) unit of measurement] in length, 4 cm in width and 0.3 cm in depth. Findings: During a review of Resident 1 ' s admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including Acute Respiratory failure (condition where the person cannot breath), dependence on renal dialysis (a treatment to cleanse the blood of wastes and extra fluids…

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 sufficient nurse staffing to provide care for one of one dependent (helper does all the effort) resident (Resident 1) in the subacute unit (dedicated area within the facility that provides a higher level of intensive nursing care compared to the standard Skilled Nursing Facility care). This deficient practice resulted in Resident 1 not being turned and repositioned every two hours, increased Resident 1 ' s risk for developing a facility-acquired, Stage II (Partial-thickness loss of skin, presenting as a shallow open sore or wound) pressure injury (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence), and has the potential to affect thirty seven Subacute residents in the facility. Findings: During a review of Resident 1 ' s admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including Acute Respiratory failure (condition where 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 one of eight sampled resident ' s (Resident 6), call light was answered in a timely manner. This deficient practice resulted in Resident 6, who was continent (ability to voluntarily control her ability to urinate and deficate) or bowel and bladder functions, having to urinate on herself, making her feel ignored and disrespected. This deficient practice had the potential for Resident 6 to developed skin related issues related to being left wet with urine and/or soiled with feces. Findings: During a review of Resident 6 ' s admission Record (Face Sheet), the Face Sheet indicated Resident 6 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including cerebral infarction (a stroke) with left side hemiplegia (paralysis [inability to move] to one side of the body), and dependency on a ventilator (a machine that breathes for the person of helps the person to breathe). During a review of Resident 6 ' 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 Restorative Nursing Assistant 1 (RNA 1) provided range of motion ([ROM] full movement potential of a joint) exercises and/or a splint application for two out of eight sampled residents (Residents 1 and 8). These deficient practices resulted in Resident 1 ' s order for passive range of motion ([PROM] the movement of a joint when an outside force, such as a person or machine, moves the body part while the person is relaxed) exercises to her lower extremity ([LE] leg), active assistive range of motion ([AAROM] a type of ROM exercise that involves moving an injured body part with assistance from another person or mechanical device) exercises to her bilateral (both) upper extremities ([BUE] arms), and LLE, a splint application to her right knee and Resident 8 ' s order for PROM to his BLE not being completed. These deficient practices placed Resident 1 and Resident 8 at risk for decline in ROM, mobility, physical functioning, and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure Restorative Nurse Assistant 1 (RNA 1) did not falsify records for one of eight sampled residents (Resident 1) indicating Resident 1 received RNA services that were not provided to her. These deficient practices resulted in RNA 1 documenting Resident 1 was provided seven minutes of passive range of motion ([PROM] the movement of a joint when an outside force, such as a person or machine, moves the body part while the person is relaxed) exercises, to her bilateral lower extremities ([BLE] both of her leg) and a splint (a rigid material or apparatus used to support an impaired joint) was applied to her right knee on 11/22/2024 at 2:59 p.m., when those services were not provided. These deficient practices resulted in Resident 1 ' s RNA services as ordered by the physician, not being provided as documentation indicated and placed Resident 1 at risk for development of contractures (loss of motion of a joint) further decline in mobility and physical…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to treat three out of four sampled residents (Resident 1, Resident 2, and Resident 3) with dignity and respect when certified nursing assistant (CNA 1) talked rudely (offensively impolite or ill-mannered) to the residents. This deficient practice had the potential to cause Resident 1, Resident 2, and Resident 3 to feel hurt, disappointed, offended, upset, angry, frustrated, and unsafe in their own home (the facility). Findings: 1. During a review of Resident 1 ' s admission Record, the admission Record indicated Resident 1 was admitted to the facility 9/5/2024 with diagnosis of malignant neoplasm of the cerebellum (brain cancer), repeated calls, hemiplegia affecting the left side (unable to move the left side of body), and cerebral edema (brain swelling). During a review of Resident 1 ' s Minimum Data Set (MDS – a federally mandated resident assessment tool) dated 9/12/2024, the MDS indicated Resident 1 was moderately cognitively impaired (Problems with a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of five sampled resident's (Resident 1) was not subjected to abuse by Resident 2 while left alone in the facility's dining room. This deficient practice resulted in Resident 2 physically assaulting Resident 1 by pulling Resident 1's hair while both residents were left unattended in the facility's dining room on 8/20/2024. This deficient practice had the potential for other residents who were left alone in the facility's dining room to have abusive behavior and or be subjected to abusive behavior. During a review of the Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including dementia (progressive loss of memory) without behavioral disturbance, major depressive disorder ([MDD] a mental disorder that causes a persistent low moods and loss of interest in activities), age related osteoporosis (disease that causes bones to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of three sampled resident's (Resident 1) Permacath (a long, thin, flexible tube with surgically inserted into a vein used for short-term dialysis [procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly) was not dislodged (displacement of a device thought to be securely in position) when Certified Nurse Assistant 1 (CNA 1) turned Resident 1 without assistance during care. This deficient practice resulted in approximately 400 milliliters (ml) of blood loss to Resident 1 and transfer of Resident 1 to a General Acute Care Hospital (GACH) via 911, where Resident 1 required surgical intervention on 7/23/2024 to replace the dislodged Permacath. Findings: During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] with diagnosis including acute (sudden onset) respiratory failure (a serious condition that makes it difficult…

