Golden Rose Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 2) received treatment and care in accordance with professional standards of practice by failing to notify the physician after Resident 2 refused the resident's Advair (an inhaled medication used daily to prevent and control shortness of breath, chest tightness, and wheezing [a high-pitched, whistling, or raspy sound produced during breathing, usually when air moves through narrowed or blocked airways in the lungs]) on three separate occasions as indicated in the facility's policy and procedure (P&P). This deficient practice placed Resident 2 at risk for experiencing respiratory distress (a condition where a person experienced difficulty breathing, often accompanied by other signs like shortness of breath, rapid breathing, and a pale or bluish tinge to the skin) which could lead to hospitalization. Findings: During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the call light (used in healthcare facilities as an alerting device for nurses or other nursing personnel to assist a resident when in need) system was functional to alert the staff for three (3) of 3 nursing stations (Stations 1, 2 and 3) from 7/10/2025 until 7/18/2025 based on the facility policy titled, Communication- Call System,. This deficient practice had potential for the delay in care and/or not to meet the residents' needs for assistance and can lead to frustration, falls and accidents.Findings:During a record review of the Maintenance Report (MTR) dated 7/14/2025, the Maintenance Report indicated, on 7/10/2025 at 8 PM, Maintenance Director (MTD) was notified that the call light system at (Stations 1, 2 and 3) was not operational and the troubleshoot was unsuccessful. The MTR also indicated on 7/11/2025 at 4 PM, 7/12/2025 at 2:30 PM, and 7/13/2025 at 3 PM call light system at (Stations 1, 2 and 3) was not operational.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 treat resident with respect and dignity, and maintain privacy for three (3) of 18 sampled residents (Residents 1, 62, and 73) in accordance with the facility policy by failing to ensure: 1. Resident 1 was fed by Certified Nursing Assistant 1 (CNA 1) at the resident's eye level on 6/3/2025. 2. Licensed Vocational Nurse 4 (LVN 4) failed to knock on the door before entering Resident 62's room. 3. LVN 4 failed to knock on the door before entering Resident 73's room. Findings: 1. During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE], with the diagnoses including but not limited to metabolic encephalopathy (abnormalities of water, electrolytes, vitamins, and other chemicals that adversely affect the brain function), dementia (progressive brain disorder that slowly destroys memory and thinking skills), and type 2 diabetes mellitus (a disease that occurs when there is a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to accommodate the needs of five (5) of 18 sampled residents (Residents 24, 69, 6, 42 and 72) by failing to ensure: 1. Resident 24's call light was answered timely. 2. Resident 69's call light was placed on the resident's side that did not have a contracture (a stiffening/shortening at any joint, that reduces the joint's range of motion). 3. and 4. Residents 6 and 42's call light was within reach. 5. Resident 72 had a tap call light (specialized nurse call device that is activated by pressure or touch on a soft pad) when the resident has a mitten restraint (a type of physical restraint, specifically a soft, large glove that covers a resident's hand, often used to prevent them from interfering with medical equipment). Findings: 1. During a review of Resident 24's admission Record, the admission Record indicated the resident was originally admitted to the facility on [DATE] and was readmitted on [DATE] with the following diagnoses of sepsis (a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a clean, comfortable and homelike (a place that feels like home) environment for five (5) of 11 sampled residents (Residents 26, 15, 78, 90 and 43) per facility policy by failing to ensure: 1. Resident 26's floor was clean and sanitary without any visible trash, dried brown smears by the commode, and brown clumps under the right side of the bed. 2. to 5. The facility's hot water temperatures were pleasurable and comfortable for Residents 15, 78, 90 and 43 for activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). These deficiencies had the potential to negatively impact the quality of care, life and psychosocial well-being for Residents 26, 15, 78, 90 and 43. Findings: 1. During a review of Resident 26's admission Record, the admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses that included anxiety…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 proper hydration and nutrition maintenance for two (2) of 2 sampled residents (Residents 11 and 40) by failing to: 1. Provide a water pitcher and fluid at bedside for Resident 11. 2. Follow the significant weight loss policy for Resident 40, after an episode of significant weight loss. These failures had the potential to place Resident 11 at risk for dehydration (harmful reduction in the amount of water or fluids in the body) and Resident 40 for continued preventable weight loss, which could affect the residents' overall physical and psychosocial well-being. Findings: 1. During a review of Resident 11's admission Record, the admission Record indicated Resident 11 was readmitted to the facility on [DATE], with the diagnoses including but not limited to metabolic encephalopathy (abnormalities of water, electrolytes, vitamins, and other chemicals that adversely affect the brain function), type 2 diabetes mellitus (a disease that occurs…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 pharmaceutical services for three (3) of 11 sampled Residents (Residents 48, 73, and 76) by failing to ensure: 1. Resident 48 received Marinol (a cannabinoid, a man-made form of cannabis [marijuana is an herbal form of cannabis] used to treat loss of appetite in people with acquired immunodeficiency syndrome [disease in which there is a severe loss of the body's immunity, greatly lowering the resistance to infection and malignancy] and to treat severe nausea and vomiting caused by cancer chemotherapy) medication two times daily from 5/6/2025 to 5/13/2025 (8 days, total of 15 missed doses). 2. Resident 73's medications were administered timely in accordance with the physician's order. a. Apixaban (a medication used to help prevent strokes or blood clots in people who have atrial fibrillation [a condition in which the heart beats irregularly, increasing the chance of clots forming in the body and possibly causing strokes]) twice…

