Pasadena Grove Health Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to secure the residents personal and medical records when the facility did not destroy identifiable information on the resident's discarded oxygen humidifier (bottle device attached to an oxygen concentrator [a medical device that provides supplemental oxygen to people with breathing disorders], tank, or liquid system to add moisture to dry medical oxygen, reducing nasal dryness, nosebleeds, and throat irritation) container for one (1) of 17 sampled residents (Resident 6). This deficient practice has the potential for unauthorized release of resident's personal information.Findings: During a review of Resident 6's admission Record, the admission Record indicated the resident was admitted to the facility on [DATE] with diagnosis that included bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), depression (a common and serious medical illness…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, and record review, the facility failed to complete a Preadmission Screening and Resident Review (PASRR, a federal requirement to help ensure that every resident entering a Medicaid Certified Nursing Facility [NF] receives a Level I screening and if necessary a Level II Evaluation to ensure that the NF residence is appropriate and to identify what specialized services the resident may need) for one (1) of three (3) sampled residents (Resident 10) reviewed for PASRR care area, in accordance with the facility's policy. This deficient practice had the potential to result in inappropriate placement of Resident 10 and had the potential for the resident not to receive the necessary care and services the resident needs. Findings:During a review of Resident 10's admission Record, the admission Record indicated Resident 10 was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses that included depression (a mood disorder that causes a persistent feeling of sadness…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 low air loss mattress (LAL mattress, a specialized medical bed mattress designed to prevent and treat pressure ulcers [localized damage to the skin and/or underlying tissue usually over a bony prominence] by constantly blowing a tiny amount of air through small holes in its surface) was at a correct setting for one (1) of two (2) residents (Resident 21) reviewed for pressure ulcer , in accordance with the facility's policy and procedure. This deficient practice placed Residents 21 at risk for development of new pressure ulcers and prevent healing of the resident's existing Stage 4 pressure ulcer (full-thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage, or bone) on the sacrococcyx (pertains to both large triangular shaped bone in the lower spine that forms part of the pelvis and the tailbone).Findings: During a review of Resident 21's admission Record, the admission Record indicated the resident 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 oxygen via nasal cannula (NC, a medical device used to provide supplemental oxygen therapy to people who have lower oxygen levels) was administered for one (1) of three (3) sampled residents (Resident 66) reviewed for respiratory services in accordance with the facility's policy. This deficient practice had the potential for Resident 66 not being able to receive the benefits of the supplemental oxygen ordered and had the potential to compromise the resident's respiratory function which could lead to complications. Findings: During a review of Resident 66'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 chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing) and pulmonary edema (the buildup of excess fluid in the lungs air sacs making it hard to breath). During a…

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

Based on observation, interview, and record review, the facility failed to ensure one (1) of two (2) dumpsters (a movable waste container) were closed and not overflowing, in accordance with the facility's Garbage and Trashcan Use and Cleaning Policy and Procedure (P&P). This deficient practice had a potential to attract vermin (animals that are believed to be harmful, carry diseases such as rodents, parasitic worms, or insects), pests (any living thing that has a negative effect on humans), and wildlife (undomesticated animal species), increasing the risk of disease transmission and health issues for residents, staff, and the surrounding community.Findings: During a concurrent observation and interview on 3/31/20226 at 8:05 AM with the Dietary Supervisor (DSS1) in the facility parking lot, DSS1 stated that 1 dumpster was overflowing with trash, emitted a foul odor, and had its lid left open. During an interview on 4/2/2026 at 12:44 PM, Dietary Aide (DA 1) stated that dumpsters should not overflow to prevent odors and the attraction of rodents and insects, which could potentially…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to maintain a complete and accurate medical records for three (3) of 17 sampled residents (Residents 12, 21, and 9) in accordance with the facility's Charting and Documentation policy and procedure (P&P) by failing to ensure: 1. Resident 21's sacro-coccyx (pertains to both large triangular shaped bone in the lower spine that forms part of the pelvis and the tailbone) wound care treatment in the Treatment Administration Record (TAR) on 3/15/26, 3/16/2026 and 3/17/2026.2. Resident 9's physician order for Seroquel (drug used to treat schizophrenia) included an indication for use.3. Resident 12's pneumonia (an infection that inflames the air sacs (alveoli) in one or both lungs, causing them to fill with fluid or pus) vaccine consent and Covid-19 (a severe respiratory illness caused by virus and spread from person to person) vaccine consent form included Resident 12's signature.This deficient practice resulted in the medical records inaccurate representation…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 was within resident's arm's reach for one (1) of five (5) sampled residents (Resident 21) reviewed for environment in accordance with the facility's policy. This deficient practice had the potential for Resident 21 not to be able to call the facility staff for help or assistance, especially during an emergency.Findings: During a review of Resident 21's admission Record, the admission Record indicated the resident was admitted to the facility on [DATE] with diagnosis that included anxiety disorder (a mental health disorder characterized by feeling of worry, or fear that are strong enough to interfere with one's daily activities) and bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs). During a review of Resident 21's Minimum Data Set (MDS- a resident assessment tool), dated 1/16/2026, the MDS indicated Resident 21 had…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement the facility's policy and procedure (P&P) for abuse for two (2) of two sampled residents when the facility failed to investigate an allegation of abuse by Resident 2 to Resident 1 on 12/18/2025. On 12/18/2025, Resident 1 reported to Registered Nurse 1 (RNS 1) that Resident 1 was getting harassed (to experience persistent, unwelcome conduct that is offensive, intimidating, or humiliating, often targeting a person's protected traits like race, gender, or religion, or simply making them feel threatened, distressed, or that creates a hostile environment) and assaulted (threatening or attempting to physically harm someone, causing them to reasonably fear immediate injury, even without actual contact) by Resident 2. This failure has the potential for Resident 1 and Resident 2 to feel unsafe and at risk of further abuse in the facility.Findings: 1.