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 injury of unknown origin for one out of 10 sampled residents (Resident 1) when Resident 1 was assessed with a non-displaced fracture (a bone that cracks or breaks but stays in place) of the left elbow to the California Department of Public Health ([CDPH] a state agency that works to protect the health of California residents and visitors) and law enforcement. This deficient practice resulted in the inability of Resident 1 ' s left elbow fracture to be investigated by CDPH in a timely manner and had the potential for other injuries of unknown origin to not be reported by the facility. Findings: During a review of Resident 1 ' s admission record (Face sheet), the Face Sheet indicated, Resident 1 was originally admitted to the facility on [DATE] and re-admitted on [DATE]. The Face Sheet indicated Resident 1 had a diagnosis of epilepsy (a chronic, noncommunicable brain condition that causes people to have repeated seizures [brief episodes of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to ensure a thorough investigation was conducted when one out of ten sampled residents (Resident 1) was found to have a non-displaced fracture (a bone that cracks or breaks but stays in place) of the left elbow. This deficient practice resulted in the facility ' s inability to determine how Resident 1 ' s fracture occurred and had the potential for other injuries of unknown origin to not be investigated. Findings: During a review of Resident 1 ' s admission record (Face sheet), the Face Sheet indicated Resident 1 was originally admitted to the facility on [DATE] and re-admitted on [DATE]. The Face Sheet indicated Resident 1 had a diagnosis of epilepsy (a brain disorder in which a person has repeated seizures [uncontrolled movement]). During a review of Resident 1 ' s Minimum Data Set ([MDS] a standardized assessment and care screening tool) dated 5/10/2024, the MDS indicated Resident 1 was dependent on staff to complete his activities of daily living…

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 enteral feeding (a method of supplying liquid nutrients directly into the stomach) tube for one out of six sampled residents (Resident 3) was connected to Resident 3 ' s Gastric Tube ([GT] a small tube surgically inserted through the abdomen to deliver nutrition and/or medication directly into the stomach) port. This deficient practice resulted in Resident 3 ' s enteral nutrition to spill on the floor and had the potential for Resident 3 to receive the incorrect amount of nutrients that could contribute to weight loss, hunger and/or malnutrition. Findings: During a review of Resident 3 ' s admission Record (Face Sheet) the Face Sheet indicated Resident 3 was admitted to the facility on [DATE]. The Face Sheet indicated Resident 3 had diagnoses including unspecified severe protein-calorie malnutrition (a nutritional condition that occurs when the body doesn ' t have enough nutrients), placement of a GT, and dysphagia (difficulty swallowing).…