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

Based on observation, interview, and record review, the facility failed to follow proper food handling practices in accordance with its policy and procedure by failing to: a. Label open foods in the kitchen with item name and 'use by' date (the last date recommended for the use of the product) or open date. b. Discard expired foods in the kitchen. These deficient practices had the potential to result in pathogen (germ) exposure to residents and placed residents at risk for developing foodborne illness (food poisoning) with symptoms including upset stomach, stomach cramps, nausea, vomiting, diarrhea, and fever and can lead to other serious medical complications and hospitalization. Findings: During a concurrent observation in the kitchen and interview with the Dietary Supervisor (DS) on 6/2/2025 at 7:50 AM, the kitchen was observed with food items not labeled to indicate the food item names, open date, and use by date. The DS stated all food items were supposed to be labeled with food item name, use by date, and food must be discarded when expired. DS stated. the following were found…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 garbage were properly disposed and contained. This deficient practice had the potential to attract pests and rodents. Findings: During an observation on 6/2/2025 at 8:28 AM with the Dietary Supervisor (DS), there were four (4) trash dumpsters overfilled with trash and the lids were not closed. All 4 trash dumpsters were filled, stacked with bags of trash high above the brim of the receptacle. A concurrent interview with the DS, the DS stated the lids to the trash cans need to be closed and not left open. DS attempted to close the lid of the trash dumpster however the lid could not be fully close due to the bags of trash in the dumpster. During a follow up interview on 6/5/2025 at 12:37 PM with DS, DS stated proper trash disposal was needed to prevent pest infestation (a destructive insect or other animal that attacks crops, food, livestock, etc.) and contamination. During a review of the U.S. Food and Drug Administration (FDA) Food Code 2022, dated 1/18/2023, indicated proper storage and disposal 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 standard infection prevention control practices (a set of practices that prevent or stop the spread of infections and or diseases in the healthcare setting) were followed for six (6) of 18 sampled residents (Residents 72, 69, 24, 62, and 73) in accordance with the facility's policy and procedure when: 1. and 2. Certified Nursing Assistant 4 (CNA 4) failed to change gloves and perform hand hygiene (cleaning hands with the use of alcohol-based hand rubs containing 60%-95% alcohol or hand washing with soap and water) after providing incontinence care (assistance provided due to the inability to control the release of urine or stool) to Residents 72 and 69. 3. Respiratory Therapist Director (RTD) failed to change gloves and perform hand hygiene after touching Resident 24's personal items during tracheostomy (a surgical procedure where an opening is created in the neck to directly access the trachea [windpipe] for breathing) care…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 did not ensure the Preadmission Screening and Resident Review (PASARR - a federal assessment requirement to help ensure that individuals who have a mental disorder [MD] or intellectual disabilities [ID] are placed in facilities that can provide the appropriate care) Level II was completed for one (1) of three (3) sampled residents (Resident 40), as indicated in facility policy. This deficient practice had the potential to result in inappropriate placement and unidentified specialized services for Resident 40. Findings: During a review of Resident 40's admission Record, the admission Record indicated Resident 40 was admitted to the facility on [DATE], with diagnoses that included anxiety disorder (a mental disorder that involves persistent and excessive worry that can interfere with daily activities), unspecified psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality) and End Stage Renal 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 observation, interview and record review, the facility failed to develop individualized resident-centered care plans (a care plan that prioritizes the unique health needs and desired outcomes of the resident) with measurable objectives, timeframe, and interventions for two (2) of 18 sampled residents (Resident 72, and 40): 1. Resident 72 did not have a care plan to address resident's incontinence (the inability to control the flow of urine or the passage of stool) needs. 2. Resident 40 did not have a care plan to address resident's fluid restriction diet and episode of significant weight loss of eight (8) pounds from 2/1/2025 to 3/2/2025. This deficient practice had the potential to result in delayed necessary care and services for Residents 72 and 40 which could result in harm and affect the residents' overall wellbeing. Findings: 1. During a review of Resident 72's admission Record, the admission Record indicated the resident was admitted to the facility on [DATE] with the following diagnoses 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 revise the care plan for one (1) of 18 sampled residents (Resident 24) to address Resident 24's respiratory status for the discontinuance of ventilator (a medical device that provides mechanical ventilation, assisting or replacing a person's breathing when they are unable to do so adequately on their own) and current use of oxygen (a chemical element that is needed to survive) via tracheostomy (a surgical procedure where an opening is created in the neck to directly access the trachea [windpipe] for breathing). This deficient practice has the potential for a delay in the respiratory care and can cause complications associated with oxygen therapy for Resident 24. Findings: During a review of Resident 24's admission Record, the admission Record indicated the resident was originally admitted to the facility on [DATE] and was readmitted on [DATE] with the following diagnoses of sepsis (a life-threatening blood infection), urinary tract…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 incontinent care for one (1) of three (3) sampled residents (Resident 69) who was dependent on activities of daily living (ADLs- are activities related to personal care that include bathing or showering, dressing, getting in and out of bed or a chair, walking, using the toilet, and eating), in accordance with the facility's policy. This deficient practice had the potential for Resident 69 to develop skin issues/ complications. Findings: During a review of Resident 69's admission Record, the admission Record indicated the resident was originally admitted to the facility on [DATE] and was readmitted on [DATE] with the following diagnoses of anemia (a condition where the body does not have enough healthy red blood cells), 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 where an opening is…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 treatment for two (2) of 18 sampled residents (Resident 6 and 346) by failing to: 1. Reevaluate and treat Resident 6's wounds on her arms and legs. 2. Provide interventions after report of Resident 346'scomplaint of pain and episodes of confusion. These deficient practices had the potential to result to delay in the necessary care and treatment of Resident 6 and 346's which could negatively affect the residents' overall wellbeing. Findings: 1. During a review of Resident 6's admission Record, the admission Record indicated the resident was admitted to the facility on [DATE] with the following diagnoses of anxiety (common emotion characterized by feelings of fear, worry, unease, and apprehension), and schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), bipolar (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 an intervention to prevent pressure ulcer (localized damage to the skin and/or underlying tissue usually over a bony prominence) for one (1) of 1 resident sampled for pressure ulcer care area (Resident 64) in accordance with the facility's policy and procedure by failing to: 1. Ensure Resident 64's low air loss mattress (LAL, mattress used for residents who are at risk for developing sores or already have pressure ulcer designed to circulate a constant flow of air for the management of pressure sores) was at a correct setting. 2. Develop a care plan to indicate Resident 64's risk for development of pressure ulcer. These deficient practices placed Residents 64 at risk for development of pressure ulcer. Findings: During a review of Resident 64's admission Record, the admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses that included hemiplegia and hemiparesis (a condition caused by brain…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 correct foot orthosis (brace or support worn outside the body) was used to support, align, and protect the right foot for one (1) of two (2) residents (Resident 86) in accordance with the physician's order. This deficient practice had the potential for Resident 86 to develop right foot contractures (occurs when the muscles, tendons, joints, or tissues tighten or shorten causing a deformity) and increases the resident's risk of developing a pressure ulcer ( injury to skin and underlying tissue resulting from prolonged pressure on the skin) on the right heel due to improper foot support. Findings: During a review of Resident 86's admission Record, the admission Record indicated the resident was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses that included muscle wasting (weakening, shrinking, and loss of muscle) and atrophy (a decrease in muscle mass, often due to an extended period 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 follow the fluid restriction (a diet which limits the amount of daily fluid consumption) order for one of one resident (Resident 40) who was dependent on renal dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney[s] have failed) as indicated on the physician's order. This failure resulted in Resident 40 not receiving fluid restrictions from 5/19/2025 through 6/3/2025, with the potential to cause fluid overload (having too much fluid in the body), or preventable health complications for Resident 40. Findings: During a review of Resident 40's admission Record, the admission Record indicated Resident 40 was admitted to the facility on [DATE], with diagnoses that included anxiety disorder (a mental disorder that involves persistent and excessive worry that can interfere with daily activities), End Stage Renal Disease (ESRD- irreversible kidney failure) and dependence on renal…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 trauma-informed care (TIC, an approach to delivering care that involves understanding, recognizing, and responding to the effects of all types of traumas) for one (1) of 1 sampled resident (Resident 83) who was diagnosed with post-traumatic stress disorder (PTSD, a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event) in accordance with the facility's policy. This deficient practice had the potential for Resident 83 to experience re-traumatization, (unintentionally causing harm through practices, policies, and/or activities that are insensitive to the needs of the residents) that could lead to severe psychosocial harm and negatively affecting Resident 83's quality of life. Findings: During a review of Resident 83's admission Record, the admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses that included post traumatic PTSD and major depressive 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 the Medication Regimen Review (MRR, consists of a thorough evaluation of the medication regimen of a resident with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medication) for one (1) of five (5) residents (Resident 48) was conducted monthly for the months of February 2025 and March 2025. This deficient practice had the potential for Resident 48 to experience adverse effects (unwanted, uncomfortable, or dangerous effects that a drug may have) related to their medication therapy possibly leading to impairment or decline in their mental or physical condition or functional or psychosocial status. Findings: During a review of Resident 48's admission Record, the admission Record indicated Resident 48 was initially admitted to the facility on [DATE] and readmitted on [DATE], with the diagnoses including but not limited to encephalopathy (brain disease, damage, or malfunction that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure one (1) of five (5) residents (Resident 48), was free of unnecessary medication by failing to clarify the order indication (a specific reason or medical condition that justifies the use) for Marinol (a cannabinoid, a man-made form of cannabis [marijuana is an herbal form of cannabis] used to treat loss of appetite in people with acquired immunodeficiency syndrome [disease in which there is a severe loss of the body's immunity, greatly lowering the resistance to infection and malignancy] and to treat severe nausea and vomiting caused by cancer chemotherapy). This deficient practice had the potential to result in a lack of monitoring the intended indication for Marinol use. Findings: During a review of Resident 48's admission Record, the admission Record indicated Resident 48 was initially admitted to the facility on [DATE] and readmitted on [DATE], with the diagnoses including but not limited to encephalopathy (brain disease, damage, 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 observation, interview, and record review, the facility failed to ensure its medication error rate was less than five (5) percent (%). Four (4) medications errors (the observed or identified preparation or administration of medications or biologicals which is not in accordance with the prescriber's order/ manufacturer's specifications / accepted professional standards and principles) out of 33 opportunities (observed administered medications) for error and yielded a facility medication rate of 12.12% for one (1) of five (5) sampled residents (Resident 73) observed during medication administration (med pass):. Resident 73 did not receive the following medications timely in accordance with the physician's order: a. Apixaban (a medication used to help prevent strokes or blood clots in people who have atrial fibrillation [a condition in which the heart beats irregularly, increasing the chance of clots forming in the body and possibly causing strokes]) twice daily. b. Spironolactone (a medication used 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 provide one (1) of two (2) sampled residents (Resident 21) with meals that accommodated the resident's food preferences. This deficient practice had the potential to result in decreased meal intake and can lead to weight loss and malnutrition (a condition that occurs when a person's body doesn't get the right amount of nutrients it needs to function properly). Findings: During a review of Resident 21's admission Record, the admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses that included severe protein calorie malnutrition and muscle wasting and atrophy (a decrease in muscle mass, often due to an extended period of immobility). During a review of Resident 21's Minimum Data Set (MDS, a resident assessment tool), dated 4/15/2025, the MDS indicated Resident 21 had moderate impairment in cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. 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 the antibiotic stewardship program protocols for prescribing the appropriate antibiotics (medication used to treat or prevent some types of bacterial infection) was followed for one (1) of two (2) sampled residents (Resident 25) prior to the administration of the resident's antibiotic therapy. This deficient practice had the potential for Resident 25 to be prescribed inappropriate antibiotics and increased the risk for developing antibiotic-resistant organisms (bacteria that are not controlled or killed by antibiotics). Findings: During a review of Resident 25's admission Record, the admission Record indicated the resident was originally admitted to the facility on [DATE] and was readmitted on [DATE] with the following diagnoses of pneumonia (an infection/inflammation in the lungs), sepsis (a life-threatening blood infection), urinary tract infection (UTI- an infection in the bladder/urinary tract), Extended Spectrum Beta Lactamase (ESBL - It'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 the call light (an alerting device for nurses or other nursing personnel to assist a resident when in need) was within the resident's reach (arm's length) for two (2) of 18 sampled residents (Resident 23 and 86) as indicated on the facility's call system policy. This deficient practice had the potential for Residents 23 and 86 to be unable to call the facility staff for assistance especially during an emergency, which could lead to an injury or harm. Findings: 1. During a review of Resident 23's admission Record, the admission Record indicated Resident 23 was admitted to the facility on [DATE] with diagnoses that included dysphagia (difficulty swallowing), dementia (a progressive state of decline in mental abilities) and muscle wasting (weakening, shrinking, and loss of muscle). During a review of Resident 23's Minimum Data Set (MDS - a resident assessment tool), dated 5/21/2025, the MDS indicated Resident 23 with 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 interview and record review, the facility failed to accurately document records for one (1) of two (2) sampled residents (Resident 2) in accordance with professional standards and practices by failing to document Resident 2's wound treatment in Resident 2's medical record from 5/14/2025 to 5/27/2025. These deficient practices had the potential to affect the accuracy of clinical assessments and medical management for Resident 2. Findings: During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was initially admitted to the facility on [DATE] and readmitted on [DATE] with the diagnoses including but not limited to stage 4 (pressure injury/ ulcer is very deep, reaching into muscle and bone and causing extensive damage) pressure ulcer of right buttock, paraplegia (partial or complete paralysis [loss of voluntary muscle function] of the lower half of the body with involvement of both legs), and neuromuscular dysfunction of bladder (lack bladder control due to a brain,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement its facility's advance directive (AD, a legal document indicating resident preference on end-of-life treatment decisions) policy for one of two sampled residents (Resident 1) by failing to honor resident's decision to not prolong his life in accordance with the resident's AD and failing to follow the Physician's do not resuscitate (DNR- a medical order written by a doctor to instruct health care providers NOT to do cardiopulmonary resuscitation [CPR- an emergency procedure that combines chest compressions and artificial ventilation] if breathing or the heart stops) order. This failure resulted in Resident 1 receiving CPR against Resident 1's wishes which had the potential to result in broken ribs and sternum (breastbone), and potential complications like internal bleeding, damaged airways and neurological damage from lack of oxygen. Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 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 report an allegation of physical abuse (the willful infliction of injury or trauma to another person resulting physical harm, pain or mental anguish) and verbal abuse (type of psychological/mental abuse that involves the use of oral or written language directed to a victim) on 4/5/2025 for two (2) of 2 sampled residents (Residents 1 and 2) within 2-hour timeframe to the State Survey Agency (SA, where state law provides for jurisdiction in long-term care facilities) and the state ombudsman (advocates for residents of nursing homes, board and care homes and assisted living facilities), in accordance with the facility's abuse policy. This deficient practice had the potential to compromise or impede the protection of Resident 1 and 2 from further abuse, which could affect the residents' emotional and mental wellbeing. Findings: 1. During a review of Resident 1's admission Record, the admission Record indicated Resident 1 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 observation, interview and record review, the facility failed to provide functioning communication system for one of four sampled residents (Resident 1), by failing to ensure the resident's call light (a string that allows patients in healthcare settings to remotely call for help from a nurse or other medical staff) was working properly. This deficient practice resulted in delayed incontinence care for Resident 1 on 5/2/2025, with the potential to negatively impact the psychosocial well-being. 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 that included respiratory failure (condition in which not enough oxygen passes from the lungs into the blood), encounter for attention to tracheostomy (a surgically created hole through the front of the neck and into the windpipe) and muscle wasting (deterioration of muscle) and atrophy (decrease in size of muscle). During a review of Resident 1'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 staff failed to protect the medical records for six (6) of 14 sampled residents (Resident 4, 5, 6, 7, 8, and 9) when Respiratory Therapist 1 (RT 1, healthcare professional trained to evaluate and treat people who have breathing problems or other lung disorders) left the respiratory therapy (healthcare specialty that focuses in the diagnosis, treatment of breathing disorders) notes unattended on top of the therapy cart located in the hallway where other staff, residents, and visitors walk by. This deficient practice had the potential to expose Resident 4, 5, 6, 7,8 and 9's medical records to others and violate the resident's right for privacy and confidentiality (safeguarding the content of information including video, audio, or other computer stored information from unauthorized disclosure without the consent of the resident and/or the individual's surrogate or representative). Findings: 1. During a review of Resident 4's admission Record, the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide pharmaceutical services to meet the needs of three (3) of 3 sampled residents (Resident 9, 10 and 11) as indicated on the facility policy when Licensed Vocational Nurse 3 (LVN 3) failed to administer Residents 9, 10 and 11's medications within 60 minutes of scheduled time of 9 AM on 4/16/2025. This deficient practice had the potential for Residents 9, 10 and 11's health and well-being to be negatively impacted due to unintended consequences, such as decreased effectiveness of the medications and adverse reactions (an unwanted effect caused by the administration of a drug) from the medications. Findings: 1. During a review of Resident 10's admission Record, the admission Record indicated Resident 10 was admitted to the facility on [DATE] with diagnoses that included Huntington's disease (a genetic disorder that causes progressive damage to nerve cells in the brain, leading to problems with movement, thinking, and mental 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 interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) was treated with dignity and respect when Resident 1 alleged Certified Nursing Assistant 1(CNA1) of throwing the resident's legs on the bed and tossed a pillow at her face on 4/11/2025. This deficient practice resulted in Resident 1 verbalizing feeling humiliated and emotionally distressed. Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnosis of left breast cancer (a disease where cells in the breast tissue grow out of control, forming tumors). During a review of Resident 1's Minimum Data Set (MDS- resident assessment tool) dated 4/13/2025, the MDS indicated Resident 1 was independent (resident completes the activity by themself with so assistance from a helper) for cognitive (ability to think, reason, and make decisions) skills for daily decision making. The MDS indicated Resident 1 required partial…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of two sampled residents (Resident 3) allergy to eggs was clearly communicated and accommodated during meal service. This deficient practice had a potential for Resident 3 to suffer complications and to get hospitalized as a result of being served a lunch tray containing mayonnaise (an egg-based product), which potentially caused allergic reaction to Resident 3 on 4/15/2025 and being served breakfast on 4/16/2025 without a lunch tray ticket indicating resident's allergies to eggs. Findings: During a review of Resident 3's admission Record, the admission Record indicated Resident 3 was admitted to the facility on [DATE] with diagnosis of right leg fracture (a break in a bone) following surgery. During a review of Resident 3's Minimum Data Set (MDS- resident assessment tool) dated 4/13/2025, the MDS indicated Resident 3 was independent (resident completes the activity by themself with so assistance from a helper) for cognitive…