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 alleged abuse (willful infliction of injury resulting to physical harm/pain or mental anguish) to the State Survey Agency (California Department of Public Health-CDPH- where state law provides for jurisdiction in long-term care facilities), Ombudsman (OMB- advocates for residents of nursing homes, board and care homes and assisted living facilities), and local law enforcement (PD) within two (2) hours after the allegation of abuse was reported to Registered Nurse Supervisor 1 (RNS 1) for two of two sampled residents (Resident 1 and 2) This deficient practice had the potential to place Resident 1 and 2 at risk for further abuse and/or under reporting from the facility.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 diagnoses that included type 2 diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure medications were administered to meet the needs of each resident and in accordance with professional standards of practice for one of two sampled residents (Resident 1) and 3 of 4 medications (anticonvulsant, antipsychotic, and insulin). Resident 1 had three consecutive episodes of noncompliance behavior (refused medications, on 8/2, 8/3, 8/4/2025 [anticonvulsant], on 8/9, 8/10, 8/11/2025 [antipsychotic], and on 8/2, 8/3, 8/4/2025 [insulin]) for three different medications and the doctor was not notified, per the care plan interventions. In addition, Resident 1's blood glucose was not obtained prior to administration of insulin, in accordance with the policy and procedure titled, Medication - Administration, revised 11/1/2017. These deficient practices caused an increased risk in unsafe and inappropriate care of Resident 1, medication errors, and adverse outcomes to the resident. 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 report an alleged incident of staff to resident abuse for one (1) of four (4) sampled residents (Resident 1) within 2 hours to the state survey agency, adult protective services, law enforcement and the ombudsman (an advocate for residents of nursing homes, board and care centers, and assisted living facilities) according to federal and state regulations and facility policy.This deficiency resulted in the delay of onsite inspections and investigations which led to potential for Resident 1 to experience ongoing abuse from facility staff and/or other residents.Findings:During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses that included End Stage Renal Disease (ESRD- irreversible kidney failure), dependence on dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when 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 treat residents with respect and dignity and maintain privacy for one of two sampled residents (Resident 1). This deficient practice had the potential to negatively affect Resident 1's self-worth and psychosocial wellbeing. Findings: 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 type 2 diabetes mellitus (a disease that occurs when there is a problem in the way the body regulates and uses sugar as fuel), end stage renal disease (advanced stage kidney failure) and hypertension (high blood pressure). During a record review of Resident 1's Minimum Data Set (MDS, a resident assessment and tool), dated 4/15/2025, the MDS indicated the resident's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making was moderately impaired. The MDS 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 observation, interview, and record review, the facility failed to follow its policy and procedure to ensure an allegation of physical abuse (willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish) was reported to California Department of Public Health (CDPH), local law enforcement, and Ombudsman within two (2) hours for two of two residents (Residents 1 and 2). This deficient practice had the potential to place Resident 1 and other residents in the facility at risk for further abuse and resulted in a delay in the investigation for the abuse allegation. Findings: 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 type 2 diabetes mellitus (a disease that occurs when there is a problem in the way the body regulates and uses sugar as fuel), end stage renal disease (advanced stage kidney failure) and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide the necessary services to maintain good grooming and personal hygiene for three (3) of 3 sampled residents (Resident 27, 28, 38) who was dependent with 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), by failing to ensure the residents' nail were kept trimmed and clean in accordance with the facility's policy. This deficient practice resulted in Resident 27, 28, and 38 having dirty, long and jagged (having rough, sharp points protruding) fingernails, potentially leading to skin injury, infection, and scarring. Findings: 1. A review of Resident 28's admission Record indicated the facility admitted Resident 28 on 1/29/2025 with the diagnoses that included dysphagia (difficulty swallowing), depression (mood disorder that causes a persistent feeling of sadness and loss of interest),…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 proper food storage handling practices in accordance with its policy and procedure by failing to label and discard expired food items stored in the facility's kitchen refrigerators, freezers, and dry storage. This deficient practice had the potential to result in food borne illness (any sickness that is caused by the consumption of foods or beverages that are contaminated with certain infectious or noninfectious agents) in a population of 50 residents consuming food by mouth. Findings: During a concurrent observation and interview on 2/25/2025 at 7:59 AM in the facility kitchen with the Dietary Aide (DA) and Kitchen Aide (KA), the following food items were observed: a. One cube of opened butter in the refrigerator with no open date and use by date b. One carton of Smithfield Pork sausage skinless links in the freezer without a label indicating received date and use by date. c. One Frozen bag of chopped spinach without a label…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 follow its policy on Covid-19 (Coronavirus Disease 19, a respiratory viral infection that affects primarily the lungs and result in cough and difficulty breathing) by failing to: 1. Provide education, offer, and document the 2024-2025 Covid-19 vaccinations for two of five sampled residents (Residents 2 and 17). 