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

Based on observation, and interview, the facility failed to ensure keys were not left on a Respiratory Therapist (medical professionals who helps patients with breathing problems) medication cart, that contained Levalbuterol Inhalation Solution (a medication used to prevent or relieve the wheezing, shortness of breath, coughing, and chest tightness), Ipratropium Bromide (a Albuterol Sulfate (a medication used to treat wheezing and shortness of breath) and Budesonide Inhalation Suspension (a medication used to decrease inflammation of the airways to make breathing easier). This deficient practice resulted in an unsafe environment for residents by giving them access to unauthorized medications and had the potential for residents ' accidental ingestion of medications that could lead to adverse side effects such as blurred vision, diarrhea, chest pain, swelling of the face, eyes, lips, tongue or throat, chest pain, and increased heart rate, Findings: During an observation and concurrent interview on 7/13/2024, at 3:16 p.m., with Respiratory Therapist 1 (RT 1) an unattended RT medication…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement their policy ensuring the accurate receiving and reconciliation (process of verifying physician orders to medication) of home medications for one of one sampled resident (Resident 1). The facility failed to track and document the date, time, or quantity of fidaxomicin (medication used to treat diarrhea caused by an infection with Clostridium difficile [bacteria that causes colitis, a serious inflammation of the colon]) when nursing staff received the medication from Resident 1 ' s Responsible Party (RP). This deficient practice had the potential for inaccurate inventory of medications causing medication shortages and underdosage of medication. Findings During a review of Resident 1 ' s admission Record, the record indicated Resident 1 was admitted on [DATE] with the diagnosis including enterocolitis (inflammation throughout the intestines) due to clostridium difficile. During a review of Resident 1 ' s Minimum Data Set (MDS), a standardized…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to provide sufficient staffing to accommodate two out of five residents' (Residents 1 and 2) needs by not answering call lights in a timely matter. This deficient practice could have resulted in residents not receiving needed services in a timely matter. Findings: During a review of Resident 1 admission Records (face sheet), the face sheet indicated Resident 1 was admitted to the facility on [DATE] with the diagnoses of chronic respiratory failure (lungs cannot get enough oxygen [element needed for life] into the body), morbid obesity (overweight), and heart failure (heart does not pump enough blood). During a review of Resident 1's MDS Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 3/3/2024, the MDS indicated that Resident 1's cognitive (process of thinking) skills were intact for daily decision making. The MDS indicated Resident 1 was dependent (assistance of 2 or more helpers is required for the resident to complete 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 The facility failed to ensure dryer's thermometer was working properly. The facility failed to monitor Temperatures of dryer. FACILITY Infection Control 04/24/24 03:39 PM Met with [NAME] Jumaoas Infection Preventionist. Has worked here since 2018. Is the full-time IP nurse and the DSD is his backup when he is not here. LVN license expires 5/31/25. IPC Resources certification and certificate of Training in Infection Prevention and Control certificate reviewed (spoke with supervisor [NAME] and states these certs are acceptable). Total hours of training was 19.75 per the CDC Nursing Home Infection Preventionist Training Course. DSD is also a certified IP LVN, had 19.75 per the CDC Nursing Home Infection Preventionist Training Course. 04/26/24 08:05 AM Entered laundry room, laundry tech mopping the floor on the dirty side in her PPE. Hand washing station located on the dirty side. [NAME], laundy tech, has worked here for 10 years, limited English. Showed me the lint traps which were clear, log updated (picture…