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

Based on observation, interview, and record review, the Kitchen Aid (KA) failed to perform hand hygiene after opening the trash lid and prior to food preparation. This deficient practice had the potential for the residents to suffer from food borne illness (food poisoning caused by consuming food or beverages that are contaminated with certain infectious or noninfectious agents) which could lead to hospitalization. Findings: During an observation on 4/14/2025 at 10:15 AM in the kitchen, the KA was observed opening the trash lid and proceeded to cut the zucchini squash on the cutting board without performing proper hand hygiene. During an interview on 4/14/25 at 10:16 AM with KA, KA stated she did not perform hand hygiene after touching the trash lid. KA stated staff must always perform hand hygiene before handling food for safety to prevent spread of infections. During an interview on 4/14/2025 at 1:12 PM with Administrator (ADM), ADM stated the kitchen staff should perform hand hygiene thoroughly with soap and water before, during, and after food preparation. The ADM stated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide supervision and a safe environment to prevent accidents for three (3) of 3 sampled residents (Residents 1, 2 and 3) by failing to: 1. Ensure Resident 1 did not obtain and consume alcohol on facility grounds on 3/9/2025. 2. Ensure Residents 1, 2 and 3 were supervised while spending time outside by the parking lot and in the smoking area to either smoke or relax on 3/9/2025 and 3/12/2025. 3. Implement their facility's policy and procedure (P&P) titled, Smoking regarding non-compliance and Resident 1's interdisciplinary team meeting (IDT; a group of professionals from different disciplines who collaborate to achieve a common goal, often focusing on a patient's needs or a complex problem) interventions on 10/8/2024 to have an IDT meeting every Friday regarding Resident 1's smoking related violations and on 1/20/2025 that smoking materials will be continued to be kept in a secure place by facility staff and that no smoking materials is…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 current copy of the advance directives (a legal document indicating resident preference on end-of-life treatment decisions) were placed in the resident's chart with the Physician Orders for Life-Sustaining Treatment (POLST, a portable medical order form that records patients' treatment wishes so that emergency personnel know what treatments the resident wants in the event of a medical emergency, taking the patient's current medical condition into consideration) and failed implement the resident's advance directives for one (1) of two (2) sampled residents (Resident 1). This deficient practice resulted to conflict in carrying out Resident 1's wishes for medical treatment and resident's health care decisions when the resident went into respiratory arrest (a person has completely stopped breathing) with no pulse being detected on [DATE] and CPR was provided by facility staff. Findings: During a review of Resident 1's admission Record, 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 resident's Physician Orders for Life-Sustaining Treatment (POLST, a portable medical order form that records patients' treatment wishes so that emergency personnel know what treatments the resident wants in the event of a medical emergency, taking the patient's current medical condition into consideration) that confirmed the residents/resident's representatives wishes for do not resuscitate [DNR, a medical order written by a doctor to instruct healthcare providers NOT to do cardiopulmonary resuscitation {CPR- a lifesaving technique used when someone's heart stops beating, or they stopped breathing}] if breathing stops or the heart stops beating) for 1 of 2 sampled residents (Resident 1) was complete with the doctor's signature This deficient practice resulted in conflict in carrying out Resident 1's wishes for medical treatment and health care decisions when the resident went into respiratory arrest (a person has completely stopped breathing)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to develop an individualized resident-centered care plan (a care plan that prioritizes the unique health needs and desired outcomes of the resident) with measurable objectives, timeframe, and interventions to meet the Resident 1's risk of elopment (the act of leaving a facility unsupervised and without prior authorization). This deficient practice has put Resident 1 at risk of elop from safe enviroment without supervision and care and may result in injury. Findings: During a review of Resident 1 ' s admission Record indicated resident was admitted to the facility on [DATE] with the following diagnoses of seizures (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness), diabetes (a disorder characterized by difficulty in blood sugar control and poor wound healing) and muscle wasting. During a review of Resident 1 ' s History and Physical (H&P), dated 9/11/2024,…

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

Based on interview and record review, the facility failed to provide ensure a neurological assessment (neuro check, a group of questions and tests to check for disorders of the nervous system [sends messages back and forth between the brain and the body]) was completed for one (1) of two (2) sampled residents (Resident 1) who had an unwitnessed fall, in accordance with the facility's policy and procedure (P&P) titled, Neurological Assessment,. This deficient practice had the potential to result in a delay of care and services, which could negatively affect Residents 1's overall wellbeing. Findings: During a review of Resident 1's admission Record indicated the facility admitted Resident 1 on 9/6/2024. Resident 1's diagnoses included history of falling, anxiety (persistent and excessive worry that interferes with daily activities), and muscle wasting (weakening, shrinking, and loss of muscle). During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool) dated 9/14/2024, indicated Resident 1 was severely impaired with cognitive (processes of thinking and…

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

Based on interview and record review, the facility failed to note, document and report to the resident's primary physician the irregularities ( includes, but is not limited to, use of medications without adequate indication, without adequate monitoring, in excessive doses, and/or in the presence of adverse consequences, as well as the identification of conditions that may warrant initiation of medication therapy) with regards to the Lorazepam order, on the medication regimen review (MRR, or Drug Regimen Review, a thorough evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medication) done on 11/29/2024 to 11/30/2024 for one of two sampled Residents (Resident 1) in accordance with the facility policy titled Psychotherapeutic (the practice of prescribing, monitoring, and adjusting medications used to treat mental health conditions) Drug Management,. This deficient practice had the potential for unnecessary medication administration to Resident 1, which could result to…

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

Based on observation, interview, and record review, the facility failed to ensure one (1) of two (2) sampled residents (Resident 1) was free from an unnecessary psychotropic drug (any medication capable of affecting the mind, emotions, and behavior) in accordance with the facility policy and procedure (P&P) titled Psychotherapeutic Drug Management, by failing to ensure: A. Resident 1 have a specific indication for a specific diagnosis in the physician's order for the use of Lorazepam (medication used to treat anxiety [persistent and excessive worry that interferes with daily activities]). B. Resident 1 have indication for a specific target behavior such as trying to get up of bed without assistance and fidgeting (small movements especially of hands and feet when a person is nervous) indicated in the physician's order for the use of Lorazepam. C. Resident 1's Lorazepam as needed order was discontinued after 14 days from the order start date. D. Resident 1 have an order to monitor/document/report any adverse (harmful) reactions to anti-anxiety therapy. E. Resident 1 have an order 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 provide services to promote healing of pressure ulcers (damage to an area of the skin caused by constant pressure on the area for a long time) and deep tissue injury (DTI, purple or maroon localized area of discolored intact skin or blood-filled painful swelling on the surface of the skin due to damage of underlying soft tissue from pressure) for two (2) of three (3) sampled residents (Resident 1 and 2) in accordance with the facility ' s policy when: 1. Resident 1, facility did not implement a consistent wound care treatment as ordered by physician and develop a care plan for care and management of resident 1 ' s pressure ulcers and DTI. 2. Resident 2, faility did not set low air loss mattress (LAL, mattress used for residents who are at risk for developing sores or already have pressure ulcer designed to circulate a constant flow of air for the management of pressure sores) correctly according to Resident 2's weight and did not…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 safe and secure method of disposal of lorazepam (a controlled [a medication with high potential for abuse] medication used to treat anxiety [a feeling of fear, dread, or uneasiness]) one milliliters (mL - a unit of measurement for volume) vial and other discontinued medications in one of two inspected medication rooms (East Station Medication Room) 2. Ensure availability of Protonix (a medication used to reduce acid in the stomach and prevent and/or treat acid-reflux) packet for Resident 3 in one of four sampled residents. This deficient practice placed the facility and residents at risk for unintended use, accidental exposure, misuse and diversion of Lorazepam and other discontinued medications, and increased the risk for Resident 3 to experience acid reflux with the potential to cause health complications and hospitalization. Findings: 1. During a concurrent observation and interview on 12/7/2024 at 11:25 a.m. with Registered…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure two single dose unopened vials of Retacrit (a medication used to treat anemia [a condition where the body does not have enough healthy red blood cells] were labeled with expiration date, and stored in accordance with manufacturer's specifications and facility's policy and procedure (P&P) titled, Storage of Medications, dated 01/2022 affecting one resident (Resident 3) in one of three sampled medication carts (West Station Medication Cart 2). This deficient practice had the potential to result in Resident 3 receiving medication that had become ineffective or toxic due to improper storage and labeling possibly leading to anemia. Findings: During a review of Resident 3's admission Record (a document containing demographic and diagnostic information), dated 12/7/2024, the admission record indicated Resident 3 was originally admitted to the facility on [DATE] and readmitted on [DATE] with a diagnosis including, but not limited to…