2. Provide education, offer, and/or document the 2024-2025 Covid-19 vaccination for staff. This deficient practice place residents and staff at risk for possible Covid-19 infection due to missed vaccination dosage. Findings: 1. During a review of the Resident 2's admission Record, the admission Record indicated Resident 2 was initially admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses of schizophrenia (a chronic and severe mental disorder that affects how a person thinks, feels, and behaves), dementia (progressive brain disorder that slowly destroys memory and thinking skills) with behavioral disturbance, Parkinsonism…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 received reasonable accommodation of needs for two (2) of 18 sampled residents (Residents 17 and 28) by failing to ensure Residents 17 and 28's call lights were within reach. This deficient practice had the potential to result in the inability for Residents 17 and 28 to obtain necessary care and services. Findings: 1. During a review of the Resident 17's admission Record, the admission Record indicated Resident 17 was initially admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses of dementia (progressive brain disorder that slowly destroys memory and thinking skills), depression (severe feelings on sadness and hopelessness), and hypothyroidism (condition in which the thyroid gland does not produce enough thyroid hormone). During a record review of Resident 17's Minimum Data Set (MDS, a resident assessment and tool), dated 2/7/2025, the MDS indicated the resident's cognitive (mental action or process of acquiring…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 preadmission screening and resident review assessment (PASRR, preventing individuals with mental illness, developmental disability, intellectual disability, or related conditions from being inappropriately placed in nursing homes for long term care) form was accurately completed for a resident who had a mental illness for one (1) of three (3) sampled residents (Resident 2). This deficient practice had the potential for Resident 2 to not receive the necessary and appropriate psychiatric (of or relating to the study of mental illness) treatment and evaluation. Findings: During a review of the Resident 2's admission Record, the admission Record indicated Resident 2 was initially admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses of schizophrenia (a chronic and severe mental disorder that affects how a person thinks, feels, and behaves), depression (severe feelings on sadness and hopelessness), and dementia (progressive…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 update and revise the fall care plan for one (1) of 18 sampled residents (Resident 2) in accordance with the facility policy. This failure had the potential to place Resident 2 at risk for further falls, which could result in harm/injury to the resident. Findings: During a review of the Resident 2's admission Record, the admission Record indicated Resident 2 was initially admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses of schizophrenia (a chronic and severe mental disorder that affects how a person thinks, feels, and behaves), dementia (progressive brain disorder that slowly destroys memory and thinking skills) with behavioral disturbance, Parkinsonism (progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movement), and difficulty in walking. During a record review of Resident 2's Minimum Data Set (MDS, a resident assessment and tool), dated 2/14/2025, the MDS…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide Restorative Nursing Services (a program available in nursing homes to help residents maintain progress made during therapy treatments, enabling them to achieve their highest practicable level of functioning) as ordered by the physician to increase, prevent, or maintain range of motion (ROM, full movement potential of a joint) for one of three sampled residents (Resident 36). This deficient practice placed Resident 36 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 the extremities (a limb of the body, such as the arm or leg) for not receiving the ordered exercises. Findings: During a review of Resident 36's admission Record, the record indicated Resident 36 was initially admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses of right hand contracture,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 (1) of 1 sampled resident (Resident 16) receiving 5 liters of oxygen therapy (the odorless gas that is present in the air and necessary to maintain life) had a physician's order. This deficient practice had the potential to result in negative outcome of Resident 16's breathing pattern. Findings: During a review of Resident 16's admission Record, the admission Record indicated Resident 16 was initially admitted to the facility on [DATE] with diagnosis which dysphagia (swallowing difficulties), pneumonia (an infection that affects one or both lungs), pleural effusion (occurs when fluid builds up in the space between the lung and the chest wall) During a review of Resident 16's Minimum Data Set (MDS, a resident assessment tool), dated 2/1/2025, the MDS indicated Resident 16's cognitive skills (processes of thinking and reasoning) for daily decision making was intact. The MDS also indicated Resident 16 was on oxygen therapy while 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 provide one of one sampled resident (Resident 30) safe and appropriate care for the provision of dialysis (a lifesaving treatment for residents with kidney failure) consistent with professional standards and in accordance with the facility's policy by failing to: 1. Ensure Resident 30 received 1800 milliliters (ml, unit of volume) of fluids per day as indicated on the care plan. 2. Monitor Resident 30's fistula (an abnormal opening or passage between two body structures that do not normally connect) for dialysis access. These deficient practices resulted in underloading Resident 30 with fluid and had the potential for dehydration ((harmful reduction in the amount of water in the body) and placed Resident 30 at risk for a delay in detecting a non-functioning arteriovenous shunt (AV, a connection or passageway between an artery and vein used for hemodialysis [(medical procedure that filters the blood of waste products when the kidneys are not able to)])…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a medication was administered per physician's order for one of four sampled residents (Resident 21). This deficient practice had the potential for delayed absorption and decrease effectiveness of the medication, which could affect Resident 21's wellbeing. Findings: During a review of the Resident 21's admission Record, the admission Record indicated Resident 21 was initially admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses of dementia (progressive brain disorder that slowly destroys memory and thinking skills) with agitation, metabolic encephalopathy (abnormalities of water, electrolytes, vitamins, and other chemicals that adversely affect the brain function), and hypertension (high blood pressure). During a record review of Resident 21's Minimum Data Set (MDS, a resident assessment and tool), dated 1/8/2025, the MDS indicated the resident's cognitive (mental action or process of acquiring knowledge and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to act upon the facility's Pharmacy Consultant's recommendations during the 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 address the recommendation/ irregularities for the month of January 2025's MRR for one (1) of five (5) sampled residents (Resident 4). This deficient practice had the potential to result in adverse medication outcome for potential unnecessary medications to Resident 4. Findings: During a review of Resident 4's admission Record, the admission record indicated Resident 4 was initially admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included quadriplegia, (a condition characterized by the complete or partial loss of motor and sensory function in all four limbs, arms and legs), seizures (a sudden,…

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