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 three out of 42 residents (Resident 6, 14 and 24 who were on chopped meat diet (modified diet with food prepared approximately ½ inch x ½ inch) received meat texture in form that meet their needs when cook served large chunks of meat instead of chopped meat per resident diet orders and preferences as indicated on the meal tickets. This failure had the potential to result in decreased intake related to large chunks of meat and increased choking risk. Findings: During a review of the facility lunch menu on 4/23/24, the following items will be served: Roast Turkey (3 ounces (oz.)), Cranberry ginger citrus sauce; bread dressing; seasoned peas; three bean salad, vanilla mousse, and milk. During a concurrent observation and interview on 4/23/2024 at 11:40 a.m. with [NAME] (Cook) 1, on the tray line (system of food preparation, used facility, in which trays move along an assembly line.) Cook1 stated the alternative to roast turkey meal and for residents who don't want turkey were roast beef three ounces…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to identify, monitor, and track incidence of pressure injury ( breakdown of skin and underlying tissue due to pressure) as part of their Quality Assurance and Performance Improvement (QAPI- data driven, proactive approach to improving the quality of life, care, and services in nursing homes) activities for prevention of pressure injury in the facility by failing to: 1.Identify and monitor Resident 62's skin for pressure injury and implement action plan for reducing occurrence of pressure injury. This failure had the potential to negatively impact the care of the residents and cause delay of care and treatment for Resident 62. Findings: During a record review of Resident 62's admission Record, the admission Record indicated the resident was initially admitted on [DATE] and was readmitted on [DATE] to the facility with diagnoses that included hemiplegia following cerebral infarction affecting right dominant side( paralysis or weakness on the right side of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure the licensed nurses, in charge of resident assessment initiate a change of condition report and informed resident physician of open wound on the left buttock and the two wounds on the right inner buttock on 4/23/2024 for one of one sampled resident (Resident 62) These failures had the potential to result in Resident 62 not receiving proper treatment to Resident 62 redness on the left buttock on 4/22/2024 progressing to an open area to the left buttock (an injury that involves a break in the skin and leave the internal tissue exposed) on 4/23/2024 measuring 2.0 cubic centimeters ([cm] a unit of measurement) in length x 2.0 cm in width. Resident 62's right inner buttock with 2 small open areas one measuring 0.2 x 0.2 cm and a second one to the right inner buttock measuring 0.2x0.3 cm. Findings: During a review of Resident 62's admission Record, the admission Record indicated Resident 62 was originally admitted to the facility on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of three sample residents (Resident 190) received Advance Beneficiary Notice ([ABN] notice to provide information to residents/beneficiaries if they wish to continue receiving skilled services that may not be paid by Medicare and assume financial responsibility). This failure had the potential for Resident 190 to be uninformed of what services are covered. Findings: During a record review of Resident 190's admission Record, the admission Record indicated the resident was admitted on [DATE] to the facility with diagnoses that included diabetes ( high blood sugar), primary osteoarthritis ( degenerative joint disease in which the tissues in the joint break down over time)of knee and acute osteomyelitis (inflammation or swelling of bone tissue that is usually as a result of an infection) of left ankle and foot. During a record review of Resident 190's History and Physical (H&P) dated 4/23/2024, indicated the Resident 190 had the capacity to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to: 1. Ensure one of three sampled residents (Resident 62) were free from physical restraint (any action or procedure that prevents a person's free body movement to a position of choice) by placing a hand mitten restraint on the resident without a doctor's order. 2. Ensure continuous appropriate assessment and monitoring of a restraint. These failures resulted in the absence of continued assessment and monitoring of a restraint and had the potential to result in risk for complications of restraint use such as skin breakdown and severe injuries. Findings: During a record review of Resident 62's admission Record, the admission Record indicated the resident was admitted on [DATE] and re-admitted on [DATE] to the facility with diagnoses that included diabetes (a condition in which the body fails to metabolize (process) glucose (sugar) correctly ), contracture (a permanent tightening of muscles, tendons, skin, and nearby tissues that causes 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 implement a care plan for restraints(any action or procedure that prevents a person's free body movement to a position of choice) for one of three sampled residents (Resident 62). This deficient practice had the potential to negatively affect the delivery of necessary care and place the resident at risk for skin breakdown and injuries. Findings: During a record review of Resident 62's admission Record, the admission Record indicated the resident was initially admitted on [DATE] and was readmitted on [DATE] to the facility with diagnoses that included hemiplegia following cerebral infarction affecting right dominant side( paralysis or weakness on the right side of the body following a stroke), tracheostomy( procedure to help air and oxygen reach the lungs by creating an opening into the windpipe from outside the neck), chronic obstructive pulmonary disease ([COPD] group of lung diseases causing restricted airflow and breathing problems),…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure one of five sample residents (Resident 24) was assisted out of bed to wheelchair as ordered by the physician. This failure had the potential for Resident 24 to have a further decline in physical strength and mobility. Findings: During a record review of Resident 24's admission Record, the admission Record indicated the resident was admitted on [DATE] to the facility with diagnoses that included contracture(permanent tightening of the muscles, connective tissue, skin and tendons which prevents normal movement)of right and left ankle, unspecified osteoarthritis(progressive degenerative joint disease, in which the tissues in the joints break down overtime) and Parkinson's disease ( brain disorder that affects the nervous system causing unintended or uncontrollable movements). During a record review of Resident 24's Minimum Data Set ([MDS] standardized assessment and care screening tool) dated 5/20/2024, the MDS indicated the resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure one of 21 sampled residents (Resident 22) was administered medication as ordered by the physician on 2/13/2024. This failure had the potential to cause Resident 22 increased dryness and inflammation of the mouth. Findings: During a review of Resident 22 admission Record indicated Resident 22 was originally admitted to the facility on [DATE] with diagnoses including dysphagia (difficulty in swallowing), Huntington's disease (a condition that leads to progressive degeneration of nerve cells in the brain that affect movement, cognitive functions, and emotions), gastrostomy (the creation of an artificial opening into the stomach for nutritional support or gastric decompression), and epilepsy (a brain disorder that causes recurring seizures). During a review of Resident 22's History and Physical (H&P) dated 12/15/2023, the H&P indicated Resident 22 could make needs known but could not make medical decisions. During a review of Resident 22'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 ensure: a. The licensed nurses, initiate an assessment for one of three sampled residents (Resident 62) when Certified Nursing Assistant (CNA) 5 informed licensed vocational nurse (LVN 6) of Resident 62' redness on the buttocks. b. Treatment was initiated for Resident 62's open wound on the left buttock and the two wounds on the right inner buttock on 4/23/2024. These failures had the potential to result in Resident 62 not receiving proper treatment to Resident 62 redness on the left buttock on 4/22/2024 progressing to an open area to the left buttock (an injury that involves a break in the skin and leave the internal tissue exposed) on 4/23/2024 measuring 2.0 cubic centimeters ([cm] a unit of measurement) in length x 2.0 cm in width. Resident 62's right inner buttock with 2 small open areas one measuring 0.2 x 0.2 cm and a second one to the right inner buttock measuring 0.2x0.3 cm. Findings: During a review of Resident 62's admission…