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

Based on interview and record review, the facility failed to implement the comprehensive care plan related to menstruation cycle (a term to describe the sequence of events that occur in a female body as it prepares for the possibility of pregnancy each month) for one of one sampled resident (Resident 1). This deficient practice had the potential to result in inconsistent implementation of the care plan that may lead to delay or lack of delivery of care and services and had the potential to missed diagnosed pregnancy for Resident 1 who was a victim of sexual abuse on 7/20/2024. Findings: During a review of Resident 1 ' s admission Record, the admission Record indicated the facility admitted the resident on 9/30/2021 with diagnoses including aphasia (a disorder that makes it difficult to speak), hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (a condition that causes weakness or an inability to move on one side of the body), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility: 1. Failed to provide education and informed consent regarding the benefits and risks of immunization of influenza (Flu; a contagious respiratory illness) vaccine (medications used to prevent diseases usually given by injection or by mouth) prior to administration flu vaccine for one (1) of two (2) sampled residents (Resident 1). 2. Did not administer the flu vaccine on the day it was delivered (10/30/2024) until 11/5/2024. These deficient practices resulted in violated Resident 1 ' s rights to make an informed decision before received vaccine, delayed administration of the flu vaccine and incompletion of Resident 1 ' s medical record. Findings: During a review of Resident 1 ' s admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses that included paraplegia (paralysis of the legs and lower body), type 2 Diabetes (a disease in which your body does not produce enough insulin needed to control sugar levels 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 observation, interview, and record review, the facility failed to protect one of three sampled residents (Resident 1), from physical abuse (intentional act causing injury or trauma to another person) by Resident 2. On 10/25/2024, Resident 2 hit Resident 1 with a cane. This deficient practice resulted in pain, redness and swelling to Resident 1's left wrist, as well as anxiety (anticipation of future danger accompanied by a feeling of distress, sadness, hype-vigilance, and tension). Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnosis of paraplegia (paralysis of the legs and lower body, typically caused by spinal injury or disease) following a motor-vehicle accident. During a review of Resident 1's History and Physical (H&P- a term used to describe a physician's examination of a resident) dated 10/5/2024 indicated Resident 1 can understand and make own medical decisions and is bed bound (unable to move…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that one of one sampled resident (Resident 2) was supervised by a one to one (1:1) sitter (is a trained caregiver who provides supervision and support to patients who need close monitoring) as ordered by the physician. This deficient practice had the potential to result in Resident 2 verbally and/or physically abusing (intentional act causing injury or trauma to another person) other residents in the facility while he was under a 5150 hold (is the number of the section of the Welfare and Institutions Code, which allows an adult who is experiencing a mental health crisis to be involuntarily detained for a 72- hour psychiatric hospitalization when evaluated to be a danger to others, or to himself or herself, or gravely disabled). Findings: During a review of Resident 2's admission Record indicated Resident 2, a [AGE] year-old male was admitted to the facility on [DATE] with diagnosis of encephalopathy (disease of the brain that…

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

Base on interview and record review the facility failed to provide dignity to one (1) of three (3) sampled residents (Resident 1) by letting Resident 1 wait for transportation from 12:20 PM to 8:20 PM (8 hours). This failure had resulted to Resident 1's to experience loss of dignity and self-esteem. Findings: During a review of Resident 1's admission Record indicated the facility admitted Resident 1 on 6/1/2024 with the diagnoses that included seizure (sudden, uncontrolled body movements and changes in behavior that occur because of abnormal electrical activity in the brain), paraplegia (paralysis that affects your legs, making it impossible to stand or walk), diabetes mellitus (blood sugar [glucose] is too high). During a review of Resident 1's Minimum Data Set (MDS, standardized care and screening tool), dated 10/4/2024, indicated Resident 1 cognition was intact (processes of thinking and reasoning) skills for daily decision making. The MDS indicated Resident 1 partial / moderate assistance (helper does less than half the effort. Helper lifts, holds or support trunk or limbs, but…

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

Base on interview and record review the facility failed to document one of three sample residents (Resident 1), regarding Resident 1 leaving the facility to go to pulmonologist (healthcare provider that specializes in conditions that affect your respiratory system, including your airways and lungs) appointment and failed to ensure there was no inconsistency with the documentation when Resident 1 returned to the facility from his appointment on 9/25/2024. This deficient practice can prohibit appropriate communication between the staff and can result in a lack of or delay in provision of care/intervention to the resident. Findings: A review of Resident 1's admission Record indicated the facility admitted Resident 1 on 6/1/2024 with the diagnoses that included seizure (sudden, uncontrolled body movements and changes in behavior that occur because of abnormal electrical activity in the brain), paraplegia (paralysis that affects your legs, making it impossible to stand or walk), diabetes mellitus (blood sugar (glucose) is too high). A review of Resident 1's Minimum Data Set (MDS,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement interventions to prevent an accident for one of two sampled residents (Resident 1) in accordance with the facility's policy by failing to: 1. Provide proper assistance during incontinent/toileting care, keep the resident's bed in low position, and ensuring side rails were up before leaving the resident in bed on 9/19/2024. 2. Complete a Fall risk assessment in April 2024 and July 2024. 3. Develop a care plan specific to resident's need with interventions to reduce the risk of falls. These deficient practices resulted in Resident 1 falling off the bed during a brief (protective underwear to prevent leakage) change (incontinent/toileting care) and resulted in Resident 1 sustaining multiple open areas on the body from the fall and a broken left thigh bone. 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…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 resident was free from verbal abuse (using words to name call, bully, demean, frighten, intimidate, or control another person) for one of two sampled residents (Resident 2). On 9/12/2024, Resident 1 had verbal aggression towards roommate (Resident 2). This deficient practice violated Resident 2's right to be free from abuse and can cause emotional trauma to Resident 2. Cross reference with F740. Findings: 1. During a review of Resident 1's admission Record, the record indicated Resident 1 was admitted to the facility on [DATE], with diagnoses of restlessness and agitation, bipolar disorder (mental disorder characterized by episodes of mania [extreme highs] and depression [extreme lows]), and recurrent major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). During a review of Resident 1's General Acute Care…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 provide necessary behavioral care services for one of two sampled residents (Resident 1) by: 1. Failing to monitor and document Resident 1's behavior of restlessness and agitation after admission at the facility on 9/4/2024. 2. Failing to monitor and/ or document for side effects and effectiveness of Reisdent 1's medication (Caplyta [lumateperone tosylate] antipsychotic medication used to manage and treat schizophrenia [a chronic and severe mental disorder that affects how a person thinks, feels, and behaves] and other neuropsychiatric disorders [condition that affects both the nervous system and mental health]), and to monitor behaviors and document observed behavior as indicated in the resident's care plan dated 9/13/2024. This deficient practice resulted in delay of care and/ or treatment for Reisdent 1's restlessness and agitation and placed Resident 1 at risk for worsening of condition and/ or serious injury. Cross reference with F600. 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.