Based on observation, interview, and record review, the facility failed to ensure the lids of one garbage container (dumpster) remained closed as indicated in the facility policy titled, Garbage and Trash Can Use and Cleaning. This failure had the potential to result in the attraction and spread of vermin (animals that are believed to be harmful, or that carry diseases, such as rodent's parasitic worms or insects) that could potentially enter the facility and spread diseases to the residents. Findings: During an observation on 2/25/2025 at 12:08 PM in the facility's parking lot dumpster area, there was one dumpster with two (2) lids which were both left opened. The gate of the dumpster area was not closed. During an observation on 2/26/2025 at 2:50 PM in the facility's parking lot dumpster area, the dumpster was observed with one lid closed and one lid open exposing the contents inside the dumpster. The gate of the dumpster area was not closed. During an interview on 2/27/2025 at 3:32 PM with the Maintenance Supervisor (MS) and Dietary Supervisor (DSS), MS and DSS both stated per…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 provision of hospice (specialized care providing physical comfort and emotional, social and spiritual support for people nearing the end of life) services for one of two sampled residents (Resident 36) by failing to ensure: 1. Hospice nurses (Skilled Nurses [licensed nurses] and Certified Home Health Aide [CHHA]) conducted a visit according to the hospice care summary order. 2. Hospice calendar for 2/2025 was completed to reflect frequency of hospice SN and CHHA visits according to the care summary order. These deficient practices had the potential to result in a delay or a lack of necessary care and services which could negatively affect Resident 36s' physical comfort, psychosocial well-being. Findings: During a record review of the Resident 36's admission Record, the admission Record indicated Resident 36 was initially admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses of hemiplegia (a condition caused by brain damage…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 protocol for Antibiotic Stewardship to reduce inappropriate antibiotic (medication used to kill bacteria and to treat infections) use by not administering antibiotic drug if the antibiotic drug use criteria (Loeb's, an Infection Screening Evaluation in facility's medical record, surveillance definitions of infections in Long-Term Care Facilities) was not met for one (1) of two (1) sampled residents (Resident 206). This deficient practice had the potential for Resident 206 to develop antibiotic resistance (when bacteria, viruses, fungi, and parasites no longer respond to antimicrobial medicine and become ineffective making infections difficult or impossible to treat increasing the risk of disease spread, severe illness, disability, and death) and suffer adverse side effects from unnecessary or inappropriate antibiotic use. Findings: During a review of the Resident 206's admission Record, the admission Record indicated Resident 17 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 administer pneumococcal vaccination (vaccine that protect against bacteria that cause illnesses such as pneumonia [infection of the lungs], ear infections, sinus infections, meningitis [infection of the tissue covering the brain and spinal cord], and bacteremia [infection of the blood]) for one of five sampled residents (Resident 30) after obtaining a consent on 2/7/2025. This deficient practice placed Residents 30 at higher risk of acquiring and transmitting complications from the pneumococcal disease. Findings: During a review of the Resident 30's admission Record, the admission Record indicated Resident 30 was admitted to the facility on [DATE], with diagnoses of end stage renal disease (advanced stage kidney failure), type 2 diabetes mellitus (a disease that occurs when there is a problem in the way the body regulates and uses sugar as fuel), and myocardial infarction (heart attack). During a record review of Resident 30's Physician Order Summary,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 monitor the intake and output for two (2) of 2 sampled residents (Resident 1 and 3) who had an indwelling catheter (soft, plastic or rubber tube that is inserted into the bladder to drain the urine) according to facility's policy. This deficient practice had the potential to delay in the necessary care and services for Resident 1 and 3 which can lead to serious illness or injury. Findings: 1. During a review of Resident 1's admission Record, indicated the resident was originally admitted on [DATE] and was readmitted on [DATE] with the following diagnoses of urinary tract infection (UTI - an infection in the bladder/ urinary tract), chronic kidney disease (CKD; longstanding disease of the kidneys [filter waste and excess fluid in the body] leading to failure), and anemia (a condition where the body does not have enough healthy red blood cells) in CKD. During a review of Resident 1's History and Physical (H&P), dated 7/11/2024, indicated resident does…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 pain management to two (2) of 2 sampled residents (Resident 1 and 2) as indicated on the physician's order and facility policy by failing to: 1. Administer Acetaminophen (a medication used to treat minor aches, pains, and to reduce fevers) to Resident 1 as indicated in the physician's order and notify physician of increased onset of pain. Resident 1 received Acetaminophen 325 milligrams (mg, unit of measurement) 2 tablets which was indicated for mild pain (1-3/10) when Resident 1 complained of pain level of 7/10 on 10/29/2024. 2. Administer Acetaminophen to Resident 2 as indicated in the physician's order. Resident 2 received Acetaminophen 500 mg which was indicated for mild pain (1-3/10) when Resident 2 complained of pain level of 4/10 on 8/24/2024 and 9/29/2024. These failures had the potential for Residents 1 and 2 to experience unnecessary and preventable pain with the potential to result in a mental, physical and/or emotional…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 honor the rights for one of two sampled residents (Resident 1) as indicated in the facility policy by failing to honor Resident 1's request to keep his personal cellphone at bedside. This failure resulted in a violation of Resident 1's rights and had the potential to negatively impact his emotional and/ or mental well-being (the state of being comfortable, healthy, and/or happy). 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 quadriplegia (paralysis from the neck down, including legs, and arms, usually due to a spinal cord injury), depression (mood disorder that causes a persistent feeling of sadness and loss of interest in life) and anxiety (mental disorder involves persistent and excessive worry that can interfere with daily activities). The admission Record also indicated Resident 1 as a self-responsible party…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to obtain urine sample for urine analysis as indicated in the physician's order for one of two sampled residents (Resident 1). This deficient practice had the potential to delay necessary care and services, not optimized for the best possible health outcomes and the potential to cause a negative impact on the resident's overall physical well-being. Findings: During a record 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 quadriplegia (paralysis of all four limbs), urinary tract infection (UTI, a common bacterial infection that affects the urinary tract, which includes the bladder, kidneys, and urethra), and chronic kidney disease (gradual loss of kidney damage where kidneys cannot filter the blood the way they should). During a review of Resident 1's care plan, dated 6/24/2024, the care plan indicated Resident 1 had an indwelling catheter (a flexible…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to ensure one of five sampled residents (Resident 1) was provided a communication board (a device displaying photos, symbols, or illustrations to help residents with limited language skills express themselves) that was readily accessible with the language Resident 1 was able to understand. This failure had the potential to result in Resident 1 experiencing a delay in receiving appropriate care and treatment, which could result in harm. Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses that included type 2 diabetes mellitus with chronic kidney disease (high blood sugar level in the blood stream that leads to a gradual loss of kidney function over time), schizophrenia (a chronic, severe mental disorder that affects the way a resident thinks, acts, expresses emotions, perceives reality, and relates to others), dysphagia…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 develop and/or implement an individualized resident-centered care plan (a care plan that prioritizes the unique health needs and desired outcomes of the resident) for one (1) of four (4) sampled residents (Residents 1) to address inappropriate behavior and wandering as indicated on the facility policy. This failure had the potential for Resident 1 not to receive interventions specific to the resident's needs, which could result in injury and harm to Resident 1 and other residents. Findings: During a review of Resident 1's admission Record, the admission Record indicated the resident was admitted to the facility on 8/14//2024. Resident 1 's diagnoses included adult failure to thrive (insufficient weight gain or inappropriate weight loss), chronic obstructive pulmonary disease (COPD, a chronic inflammatory lung disease that causes obstructed airflow from the lungs), and hypertension (high blood pressure). During a review of Resident 1's History and Physical (H&P), dated 7/8/2024, the H&P indicated Resident 1…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide adequate supervision in accordance with the facility policy for one (1) of four (4) sampled residents (Resident 1) who was reported to exhibit inappropriate behavior and was observed with episodes of wandering. This deficient practice resulted to Resident 1 wandering into another resident's room with an allegation from the other resident (Resident 2) of inappropriate touching. This deficient practice also had the potential for Resident 1 to sustain injury and harm. Findings: During a review of Resident 1's admission Record indicated the resident was admitted to the facility on 8/14//2024. Resident 1 's diagnoses included adult failure to thrive (insufficient weight gain or inappropriate weight loss), chronic obstructive pulmonary disease (COPD, a chronic inflammatory lung disease that causes obstructed airflow from the lungs), and hypertension (high blood pressure). During 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure call light (used in healthcare facilities as an alerting device for nurses or other nursing personnel to assist a resident when in need) was within reach and failed to provide an adaptive call light (specialty call light that will fit the resident's need if unable to use the regular call light with a call button) for one (1) of four (4) sampled residents (Resident 2) as indicated in the facility's policy and procedure and care plan. This deficient practice had the potential not to meet Resident 2's needs and preference. Findings: During a review of Resident 2's admission Record, the admission Record indicated the resident was admitted to the facility on [DATE]. Resident 2's diagnoses included quadriplegia (is the condition in which both the arms and legs are paralyzed and lose normal motor function), anxiety disorder (a disorder characterized by nervousness characterized by a state of excessive uneasiness and apprehension, typically…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 reasonable accommodation of needs for two of two sampled residents (Residents 1 and 4) by failing to ensure Residents 1 and 4's call lights (a device with a button or touchpad a resident uses to set off an alarm that flashes/rings to alert the facility staff the resident needs assistance) were within the resident's reach and the call lights were answered promptly as indicated in the facility's policy and procedure. This deficient practice had the potential for Residents 1 and 4 not to receive emergency and/ or necessary care or have a delay in care and services that could result in an accident such as fall and/ or skin breakdown. Findings: 1. During a review of Resident 1's admission Record indicated the facility admitted the resident on 8/9/2024 with diagnoses that included complete atrioventricular block (a heart rhythm disorder that occurs when the heart's electrical conduction system can't transmit impulses from the atria 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 treatment and care for three of three sampled residents (Residents 1, 4, and 6) in accordance with professional standards of practice and the facility's policy and procedure by: 1. Failed to assess, document, and notify Resident 1's Attending Physician regarding the resident's pacemaker's (an artificial device for stimulating the heart muscle and regulating its contractions) dressing status. 2. Failed to check Resident 4 and 6 every two hours if they needed diaper change and/ or as needed when residents called to request for diaper change. These deficient practices had the potential to result in a delay of provision of necessary care and services to Residents 1, 4, and 6 which can lead to infection of Resident 1's surgical site and for Resident 4 and 6 to develop skin breakdown due to being left wet and/ or soiled for a long period of time. Findings: 1. During a review of Resident 1's admission Record indicated the facility…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 pain management (the process of alleviating pain) for one of two sampled residents (Resident 2) by not implementing the facility policy and procedure on pain management. This deficient practice had the potential to result in Resident 2 to experience unrelieved pain. Findings: A review of Resident 2 ' s admission Record indicated resident was admitted on [DATE] with the following diagnoses of repeated falls and anxiety (a feeling of fear, dread, and uneasiness). A review of Resident 2 ' s History and Physical (H&P) indicated resident does not have the capacity to understand and make decisions. A review of Resident 2 ' s Minimum Data Set (MDS; a standardized care screening and assessment tool), dated 5/15/2024, indicated resident is moderately impaired in cognitive (the functions your brain uses to think, pay attention, process information, and remember things) skills for daily decision making. MDS indicated resident required…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 prescribed medications to two of three sampled residents (Resident 2 and Resident 3) as ordered by the doctor. These failures resulted in Resident 2 and Resident 3 not receiving their prescribed medication as ordered according to their plan of care. Findings: A review of Resident 2 ' s admission Record indicated Resident 2 was admitted to facility on 9/23/2023 with diagnoses that include chronic obstructive pulmonary disease (COPD - a lung disease characterized by long-term poor airflow), hypothyroidism (condition when the thyroid gland doesn't make enough thyroid hormones to meet your body's needs), depression (mood disorder that causes a persistent feeling of sadness and loss of interest in life) and anxiety (an intense, excessive, and persistent worry and fear about everyday situations) and schizophrenia (a severe mental illness that causes disturbed or unusual thinking, loss of interest in life, and strong or inappropriate emotions). A…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of seven sampled facility staff (Certified Nursing Assistant 1 - CNA 1) had the competency necessary to care and ensure resident safety as identified through resident assessments, plan of care, and facility policy. This deficient practice had the potential in resident falls. Findings: A review of the Resident 1's admission Record indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE], with diagnoses of dementia (progressive brain disorder that slowly destroys memory and thinking skills), repeated falls, superficial injury of other part of head, difficulty walking, and presence of bilateral (both) artificial hip joint. A review of Resident 1's Fall Risk Assessment, dated 5/14/2024, indicated Resident 1 was a moderate risk for falls. A review of Resident 1's Care Plan, initiated 5/20/2024, indicated Resident 1 was at high risk for falls related to history of falls. Staff interventions…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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: 1 and 2. Monitoring of placement and function of the WanderGuard (a monitoring device [bracelet] that alarms when a resident tries to exit out of the door) for two of two residents (Resident 1 and 2) as indicated in the physician's order and care plan (a document that outlines the facility's plan to provide personalized care to a resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs). 3. There was a system in place to test the WanderGuard bracelet for functionality as indicated in the WanderGuard manual. These failures placed Resident 1 and Resident 2 at risk for elopement (when a resident who is incapable of adequately protecting him/herself, departs the health care facility unsupervised and undetected) and risk of injury and harm. Findings: 1. A review of Resident 1's admission Record indicated Resident 1 was readmitted to the facility on [DATE] with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement its own abuse policy and procedure (P&P) by failing to investigate and report allegation of abuse and submit the follow up investigation report in a timely manner for two of two sampled residents (Resident 1 and Resident 2). These deficient practices put the facility's residents at risk for potential abuse by failing to identify and report abuse in timely manner. Findings: A review of Resident 1's admission record, indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including depression (a constant feeling of sadness and loss of interest, which stops you from doing your normal activities), anxiety disorder (a condition in which a person has excessive worry and feelings of fear, dread and uneasiness), schizoaffective disorder (a chronic mental illness that causes a person to experience dramatic changes in their thoughts, moods, and behaviors), and insomnia (a sleep disorder that can make it hard to fall asleep or stay…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 (2) of three (3) sampled residents (Residents 1 and 2) who were assessed as high risk for elopement (to go about from place to place usually without a plan or purpose that leads a resident to completely leave the facility, unsupervised and unnoticed) were provided supervision when the courtyard gate alarm (a small device mounted next to the door to monitor the movement of the door) was broken. This failure resulted in Resident 1 and 2 having a successful elopement which had the potential to lead to injury while outside the facility's premises without supervision from staff. Resident 2 was found on 3/11/2024 and Resident 1 remained missing. Findings: 1. 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 that included unspecified kidney failure, chronic obstructive pulmonary disease (COPD- a lung disease characterized by long term…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 promote dignity and respect for two of three sampled residents (Resident 35 and 1) for dignity care area. The facility staff was observed standing above Resident 35 and Resident 1's eye level while assisting the residents during dinner. This deficient practice had the potential to affect Resident 35 and Resident 1's self-esteem and self-worth and violate Resident 35 and 1's right to be treated with dignity. Findings: 1. A Review of Resident 35's admission Record indicated Resident 35 was initially admitted to the facility on [DATE], and was readmitted on [DATE] with diagnoses that included Kwashiorkor (a form of malnutrition that occurs when there is not enough protein in the diet), pneumonia (an infection that affects one or both lungs), and chronic obstructive pulmonary disease (COPD, a lung disease characterized by long term poor airflow). A review of Resident 35's Minimum Data Set (MDS, a standardized assessment and care planning…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 follow their Advance Directives (a written instruction, such as a living will or durable power of attorney for health care, recognized under State law relating to the provision of health care when the individual is incapable) for three (3) of 3 sampled residents (Resident 30, 29, and 116) when facility failed to ensure: 1. Resident 30's Advance Directive was maintained in the resident's chart. 2. Resident 116 had a documented evidence on being informed of his choice to complete an Advanced Directive. 3.Resident 29 had a documented evidence on being informed of his choice to complete an Advanced Directive. This deficient practice had the potential not to carry out Residents 30, 116, and 29's wishes regarding health care decisions during an emergency. Findings: 1. A review of Resident 30's admission Record indicated the resident was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included dementia (a mental…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement treatment for the prevention of pressure ulcer (painful wound caused as a result of pressure or friction) for three (3) of 3 sampled residents (Residents 30, 3, and 45) for pressure injury care area, in accordance with the facility's policy and procedure by failing to ensure: 1. Resident 30'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 on the correct setting. 2. Resident 3's LAL was on the correct setting. 3. Resident 45, who was at risk for developing pressure ulcers, was provided wound treatment dressing on 2/21/24 and failed to obtain and provide treatment of Stage 4 sacrococcyx (area of skin at the bottom of the spine and lies between the lumbar spine and tailbone) pressure ulcer (full thickness tissue loss with exposed bone, tendon or muscle. Often includes…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 two (2) of 2 sampled residents (Residents 34 and 35) for respiratory care area, in accordance with the facility policy. 