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 appropriate care and services to maintain and improve range of motion for two of five sample Residents ( Resident 9 and Resident 42) are provided by failing to: 1.Ensure Restorative Nursing Assistant (RNA- assist the patient in performing task that restore or maintain physical function)Services consisting of passive range of motion( PROM- someone is physically stretching or moving a part of body) on both upper extremities (arm, forearm, wrist and hand) and bilateral lower extremities( legs from the hip to the toes) as tolerated five times a week as ordered was provided to Resident 9. 2.Ensure Resident 42 who had limited mobility received RNA Services after being readmitted to the facility under hospice care. These failures had the potential to result in further decline of Resident 9 and Resident 42 range of motion and mobility. Findings: During a record review of Resident 9's admission Record, the admission Record 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 During an interview and record review the facility failed to ensure safety precautions were implemented on one of 21 sampled residents (Resident 21) when Resident 21 fall back on the reclining high back wheelchair (a reclining high back wheelchair designed to allow the backrest to tilt back or recline). The facility failed to: 1. Ensure Certified Nursing Assistant (CNA) 3 and night shift staff were trained on how to use the reclining high back wheelchair. 2. Provide Resident 21 an appropriate wheelchair for her size and what she was used to transport in the past. These failures resulted in Resident 21 falling back on the high back wheelchair and was transferred to general acute care hospital (GACH) on 2/28/2024 and treated for left and right shoulder contusion (a bruise in the muscle by a direct, blunt blow), head injury and neck strain. Findings: During a review of Resident 21's admission Record, the admission Record indicated Resident 21 was admitted to the facility on [DATE] with diagnoses including…