Based on interview and record review, the facility failed to ensure the Narcotics (drug that produces analgesia [pain relief] count sheet contained two Licensed Nurses' signatures for one (1) of four (4) medication carts (Station 1 Medication [Med] Cart) in accordance with the facility's policy and procedure. This deficient practice had the potential for the diversion (illegal distribution or abuse of prescription drugs or their use for unintended purposes) of controlled substance (medications with a likelihood for physical and mental dependence) medications. Findings: During a concurrent record review and interview on 9/10/24 at 3:25 PM with License Vocational Nurse 1 (LVN 1), the facility's Station 1 Med Cart's Narcotic Count Sheet, for the month of August and September 2024 was reviewed, it did not indicate Licensed Nurse's signature on the following dates: 1. Incoming (starting the shift) Licensed Nurse on 8/6/24 who worked the 11 PM to 7 AM (NOC) shift. 2. Outgoing (going off duty-leaving the shift) License Nurse on 8/7/24 who worked the 7 AM to 3 PM (day) shift. 3. Incoming…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility staff failed to prevent an accident for one (1) of three sampled residents (Resident 1) by failing to perform a Fall Risk Assessment (a procedure that helps determine how likely someone is to fall which includes a series of questions about overall health, balance, standing, and walking, and whether there have been any previous falls) in accordance with the facility's policy and procedure (P&P). These deficient practices resulted in Resident 1's unwitnessed fall on 8/22/2024 which resulted in a two (2) centimeter (cm- unit of measurement) x 0.2 cm laceration (a cut or break in the skin's surface to expose underlying soft tissue) at the back of Resident 1's head and transferred to General Acute Care Hospital (GACH). Findings: During a review of Resident 1's admission Record indicated Resident 1 was admitted to the facility on [DATE] diagnoses that included urinary tract infection (UTI- an infection in any part of the urinary system), unspecified…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to develop a comprehensive and resident-centered care plan (a plan of care that summarizes a resident's health conditions, specific care needs, and current treatments) to monitor the side effects of prescribed narcotics (a drug that produces numbness and reduces pain) for one out of three sampled residents (Resident 1). This deficient practice had the potential to cause inappropriate care of Resident 1's which can potentially result in adverse reaction (harmful effect) of narcotics such as respiratory depression, lethargy (state of sleepiness or deep unresponsiveness) and can lead to the resident's hospitalization. Findings: During a review of Resident 1's admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses that included paraplegia (paralysis of the legs and lower body), Type 2 Diabetes (a disease in which your body does not produce enough insulin needed to control sugar levels in the blood), morbid…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 effective pain management that met professional standards of practice for one out of three sampled residents (Resident 1) as evidenced by: 1. Failing to do follow up call to Resident 1's attending doctor (MD 1) after the first the first call on 8/21/24 at 4:34 PM until 8/22/2024 at 7 AM to obtain an order for Norco (a controlled medication [A drug or other substance that is tightly controlled by the government because it may be abused or cause addiction] used to reduce moderate to severe pain) authorized. 2. Failing to give Resident 1 appropriate pain medication (Norco) for a pain level of 8/10 (very strong pain/ severe pain; based on a 0 to 10 numerical scale where 0 means no pain and 10 is the worst pain ever felt) when Resident 1 requested for Norco on 8/22/24 at 1:30 AM. 3. Failing to provide documented evidence that Resident 1's pain level was reassessed for effectiveness one (1) hour after giving the resident Naproxen (a medication used…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 treatments and services to increase, prevent, or maintain range of motion (ROM, full movement potential of a joint) for two (2) of two (2) sampled residents (Residents 1, and 2) as ordered by the physician when: 1. Resident 1 was not provided restorative nursing services (a program available in nursing homes that helps residents maintain any progress made during therapy treatments, enabling them to achieve their highest practicable level of functioning) as ordered by the physician. 2. Resident 2 was not provided restorative nursing services as ordered by the physician. This deficient practice placed Residents 1 and 2 at risk for decline in physical functions and developing contractures (condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints) in other extremities (a limb of the body, such as the arm or leg) for not receiving the needed exercises. Findings: 1. During a review…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement their facility's abuse policy for one of two sampled resident (Resident 1) by: 1. Facility failed to report an alleged abuse (the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish) to California Department of Public Health (CDPH), Law enforcement and Ombudsman (advocates for residents of nursing homes) within 2 hours from when the allegation of abuse was made by Resident 1 against Certified Nurse Assistant (CNA) on 7/28/2024 at 1:20 PM. 2. Facility failed to investigate the allegation of abuse made by Resident 1 against Certified Nurse Assistant (CNA) on 7/28/2024 at 1:20 PM These failures have the potential for Resident 1 to feel unprotected if the facility did not conduct an immediate investigation of the alleged abuse and prevent it from reoccurring. Cross reference F609 Findings: During a review of Resident 1's admission Record indicated Resident 1 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 report an alleged abuse (the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish) to California Department of Public Health (CDPH), Law enforcement and Ombudsman (advocates for residents of nursing homes) within 2 hours from when the allegation was made for one of two sampled resident (Resident 1). This deficient practice resulted in delay of an onsite investigation by the law enforcement. Cross reference F607 Findings: During a review of Resident 1's admission Record indicated Resident 1 was originally admitted on [DATE], with diagnoses including but not limited to hemiplegia (paralysis of one side of the body) and hemiparesis (muscle weakness or partial paralysis on one side of the body that can affect the arms, legs, and facial muscles) following cerebral infarction (stroke, a loss of blood flow to part of the brain) affecting left non-dominant side, muscle…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to meet professional standards of quality for three (3) of four (4) sampled residents (Resident 1, 3 and 4) by: 1. Failing to follow their policy when Resident 1 had a Change of Condition (COC; a sudden, clinically important deviation from a patient's baseline in physical, cognitive, behavioral, or functional domains) of coughing which started on 7/21/2024. 2. Failed to develop a Care Plan and implement interventions when resident was non-compliant with Coronavirus Disease 2019 (Covid- 19; a contagious respiratory virus caused by SARS-CoV-2) interventions and when Resident 1 refused to be tested for Covid- 19. This deficient practice had the potential to result in a delay in the necessary care and services for Resident 1 and could have contributed to Resident 1's roommates (Resident 3 and 4) tested positive for Covid- 19 on 7/29/2024. Findings: During a review of Resident 1's admission Record indicated resident was originally admitted 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 observation, interview, and record review, the facility failed to observe infection control measures for Coronavirus 2019 (Covid- 19, a respiratory virus caused by SARS-CoV-2) by: 1. The facility did not post a signage indicating the facility was currently with Covid- 19 outbreak (the occurrence of cases of disease or condition above the expected or baseline level, usually over a given period, in a specific population group). 2. The facility did not report Covid- 19 outbreak to California Department of Public Health (CDPH). 3. The facility failed to ensure that the six (6) trashcans was not overflowing with used personal protective equipment (PPE, is equipment worn to minimize exposure to hazards that cause serious workplace injuries and illnesses) on six (6) of 35 rooms. 4. The facility failed to ensure Certified Nursing Assistant 1 (CNA 1) doff (taking off PPE) before exiting Room A (isolation room) and perform hand hygiene (primary method used by health care team members to reduce the spread of germs or infection between patients and health care team members can 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, interviews and record reviews, the facility failed to set one out of two sampled residents (Resident 1) low air loss mattress (LALM; pressure relieving mattress that is filled with air) at the correct weight setting. This deficient practice had the potential to result in Resident 1's pressure ulcers (injuries to the skin and the tissue below the skin that are due to pressure on the skin for a long time) to worsen and/ or develop new pressure ulcer. Findings: During a review of Resident 1's admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses that included type 2 Diabetes (a disease that results in blood sugar being too high), morbid obesity (when a person's weight is more than 80 to 100 pounds above their ideal body weight), brain damage and quadriplegia (a symptom of paralysis that affects all a person's limbs and body from the neck down). During a review of Resident 1's Minimum Data Set (MDS; a care assessment and screening tool) dated 7/20/24,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 observation, interview and record review, the facility failed to answer the call light (a device used by residents to call for assistance from the facility staff) in a timely manner for two of three sampled residents (Residents 1 and 2) in accordance with the facility's policy and procedure. This deficient practice has the potential to delay in the necessary care and services for Resident 1 and 2. Findings: 1. During a review of Resident 1's admission Record indicated resident was originally admitted on [DATE] and is readmitted on [DATE] with the following diagnoses of respiratory failure (a serious condition that makes it difficult to breathe on your own) and myocardial infraction (heart attack, a blockage of blood flow to the heart muscle). During a review of Resident 1's History and Physical (H&P), dated 4/1/2024, indicated resident is alert and oriented to person, place, and time. The H&P also indicated resident has appropriate mood and affect with good judgement and insight. 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 identify and provide treatment and services to attain the highest practicable mental and psychosocial wellbeing for one of three sampled residents (Resident 1) who was diagnosed with major depressive disorder (a constant feeling of sadness and loss of interest, which stops you doing your normal activities) and anxiety disorder (persistent and excessive worry that interferes with daily activities) by facility staff failed to: 1. Identify, determine possible causal factors, monitor, and document Resident 1's behavior of falsely accusing staff members. 2. Contact the attending physician regarding Resident 1's new behavior of falsely accusing staff members. 3. Create a comprehensive resident centered care plan and implement interventions to address Resident 1's behavior of falsely accusing staff members. These deficient practices may result to delay in treatment and care to Resident 1. In addition, it placed Resident 1 at risk for not being treated in a manner that promotes mental and psychosocial well- being.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 maintain complete medical records for one of three sampled residents (Resident 1) who was diagnosed with major depressive disorder and anxiety disorder by failure to monitor and document Resident 1's menstruation cycle. This deficient practice resulted in staff not knowing if blood found on Resident 1's brief was from menstruation or sexual assault (when a person knowingly causes another person to engage in a sex act by threatening or placing the other person in fear, or if someone engages in a sexual act with a person who is incapable of or unable to give consent) when Resident 1 alleged Certified Nursing Attendant (CNA), CNA 1 of sexual abuse on 7/20/24 and delay in treatment. Findings: During a review of Resident 1's admission Record (Face Sheet) indicated Resident 1 was admitted to the facility, on 9/30/21, with diagnoses including aphasia (disorder that results from damage to portions of the brain that are responsible for language), cerebral infarction (damage to tissues in the brain due to a loss of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to prevent an abuse for two of seven sampled residents (Residents 162 and 260) by failing to: 1. Prevent physical (any intentional act causing injury or trauma to another person by way of bodily contact) and verbal abuse (a range of words or behaviors used to manipulate, intimidate, and maintain power and control over someone) to Resident 162 when Resident 53 hit Resident 162 on the face and threatened to kill Resident 162 on 6/23/2024. This deficient practice resulted in Resident 162 to get a cut on the bridge of his nose and a swollen bottom lip and with the potential for emotional and psychological (affecting the mind. Related to mental and emotional state of a person) trauma. 2. Ensure Resident 260 was free from verbal abuse from Resident 50. This failure resulted in Resident 260 being subject to verbal abuse with risk of a negative impact to Resident 26's psychosocial well-being and safety. Findings: 1. A review of Resident 162'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 provide appropriate treatment and services for two of three sampled residents (Resident 167 and 108) who were incontinent of bladder and/ or bowel in accordance with the facility's policy and procedure. 1. Facility failed to ensure Resident 167's indwelling catheter (foley - a tube inserted into the bladder to help drain urine) collection bag (designed to collect urine drained from the bladder via a catheter or sheath) was not touching the floor per facility policy for and to ensure Resident 167's indwelling catheter collection bag (designed to collect urine drained from the bladder via a catheter or sheath) was covered with a dignity bag (a bag used to cover and hold the catheter drainage/collection bag so the urine is not visible). This deficient practice resulted in contamination of Resident 167's indwelling catheter collection bag and placed Resident 167 at risk for infection. 2. Facility failed to ensure Resident 108 had a medical…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide necessary respiratory services for three (5) of five (5) sampled residents (Residents 260, 161, and 54) as indicated in the facility's policy by failing to: 1. Obtain a doctor's order before administering oxygen therapy to Resident 260. 2. Ensure Resident 161 received the amount of oxygen as ordered by the physician. 3. Obtain a physician's order before administering oxygen therapy to Resident 54 This deficient practice had the potential to cause complications or adverse effects (an undesired harmful effect resulting from a medication or other intervention) to Residents 260, 161, and 54 associated with oxygen therapy. Findings: 1. A review of Resident 260's admission Record indicated Resident 260 was readmitted to the facility on [DATE] with diagnoses that included acute respiratory failure (a sudden condition in which not enough oxygen passes from the lungs into the blood), end stage renal disease (ESRD - a stage 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 Cross reference: F759 Based on observation, interview, and record review, the facility failed to provide pharmaceutical services to meet the needs of two (2) of seven (7) sampled residents (Resident 208 and 3) as indicated on the facility policy by: 1. During a Medication Pass observation on 7/10/2024, Licensed Vocational Nurse 3 (LVN 3) failed to administer Resident 208's 12 medications within 60 minutes of scheduled time of 7:30 AM and 9 AM. LVN 3 did not indicate the actual time of medication administration in the medication administration record (MAR). This deficient practice had the potential for Resident 208's health and well-being to be negatively impacted due to unintended consequences, such as decreased effectiveness of the medications and adverse reactions (an unwanted effect caused by the administration of a drug) from the medications. 2. Facility failed to administer Resident 3's levothyroxine sodium (a medicine used to treat an underactive thyroid gland [produces hormones in the body and plays a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that its medication error rate was less than five (5) percent (%). 12 medication errors out of 27 total opportunities for error, to yield an overall medication error rate of 44.44 % for on (1) of six (6) residents observed for medication administration (Resident 208). The medication errors were as follows: A. During a Medication Pass observation, Licensed Vocational Nurse 3 (LVN 3) failed to administer Resident 208's medications within 60 minutes of scheduled time of 7:30 AM on 7/10/2024. B. During a Medication Pass observation, LVN 3 failed to administer Resident 208's medications within 60 minutes of scheduled time of 9 AM on 7/10/2024. These deficient practices had the potential to result in Resident 208 to experience medication adverse effects (unwanted, uncomfortable, or dangerous effects that a medication may have) and the potential to result in Residents health and well-being to be negatively impacted. Findings: A review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to follow its policy by failing to: 1. Remove six (6) vials of Epogen (drug used to treat anemia [lack of blood]) of a resident who has been discharged from Medication Refrigerator 3. This deficient practice had the potential for this medication to be mistakenly given to other residents that can lead to a medication error. 2. Defrost (become free of accumulated ice) Medication Refrigerator 1 and 2. This deficient practice had the potential to affect the temperature quality of Medication Refrigerator 1 and 2, which might affect the efficacy of the refrigerated medications for the residents. 3. Secure medications at all times to prevent unauthorized access of the medications in the facility and failed to not leave the narcotic (drug or other substance used to treat moderate to severe pain that affects mood or behavior) key attached to the narcotic drawer of the medication cart while attending to Resident 3. This deficient practice had the…