1. The facility failed to ensure Licensed Vocational Nurse (LVN 1) did not leave Resident 34 unattended during the administration of her scheduled dose of Budesonide (medication that makes breathing easier by reducing the irritation and swelling of the airways) via a handheld nebulizer (a machine that delivers medicines in the form of aerosols to add moisture and help control the respiratory symptoms). This deficient practice had the potential to result in ineffectiveness of the medication and had the potential to cause inability of the facility to readily identify sign and symptoms of possible adverse drug reaction (an undesired harmful effect resulting from a medication) to the medication such as vomiting, passing out, muscle weakness and a change in heart rate. 2. 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 store and prepare food in a sanitary manner to prevent the growth of microorganisms that could cause food borne illness (food poisoning: any illness resulting from the food spoilage of contaminated food, pathogenic bacteria, viruses, or parasites that contaminate food, as well as toxins) as indicated on the facility policy by failing to ensure: 1. Personal items of kitchen staff were stored in the designated area. 2. Personal food of the kitchen staff was not left on top of the food preparation table and was not placed in the kitchen refrigerator. 3. Utensils drawer and utensils were free from dirt and debris. 4. Food items in the facility's kitchen, two (2) freezers located in the dietary office and dry storage were labeled and dated with the received and opened date. 5. Food items were properly sealed and stored. 6. Fish was not placed in the Freezer 1 (designated for baked goods, ice cream and sherbet only) in the big dry storage room. 7. Expired food was discarded and not stored in the dry storage room…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 (3) of four (4) sampled residents (Residents 13, 214, and 266), for infection control care area, by failing to maintain infection control measures when: 1. Resident 13 who was on contact isolation (used for infections, diseases, or germs that are spread by touching the resident or items in the resident room, healthcare workers are required to wear gloves, gown and optional mask during care) for Carbapenem-Resistant Enterobacterales (CRE, a type of bacteria that can cause severe infections and are resistant to most available antibiotics including strong antibiotics called carbapenems) was allowed to participate in activities held in the Activity Room with other residents. 2. Certified Nursing Assistant 5 (CNA 5) did not perform hand hygiene (the act of cleaning the hands to prevent the spread of germs by either washing hands with soap and water or using alcohol based hand sanitizer…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to obtain an informed consent for two (2) of 17 sampled residents (Resident 15 and 115): 1. Resident 15 did not have a psychoactive medication (a drug that changes brain function and results in alterations in perception, mood, consciousness, or behavior) consent form for the use of trazodone (medication used to treat depression and anxiety disorders) and Zyprexa (medication used to treat certain mental/mood disorders). 2. Resident 115 was not provided a consent form for the use of wander guard (a wearable bracelet integrated with a resident's security system to alert care givers when the resident has wandered from the protected zone). This deficient practice had the potential to violate Resident 15 and Resident 115's right to be informed and to choose the type of care or treatment to be received, or alternatives the resident or responsible party preferred. Findings: 1. A review of Resident 15's admission Record indicated the resident 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 develop and/or implement 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 residents' needs for five (5) of 17 sampled residents (Residents 34, 13, 15, 29 and 35) as indicated on the facility policy: 1. and 2. Residents 34 and 13 did not have an individualized resident-centered care plan addressing Restorative Nursing Assistant (RNA) services for range of motion exercises (ROM, extent of movement of a joint). This deficient practice had the potential to result in a lack or delay in the delivery of necessary care and services, which could result in Residents 34 and Resident 13 developing contractures (abnormal shortening of muscle tissue). 3. Resident 15's comprehensive care plan on history of drug use and drug therapy was not developed. This deficient practice could result in drug…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 an environment that was safe and free from accident hazards, in accordance with the facility's policy for one (1) of three (3) sampled residents (Resident 15), for accidents care area, when Resident 15 was found in possession of an illegal substance on 2/1/24. This deficient practice had the potential for other residents to have access to the illegal substance and place Resident 15 and other residents at risk for harm and hospitalization. Findings: A review of Resident 15's admission Record indicated the resident was admitted to the facility on [DATE] with a diagnosis that included personal history of drug use and drug therapy. A review of Resident 15's History and Physical (H&P), dated 10/25/23, indicated Resident 15 had the capacity to understand and make decisions. A review of Resident 15's Minimum Data Set (MDS, an assessment and care screening tool), dated 1/26/24, indicated Resident 15 had moderate cognitive skills (mental action 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 provide nutritional services for one of one sampled resident (Resident 45 ) for nutritional care area when: 1. Resident 45 was not provided assistance as assessed on the Minimum Data Set (MDS, a comprehensive standardized assessment and screening tool) during lunch on 2/22/24 and was not on the Restorative Nurse's Aide (RNA) feeding program (a program that provides nursing interventions that promote the resident's ability to adapt and adjust to living as independently and safely as possible by focusing on achieving and maintaining optimal physical, mental, and psychosocial functioning) as indicated on the physician's order and care plan. 2. Resident 45's meal intake was not monitored by not having documented evidence of resident's breakfast and lunch food intake percentage on 2/22/24 to ensure Resident 45 consumed 80 percent (%) of meals according to the care plan. This deficient practice had the potential for Resident 45 to lose further…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 patient when in need) was within the resident's reach (arm's length) for one (1) out of 17 sampled residents (Resident 30) as indicated on the facility's communication-call light policy. This deficient practice had the potential for Resident 30 not being able to call the facility's staff for help or assistance especially during an emergency. Findings: A review of Resident 30's admission Record indicated the resident was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis that included dementia (a mental disorder in which a person loses the ability to think, remember, learn, make decisions, and solve problems) and adult failure to thrive (happens when a person losses appetite, eats and drinks less than usual, loses weight, and is less active than normal). A review of Resident 30'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.