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 21 sampled residents Resident 140's oxygen humidifier (devices that add moisture to supplemental oxygen) was changed weekly. This failure had the potential to result in Resident 140 developing a respiratory infection. Findings: During a review of Resident 140's admission Record, the admission Record, indicated Resident 140 was admitted to the facility on [DATE], with diagnoses including atelectasis (the collapse of a lung or part of the lung), sepsis (an infection of the bloodstream), diabetes (a condition in which the body fails to metabolize (process) glucose (sugar) correctly), and atrial fibrillation (an abnormal heart rhythm). During a review of Resident 140' s History and Physical (H&P) dated 4/11/2024, the H&P indicated Resident 140 has the capacity to understand and make decisions. During a review of Resident 140's Minimum Data Set ([MDS]- a standardized assessment and care screening tool), dated 4/15/2024, 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 ensure one of three sampled residents (Resident 70) who received hemodialysis ([HD], a medical procedure to remove fluid and waste products from the body), had an appropriate supply available inside an emergency kit. This failure had the potential for delayed intervention during accidental bleeding from the hemodialysis site for Resident 70. Findings: During a record review of Resident 70's admission Record indicated Resident 70 was admitted to the facility on [DATE] and was re-admitted on [DATE] with diagnoses including end stage renal disease [(ESRD) the kidneys no longer support body's needs], dependence on renal dialysis ( to remove fluids and waste products from the body), anemia (low red blood cells to carry oxygen to other body tissues), type 2 diabetes mellitus (abnormal blood sugar), hypertension (high blood pressure), and atrial fibrillation (irregular fast heart rate ). Resident 70 had a hemodialysis fistula (a connection that'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.

Based on observation, interview and record review, the facility failed to ensure one of one medication cart (a movable piece of equipment used in healthcare facilities to store, transport, and dispense medicines, medical supplies, and emergency equipment.) was locked. This deficient practice resulted in resident's, visitors, and other staff having immediate access to medications and had the potential for theft, loss, and unauthorized consumption of medications. Findings: During an observation on 4/11/2024 at 3:04 p.m. in the facility hallway, there was an unlocked and unattended medication cart. During an interview on 4/11/2024 at 3:05 p.m., with Registered Nurse (RN 2), RN 2 confirmed the medication cart was unlocked. RN 2 stated the medication cart was unlocked because the lock button was popped out and the drawers can be opened. RN 2 stated the licensed nurse assigned to that medication cart must make sure it was kept locked prior to stepping away from it. During an interview on 4/11/2024 at 3:10 p.m., with Licensed Vocational Nurse (LVN 1), LVN 1 stated she forgot to lock the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of one resident's (Resident 1) Power of Attorney/Responsible Party (POA 1) was informed immediately after Resident 1 had an abnormal blood glucose (a blood sugar level less than 140 milligrams [mg, one thousandth of a gram]/deciliter [dL, a metric unit of capacity] is considered normal) reading of 444 mg/dL on 3/28/2024 at 9 p.m. This deficient practice resulted in the POA/responsible party being unaware of Resident 1's elevated blood glucose and had the potential for the POA/responsible party's inability to ask questions regarding to Resident 1's plan of care. Findings: During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was originally admitted to the facility on [DATE] and re-admitted on [DATE] with diagnosis including type 2 diabetes mellitus (a chronic disease characterized by elevated levels of blood glucose or blood sugar in the bloodstream). During a review of Resident 1's History and…