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

Based on observation, interview, and record review, the facility failed to follow proper food handling practices in accordance with the facility's policy and procedure by failing to: 1. Ensure a box of raw porkchops were stored and labeled per protocol once opened. 2. Ensure plastic containers of flour and dry pasta were tightly sealed while in storage. 3. Boxed juice concentrates were labeled. 4. Walk in refrigerator temperature was below 41 degrees Fahrenheit (°F: a scale of temperature). These deficient practices had the potential to result in contaminated (the presence of unwanted substances, such as bacteria, viruses, parasites, and other microorganisms) food items being given or exposure to residents, with risk for residents to develop foodborne illness (food poisoning) with symptoms including upset stomach, stomach cramps, nausea, vomiting, diarrhea, and fever and can lead to other serious medical complications and hospitalization. Findings: 1. During a concurrent observation and interview on 7/8/2024 at 7:56 AM with DSS, in the kitchen walk in refrigerator, an unlabeled,…

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

Based on observation, interview, and record review, the facility failed to ensure food items placed in the resident refrigerator (used to store residents' perishable foods brought from outside the facility) were stored and labeled with resident's name and date as indicated in the facility policy. This failure had the potential for residents to consume expired and/or contaminated foods resulting in food-borne illnesses (food poisoning) with symptoms including stomach cramps, nausea, vomiting, diarrhea and fever. Findings: During a concurrent observation and interview on 7/8/2024 at 8:16 AM with Dietary Service Supervisor (DDS), the residents' refrigerator was observed with the following food items unlabeled with a resident room number and/or date: a. one bottle of creamer b. one two-liter bottle of soda c. one bottle of protein shake d. two uncontained heads of lettuce e. seven plastic containers of food f. one bag of bean sprouts g. two whole watermelons h. one bag of corn ears i. one bag of raw apples j. one carton of eggs DDS stated food and drinks in the residents' refrigerator…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 care in a manner that maintained or enhanced a Resident's dignity and respect in full recognition of their individuality for one of 24 sampled residents (Resident 167) by failing to ensure Resident 167's indwelling catheter (foley - a tube inserted into the bladder to help drain urine) collection bag (designed to collect urine drained from the bladder via a catheter or sheath) was covered with a dignity bag (a bag used to cover and hold the catheter drainage/collection bag so the urine is not visible). This deficient practice violated Resident 167's right for privacy and had the potential to affect Resident 167's self-worth, self-esteem, and psychosocial well-being. Findings: A review of Resident 167's admission Record indicated Resident 167 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included other seizures (abnormal electrical activity in the brain that happens quickly), type 2…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 accommodate the needs of two (2) of 24 sampled residents (Resident 159 and 212) by failing to: 1. Provide Resident 159 with a fully functional wheelchair. This deficient practice resulted in Resident 159 having to use the wheelchair tire to wheel himself around the facility resulting in dirt accumulating on his hand and placing him at risk for infection. 2. Ensure Resident 212's call light device (an alerting device for nurses or other personnel to assist a resident when in need) was maintained within easy reach. This deficient practice had the potential to cause a delay in resident care and for Resident 212's needs to remain unmet. Findings: 1. A review of Resident 159's admission Record indicated Resident 159 was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses that included bipolar disorder (a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of one sampled resident (Resident 110) was free from physical restraints (any manual method, physical or mechanical device, equipment, or material that is attached or adjacent to the resident's body; cannot be removed easily by the resident; and restricts the resident's freedom of movement or normal access to his/her body) when the facility failed to: a. Conduct an assessment for the use of geriatric chair (Geri chair, a large, padded, and mobile reclining chair that prevents a resident from rising). b. Obtain a physician's order for the use of Geri chair. This deficient practice had the potential to result in limiting Resident 110's mobility and cause injury. This also had the potential for Resident 110 not to be being treated with respect and dignity with the use of restraints. Findings: A review of Resident 110's admission Record indicated resident was admitted to the facility on [DATE] and readmitted on [DATE]. 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 implement the abuse policy and procedure by not thoroughly investigating an allegation of abuse and not providing a complete follow up report of the outcome of the investigation to California Department of Public Health (CDPH) for one of seven sampled resident (Resident 19's) who sustained a thigh bruise (injury of unknown origin). These deficient practices resulted in an incomplete investigation of an allegation of abuse from Resident 19 and the facility's lack in communicating the outcomes to appropriate agencies (CDPH) regarding abuse investigations. Findings: A review of Resident 19's admission Record indicated Resident 19 was readmitted to the facility on [DATE] with diagnoses that included dorsalgia (a group of disorders characterized by mild to moderate or intense pain that emerges from muscles nerves or joints associated with spine), anxiety disorder (mental disorder involves persistent and excessive worry that can interfere with daily…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 transmit a Minimum Data Set (MDS, a standardized assessment and care screening tool) Discharge Tracking Form (DTF, an assessment submitted when a resident has been discharged from the facility) within 14 days after completion for five (5) of 11 sampled residents (Residents 1, 14, 46, 47, and 48) in accordance with the facility policy. This failure had the potential to result in inaccurate information to identify and track the movement of residents in and out of the facility. Findings: 1. A review of Resident 1's admission Record indicated Resident 1 was admitted to the facility on [DATE]. A review of Resident 1's DTF indicated resident was discharged on 2/15/2024. 2. A review of Resident 14's admission Record indicated Resident 14 was admitted to the facility on [DATE]. A review of Resident 14's DTF indicated resident was discharged on 1/23/2024. 3. A review of Resident 46's admission Record indicated Resident 46 was admitted to the facility on [DATE].…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 complete resident-centered baseline care plan (a form that summarizes a person's health conditions and current treatments for their care) with 48 hours of admission to meet the immediate needs that included interventions for safety and preferences for two of 24 sampled residents (Resident 108 and 110). This deficient practice had the potential to delay necessary care and services based on the specific needs of Resident 108 and 110. Findings: 1. A review of Resident 108's admission Record indicated Resident 108 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses that included tracheostomy (a procedure to help air and oxygen reach the lungs by creating an opening into the trachea [windpipe] from outside the neck), gastrostomy (an opening into the stomach from the abdominal wall, made surgically for the introduction of food), and hypotension (low blood pressure). A review of Resident 108's Minimum Data Set (MDS, a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to develop a Resident-centered comprehensive care plan (a care plan developed and implemented to meet the resident's preferences, goals, and addressed the resident's medical, physical, mental, and psychosocial needs) for three (3) of 24 sampled residents (Resident 26, 9, and 50) as indicated on the care plan by failing: 1. Implement the care plan interventions for Resident 26, who was on contact isolation (used when a resident has an infectious disease that may be spread by touching either the resident or other objects the resident has handled) for Candida auris (C. auris- a type of yeast that can cause severe illness and spreads among residents with weakened immune systems in healthcare facilities). Facility also failed to develop a care plan for Resident 26 to include interventions to prevent spread while resident is outside of his room. This deficient practice placed all the residents, staff, and visitors at higher risk 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to review and revise the care plan for one (1) of 24 sampled residents (Resident 167) who had a history of pulling out the gastrostomy tube (g-tube - a flexible tube surgically inserted through the wall of the abdomen directly into the stomach for feeding, fluid, and medication administration). This deficient practice resulted in multiple incidences of Resident 167 pulling out her g-tube potentially causing further injury and/or pain to Resident 167's g-tube site. Findings: A review of Resident 167's admission Record indicated Resident 167 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included other seizures (abnormal electrical activity in the brain that happens quickly), type 2 diabetes mellitus (a disease that occurs when the blood sugar is too high), and encounter for attention to gastrostomy (G-Tube- a flexible tube surgically inserted through the wall of the abdomen directly into the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure one of 24 sampled residents (Residents 207) was provided one to one (1:1, one staff to one resident) feeding assistance (the action of a person feeding another person who cannot otherwise feed themselves) during mealtime (lunch) on 7/11/2024. This deficient practice had the potential to result in Resident 207 not being supervised during mealtime, with Resident 207 potentially experiencing a change in condition or weight loss. Findings: A review of Resident 207's admission Record indicated Resident 207 was admitted to the facility on 5/23/ 2024 and readmitted on [DATE] with diagnoses that included malignant neoplasm of sigmoid colon, (a cancerous tumor in the sigmoid colon, which is the part of the large intestine that connects to the rectum. It's also known as sigmoid colon cancer), schizophrenia, (a chronic, severe mental disorder that affects the way a person thinks, acts, expresses emotions, perceives reality, and relates 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 observation, interview, and record review, the facility failed to provide the necessary care and treatment for three (3) of 24 sampled residents (Residents 161, 260 and 3) by failing to: 1. Implement the physician's order for fluid restriction (limiting the amount of liquid consumed daily) for Resident 161who has diagnosis of congestive heart failure (CHF- a serious condition in which the heart does not pump blood as efficiently as it should). This deficient practice had the potential to place Resident 161 at risk for fluid overload (too much fluid in the body which can raise the blood pressure (the pressure of circulating blood against the walls of the blood vessels, cause swelling, and impact organ function), which can lead to health complications, harm, hospitalization, and death. 