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 facility remains free of pests (a general term for organisms [rats, insects, cockroach etc.] which may cause illness) and rodents (a type of small mammal with sharp front teeth such as rats, mice, and squirrels) for one (1) of four (4) sampled residents (Residents 9) in accordance with the facility's policy and procedure. This deficient practice had the potential for Resident 9 and other residents to be bitten by cockroaches, which could result to irritation, lesions, swelling, and infection. Findings: A review of Resident 9's admission Record indicated the resident was admitted to the facility on [DATE] and re-admitted on [DATE]. Resident 9's diagnoses included Cauda equina syndrome (occurs when the nerve roots in the lumbar spine [is the lower back region of your spinal column or backbone] are compressed, cutting off sensation and movement), Multiple sclerosis (MS, a disorder of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to permit one of one sampled resident (Resident 1) to be admitted to the facility on ce they have an open bed available on 12/14/2023. As a result, Resident 1 remained in the general acute care hospital (GACH) from 12/14/2023 to 12/17/2023 (a total of four [4] days) waiting to be admitted to the skilled nursing facility (SNF 1). Patient 1 was subsequently discharged by the GACH to another skilled nursing facility (SNF 2) on 12/18/23. Findings: A review of Resident 1's admission record indicated the resident was originally admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses that included chronic obstructive pulmonary disease (COPD; a group of lung diseases that block airflow and make it difficult to breathe), extrapyramidal and movement disorder (include movement dysfunction such as dystonia [continuous spasms and muscle contractions], akathisia [may manifest as motor restlessness], parkinsonism characteristic symptoms…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 control practices (a set of practices that prevent or stop the spread of infections and or diseases in the healthcare setting) were implemented as indicated on the Centers for Disease Control and Prevention (national public health agency) guidelines by: 1. Failing to label contaminated laundry. 2. Failing to have a trash can for doffing(remove an item of clothing) of personal protective equipment (PPE, protective clothing designed to protect the wearer's body from infection) at doorway for PPE doffing. This deficient practice had the potential for spread of Coronavirus 2019 (COVID-19, infectious disease caused by coronavirus) to the residents and staff in the facility. Findings: 1. During a concurrent observation in the facility back parking lot where resident laundry was stored and interview with Laundry Staff (LS) and Maintenance Manager (MM) on 11/17/23 at 11:51 AM, LS stated all the dirty linens and 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 develop a comprehensive and resident-centered care plan to prevent falls (unintentionally coming to rest on the ground, floor, or other lower level but not as a result of an external force) for one of four sampled residents (Resident 3). Resident 3's care plan did not indicate how often Resident 3 should be observed or monitored to prevent from falling. This deficient practice resulted in Resident 3 suffering an unwitnessed fall which resulted in an acute right femoral neck fracture (right hip fracture). Findings: During a review of Resident 3's admission Record indicated Resident 3 was admitted on [DATE] with diagnoses that included encephalopathy (damage or disease that affects the brain), type 2 diabetes mellitus (a chronic condition that affects the was the body processes blood sugar), and dementia (a brain disorder that results in memory loss, poor judgment, and confusion. During a review of Resident 3's Minimum Data Set (MDS, a standardized…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide adequate supervision for one of three sampled residents (Resident 3) who was assessed at high risk for falls (unintentionally coming to rest on the ground, floor, or other lower level but not as a result of an external force) with severely impaired vision. This deficient practice resulted in Resident 3 suffering a fall which resulted in an acute right femoral neck fracture (right hip fracture). Findings: During a review of Resident 3's admission Record indicated Resident 3 was admitted on [DATE] with diagnoses that included encephalopathy (damage or disease that affects the brain), type 2 diabetes mellitus (a chronic condition that affects the was the body processes blood sugar), and dementia (a brain disorder that results in memory loss, poor judgment, and confusion. During a review of Resident 3's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 9/29/23, indicated Resident 3 had moderately 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 report an allegation of neglect (the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress) on 7/14/2023 for one of three sampled residents (Resident 1) within two (2) hour timeframe to the State Survey Agency (SA, where state law provides for jurisdiction in long-term care facilities) and local law enforcement. This failure may result to further abuse to Resident 1 and other residents in the facility. Findings: A review of the admission record indicated Resident 1 was admitted to the facility on [DATE], with diagnosis including chronic obstructive pulmonary disease (COPD, is a chronic inflammatory lung disease that causes obstructed airflow from the lungs), hypertension (high blood pressure) , and polyneuropathy (the most common form of a group of disorders known as peripheral neuropathy, is caused by damage 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.