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

During an observation, interview and record review, the facility failed to ensure one of one direct care staff, Respiratory Therapist 1 (RT1), followed infection control policies when RT 1: a. Failed to doff (remove) a used glove after exiting resident care areas of Resident 6 and 7, walking in the hallway, and touching bedside equipment for Resident 8 and 9; and b. Failed to perform hand hygiene prior to exiting Resident 6 and 7's room, prior to entering Resident 8 and 9's room, and prior to donning (putting on) new gloves. These deficient practices had the potential to result in cross contamination (physical transfer of germs from one person, object, or place to another) that could be harmful to the residents' health and well-being. Findings: During a review of Resident 6's admission Record (face sheet), the face sheet indicated Resident 6 was admitted at the facility on 6/21/2023 with a diagnosis that included respiratory failure (a condition that develops when the lungs can't get enough oxygen into the blood), sepsis (infection in the blood) and dependency on ventilator (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 a care plan was developed and implemented for one of five sampled residents (Resident 1) after the responsible party 1 (RP 1) reported that Resident 1 was assisted during peri care (washing private areas) with water that was too hot. This deficient practice resulted in the lack of interventions and left Resident 1 unmonitored for potential skin complications that may occur from being exposed to hot water during incontinence care. Findings: During a review of Resident 1's admission Record (Face sheet), the face sheet indicated Resident 1 was admitted to the facility on [DATE] with a diagnosis that included cerebral infarction (blood flow to the brain is interrupted) with right side hemiplegia (paralysis to the right side of the body), and diabetes mellitus (a disease that occurs when the blood glucose, also known as blood sugar, is too high). During a review of Resident 1'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 monitoring was implemented for one of five sampled residents (Resident 1) when the responsible party 1 (RP 1) reported that Resident 1 was provided with peri care (cleaning the private parts) using water that was too hot. This failure left Resident 1's skin condition unmonitored for potential skin complications that may occur from being exposed to hot water during incontinence care. Findings: During a review of Resident 1's admission Record (Face sheet), the face sheet indicated Resident 1 was admitted to the facility on [DATE] with a diagnosis that included cerebral infarction (when blood flow to the brain is disrupted) with right side hemiplegia (unable to move the right side of the body), and diabetes mellitus (a disease that occurs when the blood glucose, also known as blood sugar, is too high). During a review of Resident 1's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 1/6/2024, the MDS indicated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure three of three licensed nurses (charge nurse 1[CN 1], licensed vocational nurse 2 (LVN 2) and Registered Nurse Supervisor [RNS 1]) knew the location of glucagon (an emergency medication used to increase blood sugar). This deficient practice had the potential to result in the provision of inadequate care and services for residents who suffer from hypoglycemia (low blood sugar), a potentially fatal complication of diabetes (condition that affects how the body processes sugar). Findings: During a review of Resident 1 ' s admission record dated 12/19/2023, the admission record indicated, Resident 1 was admitted on [DATE]. Diagnosis included Type 2 Diabetes Mellitus (chronic condition that affects how the body processes sugar), essential hypertension (occurs when you have abnormally high blood pressure that ' s not the result of a medical condition), hemiplegia and hemiparesis (inability to move on one side of the body) following cerebral infarction…