2. Implement the physician's order for fluid restriction for Resident 260 by providing Resident 260 a water pitcher at bedside. This failure had the potential for Resident 260 to consume more water than prescribed, placing him…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 gastrostomy tube (GT - a flexible tube surgically inserted through the abdomen into the stomach for feeding, fluid, and medication administration) feeding was labeled with a date and time for one of two residents (Resident 52) as indicated in the facility's policy. This failure had the potential for Resident 52 to be administered an expired GT feeding, causing preventable gastric complications like nausea, vomiting and/or diarrhea. Findings: A review of Resident 's admission Record indicated Resident 52 was readmitted [DATE] with diagnoses that included dysphagia (difficulty swallowing), protein-calorie malnutrition (PCM- a nutritional status in which reduced availability of nutrients leads to changes in body composition and function), respiratory failure (condition in which not enough oxygen passes from the lungs into the blood), and hypertensive heart disease (heart complications caused by high blood pressure that is present…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 trauma-informed care (an approach to delivering care that involves understanding, recognizing, and responding to the effects of all types of traumas) to one of 24 sampled resident (Resident 9) who was diagnosed with post-traumatic stress disorder (PTSD-a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event). This deficient practice had the potential for Resident 9 to experience re-traumatization, (unintentionally causing harm through practices, policies, and/or activities that are insensitive to the needs of the residents) that could lead to severe psychosocial harm and negatively affecting his quality of life. Findings: A review of Resident 9's admission Record indicated the resident was admitted to the facility on [DATE], with diagnoses that included post traumatic PTSD, depression (mood disorder that causes a persistent feeling of sadness and loss of interest in life), bipolar disorder (a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to relay the recommendations of pharmacist in Medication Regimen Review (MRR, a monthly thorough evaluation by the consulting pharmacist of a resident's medication regimen, with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medication) to the doctor and to take action to address the recommendation/ irregularities for the month of June 2024's MRR for two of five sampled residents (Resident 11and 19) for unnecessary medications review. This deficient practice had the potential to result in adverse medication outcome for potential unnecessary medications to the resident. Findings: 1. A review of Resident 19's admission Record indicated Resident 19 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included major depressive disorder (mental disorder characterized by a pervasive and persistent low mood that is accompanied by a loss of interest or pleasure in…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 for one of six (6) sampled residents (Residents 208) was free from significant medication error (the observed or identified preparation or administration of medications or biologicals which is not in accordance with the prescriber's order; manufacturer's specifications [not recommendations] regarding the preparation and administration of the medication or biological; or accepted professional standards and principles which apply to professionals providing services) by failing to administer two (2) medications due to be given at 7:30 AM with meals in accordance with the physician's order and four (4) medications due to be given at 9 AM in accordance with the physician's order. The following medications for Resident 208 were administered more than one (1) hour from the scheduled administration time: 1. Metoprolol Tartrate (used to treat high blood pressure) tablet 25 milligram (mg, unit of measurement). 2. Ranolazine (used to treat…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility staff failed to administer the influenza (flu- a common but sometimes deadly viral infection of the nose, throat, and lungs) vaccine (a preparation that used to stimulate the body's immune response against diseases) for one (1) of five (5) sampled residents (Resident 34) after the responsible party signed the consent form on 2/2/2024. This deficient practice placed Resident 34 at a higher risk of acquiring and transmitting the flu virus to other residents in the facility. Findings: A review of Resident 34's admission Record indicated Resident 34 was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses that included nontraumatic intracerebral hemorrhage (bleeding in the substance in the brain in the absence of trauma or injury), chronic respiratory failure (a condition that occurs when the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body), and immunodeficiency (decrease ability 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 maintain an effective pest control program to ensure the facility remains free of pests (a general term for organisms [rats, insects, cockroaches, etc.] which may cause illnesses) for two (2) of 24 sampled residents (Resident 36 and Resident 165) in accordance with the facility's policy and procedure (P&P). This deficient practice had the potential to affect residents when the flies that carry bacteria land on the food that the residents eat, which could result to illness. Findings: 1. A review of Resident 36's admission Record indicated Resident 36 was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses that included hemiplegia (paralysis on one side of the body) and hemiparesis (weakness of the inability to move one side of the body) following cerebral infarction affecting left non-dominant side (when the blood supply to part of the brain is blocked or reduced causing muscle weakness or partial…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 infection control practices were followed for three of eight sampled residents (Residents 1, 3, and 4) by Certified Nurse Assistant 1 (CNA 1) failed to: 1. a. Perform hand hygiene (action of hand cleansing, could be through hand washing with soap and water or hand sanitizing with and antibacterial sanitizer solution) after providing a brief (protective underwear to prevent leakage) change for Resident 1 who had signs and symptoms of diarrhea. b. Remove dirty gloves and perform hand hygiene before getting a clean gown from linen cart to bring to Resident 4 (resident without signs and symptoms of vomiting and diarrhea) in Room B. c. Properly discard Resident 1's trash and linen. 2. Perform hand hygiene prior to entering Rooms A (Resident 1 and 3's room, on contact isolation [measure used to reduce transmission of microorganisms]) and B. These deficient practices had the potential to transmit infectious microorganisms and increase 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 provide supervision for one of three sampled residents (Resident 1) in accordance with the facility policy when Certified Nursing Assistant 1 (CNA 1) left Resident 1, who was assessed as high risk for fall, sitting in a shower chair inside the resident's room unattended. This failure resulted in Resident 1 getting up out of his wheelchair to go to the restroom which resulted in Resident 1's fall on 5/17/2024. Findings: During a review of Resident 1's admission Record, the admission Record indicated the resident was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of hemiplegia (muscle weakness or partial paralysis on one side of the body that can affect the arms, legs and facial muscles) and hemiparesis (one side muscle weakness) following cerebral infarction (damage to the tissues in the brain due to a loss of oxygen to the area) affecting the left non-dominant side. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to protect one of three residents (Resident 1) from further abuse (the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish) after Resident 2 hit Resident 1 on 3/4/2024 and 5/8/2024, per facility's policy and procedure. This deficient practice resulted in two counts of physical abuse (intentional bodily injury such as pinching, slapping and hitting) and psychosocial (combined influence of psychological factors and the surrounding social environment on physical, emotional, and/or mental wellness) harm for Resident 1. Findings: A review of Resident 1's admission Record indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses of recurrent major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 assistance with Activities of Daily Living (ADLs - activities related to personal care which include bathing/showering, dressing, getting in and out of bed or a chair, walking, using the toilet, and eating) when Resident 1 requested to get ready to participate in a scheduled activity. This deficient practice placed Resident at risk for psychosocial harm such as feeling depressed or lonely. Findings: A review of Resident 1's admission Record indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of suicidal ideations (suicidal thoughts), major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), multiple sites of contracture (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints)of muscle, and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to report to the resident's primary physician the irregularities ( includes, but is not limited to, use of medications without adequate indication, without adequate monitoring, in excessive doses, and/or in the presence of adverse consequences, as well as the identification of conditions that may warrant initiation of medication therapy) with regards to the Depakote (used to treat seizure [temporary abnormalities in muscle tone or movements {stiffness, twitching or limpness}] disorders) order, on the medication regimen review (MRR, or Drug Regimen Review, a thorough evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medication) since October 2023 for one of two sampled Residents (Resident 1) in accordance with the facility policy. This deficient practice had the potential for unnecessary medication administration to Residents 1, which…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to ensure one of two sampled resident (Residents 1) was free from an unnecessary psychotropic drug (any medication capable of affecting the mind, emotions, and behavior) in accordance with the facility policy and procedure by failing to ensure: 1. Resident 1 have a specific indication for the use of Depakote (used to treat seizure disorders, extended release (ER) oral tablet once a day ordered on 9/12/2023. 2. Resident 1 have accurate indication for the use of Seroquel (antipsychotic medication used for the treatment of schizophrenia [mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration, bipolar disorder, and major depressive disorder [ characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life]) that was started on 2/13/2024. These deficient practices had the potential to place Residents 1 at risk for significant adverse (harmful)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 prevent one of four sampled residents (Resident 1) from falling by failing to provide adequate supervision when resident's care plan to move resident to a room closer to the nurse's station was not implemented. This deficient practice resulted in Resident's 1 fall (refers to unintentionally coming to rest on the ground, floor, or other lower level, but not as a result of an overwhelming external force ) and transfer to General Acute Care Hospital (GACH) on 2/14/24 for evaluation. Findings: A review of the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included Parkinson's disease (a disorder of the central nervous system that affects movement, often including tremors), dementia (the loss of thinking, remembering, and reasoning), and glaucoma (eye diseases that can cause vision loss and blindness). A review of Resident 1's Fall Risk Assessment, dated 11/2/2023, indicated Resident 1 had a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record review, the facility failed to ensure inventory of all clothing, valuables were documented, signed and dated in the Inventory Form for one of four sampled residents (Resident 1). This deficient practice had the potential to cause misappropriation of property related to the lack of safekeeping of the residents' personal belongings. Findings: A review of Resident 1's admission Record indicated Resident 1 was admitted to the facility on [DATE]. Resident 1's diagnoses included end stage renal disease (also known as kidney failure - condition when the kidney function is gone) and major depression (a serious medical illness that negatively affects how you feel, the way you think and how you act.) A review of Resident 1's Minimum Data Set (MDS, a resident assessment and care screening tool), dated 10/13/23, indicated the resident did not have an impairment in cognitive (ability to un understand, reason, and remember) skills for daily decision making. 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 administer Vimpat ([Lacosamide] an antiepileptic [anti-seizure] medication) 100 milligrams (mg - a unit of measure of mass) from 9/10/23 and 11/16/23 as ordered for one of three sampled residents (Resident 1). This deficient practice placed Resident 1 at increased risk for uncontrolled seizure activity, hospitalization, and decline in the resident's health. Findings: A review of Resident 1's admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 1's diagnosis included epilepsy (a neurological condition that causes unprovoked, recurrent seizures [sudden rush of abnormal electrical activity in your brain]), quadriplegia (a form of paralysis that affects all four limbs, plus the torso), and gastrostomy status (a surgical procedure used to insert a tube, often referred to as a G-tube, through the abdomen and into the stomach). A review of Resident 1's History and Physical (H&P), dated…