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 confirm the physician received the urinalysis (urine test to check for infections of problems, UA) results for one out of three sampled residents (Resident 1). This deficient practice had the potential to result in an untreated infection which can lead to sepsis (blood infection). Findings: During a review of Resident 1 ' s admission record dated 12/19/2023, the admission record indicated, Resident 1 was admitted on [DATE]. Diagnosis included Type 2 Diabetes Mellitus (chronic condition that affects how the body processes sugar), essential hypertension (occurs when you have abnormally high blood pressure that ' s not the result of a medical condition), hemiplegia and hemiparesis (inability to move on one side of the body) following cerebral infarction (damage to tissues in the brain). During a review of Resident 1 ' s History and Physical (H&P), dated 3/7/2023, the H&P indicated Resident 1 had fluctuating capacity to understand and make decisions.…

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

Based on observation, interview and record review the facility failed to ensure one of four sampled residents (Resident 2)received the necessary treatment services by: a. Failing to ensure Resident 2 ' s toenails were trimmed and failing to address Resident 2's red big toe on the right foot. b. Failing to assist to schedule a follow-up appointment with an endocrinologist (a medical specialist who treats people with a range of conditions including diabetes[disease that affect how the body uses sugar]). This deficient practice had the potential for Resident 2 ' s to experience delay of care and treatment due to lack of assessment and follow up. Findings: During a review of Resident 2 ' s admission Records (face sheet), the face sheet indicated Resident 2 was admitted at the facility on 1/17/2023 with a diagnosis that included diabetes mellitus (a condition that happens when the blood sugar is too high), Major Depressive Disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in life ' s activities) and Chronic Obstructive Pulmonary Disease…

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 Prolia (injectable medicine to treat osteoporosis[disease that weaken the bones] at high risk for fracture[broken bones]) was continued and administered for one of three residents (Resident 1) as prescribed by the physician. This failure resulted in omission of Prolia ' s dose and had the potential to increase the risk of fracture for Resident 1. Findings: During a review of Resident 1 ' s admission Record (Face Sheet), the Face Sheet indicated Resident 1 was initially admitted to the facility on [DATE] and was readmitted on [DATE]. The Face Sheet indicated Resident 1 had diagnoses that included age-related osteoporosis, atrial fibrillation (abnormal and irregular heartbeat), and dementia (group of symptoms affecting memory, thinking and social abilities that can interfere with daily life). During a review of Resident 1 ' s Minimum Data Set ([MDS] a standardized assessment and care screening tool), dated 7/16/2023, the MDS indicated Resident 1…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to secure the personal belongings for one of three sampled residents (Resident 1). This deficient practice resulted in facility misplacing Resident 1 ' s iPad( small tablet computer) and had the potential to negatively affect Resident 1 ' s psychosocial wellbeing. Findings: During a review of Resident 1 ' s admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE]. The Face Sheet indicated Resident 1 had diagnoses that included atrial fibrillation (abnormal and irregular heartbeat), dementia (group of symptoms affecting memory, thinking and social abilities that can interfere with daily life) and gastro-esophageal reflux disease (occurs when stomach acid repeatedly flows back into the tube connecting your mouth and stomach). During a review of Resident 1 ' s Minimum Data Set ([MDS] a standardized assessment and care screening tool), dated 7/16/2023, the MDS indicated Resident 1 had severely impaired…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to assess and treat the skin surrounding one of two sampled resident's (Resident 1) ileostomy (a surgically created opening through the stomach for the purpose of evacuating feces) from 8/28/2023 to 8/30/2023. This deficient practice resulted in the skin surrounding Resident 1's ileostomy going untreated until 8/31/2023, three days after the skin surrounding Resident 1's ileostomy site was noted to be red, causing a delay in the care and treatment to Resident 1's skin. Findings: During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE]. The Face Sheet indicated Resident 1 had diagnoses that included atrial fibrillation (abnormal and irregular heartbeat), dementia (group of symptoms affecting memory, thinking and social abilities that can interfere with daily life) and gastro-esophageal reflux disease (occurs when stomach acid repeatedly flows back into the tube…

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.