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

Based on interview, and record review, the licensed nursing staff failed to ensure one of two sampled residents (Resident 1), who has a diagnosis of neuromuscular dysfunction of the bladder unspecified (when a resident lacks bladder control due to brain, spinal cord, or nerve problems) and/or responsible party (RP) were informed of the resident ' s treatment plan regarding the discontinuance of the use of foley catheter (a thin flexible tube to drain urine from the bladder) without foreknowledge of Residents 1 ' s physician, as indicated on the facility policy. This deficient practice violated the residents' right and/or RP to make an informed decision regarding change in resident ' s plan of care with the use of a foley catheter. Findings: A review of Resident 1 ' s admission Record indicated the facility admitted the resident on 5/12/2023 with diagnosis of epilepsy unspecified (repeated rhythmical jerking movements), quadriplegia unspecified (severe or complete loss of motor function in all four limbs), neuromuscular dysfunction of the bladder unspecified (when a person lacks…

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

Based on interview and record review, the facility failed to notify the physician of Resident 1's change of condition when resident's foley catheter (a thin flexible tube to drain urine from the bladder) was removed on unknown date for one of four sampled residents (Resident 1), as indicated on the facility policy. This deficient practice had the potential to not provide the necessary urinary care and services needed by Resident 1, which can affect resident's overall wellbeing. Findings: A review of Resident 1's admission Record indicated the facility admitted the resident on 5/12/2023 with diagnosis of epilepsy unspecified (repeated rhythmical jerking movements), quadriplegia unspecified (severe or complete loss of motor function in all four limbs), and neuromuscular dysfunction of the bladder unspecified (when a person lacks bladder control due to brain, spinal cord, or nerve problems). A review of Resident 1's Physician Order Summary, dated 10/12/2023 indicated, 18 French (a measurement of the external diameter of the catheter tube) Foley catheter (fc) to be inserted with urinary…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 pharmacy services for one of two sampled residents (Resident 1) by: 1. Failed to ensure accurate Controlled Drug Record (documentation of the controlled medication [CM- medications which have a potential for abuse and may also lead to experiencing unpleasant physical symptoms when one stops the medication or get emotionally and mentally addicted]) for Resident 1's oxycodone (a CM used to treat pain) 10 milligram (mg, unit of measurement) in one of four inspected medication carts (Medication Cart [NAME] Station). 2. Failed to transcribe oxycodone 10 mg one tablet via Jejunostomy tube (J- tube, a tube placed through the small intestine to deliver food and medications) every four hours as needed for severe pain level 7 and 10 (pain level of 10 as most painful) for one of three sampled resident orders (Resident 1) on 8/21/23 to Resident 1's Medication Administration Record ([MAR] - a record of medications administered to residents). 3. Failed 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 and maintain: 1) Accurate Controlled Drug Record (documentation of the controlled medication [CM- medications which have a potential for abuse and may also lead to experiencing unpleasant physical symptoms when one stops the medication or get emotionally and mentally addicted]) for Resident 1's oxycodone (a CM used to treat pain) 10 milligrams ([mg]- a unit of measure of mass) was signed twice by Licensed Vocational Nurse (LVN) 1 on 7 different dates and time in one of four inspected medication carts (Medication Cart [NAME] Station). 2) Controlled Drug Record for oxycodone 5 mg dated from 8/16/23 to 8/31/23 were retained in the facility for Resident 1 in one of four inspected medication carts (Medication Cart [NAME] Station). This practice could result in creating staff confusion due to an inaccurate clinical record and increase the risk for Resident 1 not receiving appropriate care, being overdosed (receive more than the intended amount 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 provide qualified personnel to assist seven of thirteen sampled residents (Resident 1, 2, 3, 4, 5, 6, and 7) on mechanical ventilation (MV, a form of life support that helps you breathe [ventilate] when you cannot breathe on your own) on 10/14/2023 for the night shift (10 PM to 10/15/2023 at 6 AM). This deficient practice resulted to Resident 1 not attended by a qualified personal to assist with the resident ' s MV when the resident experienced breathing above the MV with rapid respirations and extensive use of accessory muscle (muscles of the shoulder girdle and chest wall) which resulted to transfer to general acute care hospital (GACH) on 10/15/2023 at 1:44 AM. In addition, this placed all the other six (6) residents (Resident 2, 3, 4, 5, 6 and 7) in the facility ' s subacute unit who are on MV of not getting timely care and treatment which could result to serious harm and/ or death. Findings: A review of the facility ' s census, dated 10/14/2023,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to develop and implement a comprehensive resident-centered care plan (a written plan that focuses on the choices of the resident and outlines how the nursing home staff will help the resident) to monitor one of two sampled residents (Resident 1) for 72 hours after Resident 2 hit Resident 1 in the left leg with Resident 2's wheelchair leg rest on 9/14/23. This failure resulted in Resident 1 not receiving 72-hour nurse monitoring after a resident-to-resident altercation, which had the potential to cause a delay or lack of necessary care for Resident 1 following a resident-to-resident altercation. Findings: During a review of Resident 1's admission record, dated 9/28/23, the admission record indicated Resident 1 was admitted to the facility on [DATE] with the following diagnoses dementia (a loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), hyperlipidemia (an abnormally…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 all controlled medications (CM, medications which have a potential for abuse and may also lead to physical or psychological dependence) for three (3) of 3 medication carts (Medication Cart Subacute 1, East, and West) were properly accounted for as indicated on the facility policy and procedure when: 1. 117 Licensed Nurse signatures were missing on the Narcotic Count Sheets (NCS, document where two licensed nurses sign at each shift change verifying the CM inventory) from July 2023 to September 2023. 2. 14 doses of CM administrations documented on the Controlled Drug Record (CDR, inventory and accountability record for CM for each resident) were not reflected on the Medication Administration Record (MAR) for Resident 1. These deficient practices have the potential for CM diversion (the transfer of a controlled substance or other medication from a lawful to an unlawful channel of distribution or use) and increase risk for medication management…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 supervision for one of two sampled resident (Resident 1) when Resident 1 was able to exit the facility and eloped (when a resident who is not capable of protecting or caring for themselves leaves the facility without authorization) on 7/29/23. Resident 1 also did not have a timely wandering and elopement assessment completed as indicated on the facility policy. This failure had the potential for Resident 1 to sustain an accidental injury, exposure to harsh environmental conditions including excessive heat and or cold, and medical complications including malnutrition, dehydration, stroke, heat stroke and possible death. Findings: A review of Resident 1's admission Record indicated resident was admitted to the facility on [DATE]. Resident 1's diagnoses included end stage renal disease (a medical condition in which a resident's kidneys stop functioning on a permanent basis leading to the need for a regular course of long-term dialysis…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to implement the resident ' s care plan to monitor episodes of wandering every shift for one of two sampled residents (Resident 1). This deficient practice resulted in Resident 1 wandering to another resident ' s room and resulted in an altercation with another resident. Findings: A review of Resident 1's admission Record indicated an admission to the facility on 8/15/19 and a re-admission on [DATE]. Resident 1's diagnoses included dementia (a disorder of mental processes caused by brain disease or injury and marked by memory disorder, personality changes, and impaired reasoning), schizophrenia (a mental disorder marked by hallucinations, delusions, and disintegration of the thought processes), and insomnia (trouble falling sleep). A review of Resident 1's Minimum Data Set (MDS- a standardized comprehensive assessment and care planning tool), dated 8/23/22, indicated the resident had severe impairment to cognition (ability to learn, reason, remember,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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's clinical records were updated about advance directives (written statement of a person's wishes regarding medical treatment made to ensure those wishes are carried out should the person be unable to communicate them to a doctor) for four (4) out of the 13 sampled residents (Resident 8, 9, 46, and 212) by failing to maintain a current copy of the resident's advance directives in the resident's clinical record. This deficient practice had the potential to cause conflict with a resident's wishes regarding health care (Resident 8, 9, 46, and 212). Findings: a. A review of Resident 8's admission Record indicated the resident admitted to the facility on [DATE], with a diagnosis that included convulsions (uncontrollable muscle contractions which cause the body to shake uncontrollably). A review of Resident 8's admission Record indicated that his responsible party is his spouse. A review of Resident 8's Minimum Data Set (MDS, a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure two of three sampled residents (Residents 25 and 40) were provided with Medicare coverage information according to the facility's policy and procedure not later than two days before the termination. The facility failed to provide: a. Resident 25 with a Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN, Form CMS -10055, a notice of liability) and Notice of Medicare Non-Coverage (NOMNC, Form CMS 10123) forms. b. Resident 40 with a SNF ABN (Form CMS -10055) form. These deficient practices had the potential to result in the residents and/or the resident's responsible party to not be aware of possible charges for services rendered that were not covered after their last Medicare coverage day. Findings: a. A review of Resident 25's admission Record indicated the resident admitted to the facility on [DATE] and readmitted to the facility on [DATE], with diagnoses that included cardiac arrhythmias (irregular heartbeats),…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 safe storage of opened food items. During an observation of the kitchen, the following were observed: 1. On open, unsealed bag of sliced deli ham, 2. Two bags of open, unsealed tortillas, 3. Two bags of open, unsealed cheese, 4. One unsealed container of applesauce, 5. Open, unsealed bag of raisin bran cereal, and 6. Open, unsealed box of lentils. These deficient practices had the potential for food borne illnesses. Findings: 1. On 10/26/21 at 8:40 A.M., during the initial inspection of the kitchen with the Dietary Supervisor (DS), the following were observed: 1. Two bags of corn tortillas were not sealed and open to air. 2. Large clear container of applesauce had a lid that did not seal correctly. 3. A package of deli ham was open to air. 4. An open bag of Monterey [NAME] cheese. 5. An open bag of Cheddar Cheese. 6. A bag of raisin bran cereal was open and not sealed. 7. A box of lentils was open and in a cardboard box that could not be sealed. During in an interview and observation on 10/26/21 at 8:50…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 interventions to prevent injury for two of four sampled residents (Residents 8 and 207). The facility failed to place bilateral (both left and right side) siderail pads: a. According to Resident 8's physician order and care plan, who had a history of seizure (burst of uncontrolled electrical activity between brain cells that causes temporary abnormalities in muscle tone or movements and can cause the body to shake uncontrollably) episode. b. For Resident 207, who was on Keppra (a seizure medication) and was at risk for injuries from seizures. This deficient practice had the potential for the residents to sustain injuries to the body during a seizure episode. Findings: a. A review of Resident 8's admission Record indicated the resident admitted to the facility on [DATE], with a diagnosis that included convulsions (uncontrollable muscle contractions which cause the body to shake uncontrollably). A review of Resident 8'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 interview and record review, the facility failed to ensure appropriate services/treatment for respiratory care for one of one sampled resident (Resident 2). The facility did not change Resident 2's water container used to provide humidification (a container of water used to add moisture to the oxygen being delivered to the resident) oxygen (O2, supplemental air for treatment of difficulty with breathing) or change Resident 2's nasal cannula (NC, a tube used to deliver O2) per facility's policy and procedure. This deficient practice had the potential to put the resident at risk for infection. Findings: A review of Resident 2's Face Sheet (admission record) indicated the resident admitted to the facility on [DATE] with diagnoses that included dysphagia (difficulty when swallowing) and adult failure to thrive (a decline seen in older adults, typically those with multiple chronic medical conditions which results in a downward spiral of poor nutrition, weight loss, inactivity, depression and decreasing…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 remove and replace expired medications from the medication room in the subacute unit. Two influenza vaccine (medication used to treat respiratory infection caused by viruses, presented with symptoms of fever, headache, and chills) vials with an expiration date of 6/30/21 were found in a plastic bag. This deficient practice had the potential to result in the use of ineffective medications for the residents. Findings: On 10/29/21 at 12:13 P.M., during an inspection of the refrigerator located in medication room located in the subacute hall with a Registered Nurse (RN 1), two influenza vaccine vials with an expiration date of 6/30/21 were found in a plastic bag. During an interview on 10/29/21 at 1 P.M., the Interim Director of Nursing (IDON) stated that the all expired vaccines should have been disposed of so that residents would not get an old medication which may not be effective in treatment. IDON stated that it was all licensed nurses responsibility to go through medications to check for expired…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 have a working call light for one sampled resident (Resident 19). Resident 19's call light did not light up outside the resident's room and did not light up at the nursing station to notify the facility's staff that assistance was needed. This deficient practice had the potential for the resident not being able to get assistance when needed. Findings: A review of Resident 19's admission Record indicated the resident was originally admitted to the facility on [DATE] and then readmitted on [DATE], with a diagnoses that included schizoaffective disorder (a mental illness that is characterized by disturbance in thoughts), Glaucoma (an eye condition that can cause blindness), Hearing loss, and Dementia (a group of thinking and social symptoms that interferes with daily functioning). A review of Resident 19's Minimum Data Set (MDS, a standardized assessment and care-screening tool), dated 9/8/2021, indicated the resident had mild impairment 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.