Pasadena Park Healthcare And Wellness Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, facility failed to follow its policy on infection control for five (5) of 5 sampled Residents (Resident 25, 81, 294, 11, and 84) by failing to ensure: 1. Resident 25's humidifier bottle (bottle of water that adds moisture to oxygen therapy) was labeled with the oxygen tubing connected to it. Facility also failed to store Resident 25's Bilevel positive airway pressure (BiPAP, a mechanical breathing device with a mask that is used to help breathing) mask in a plastic bag. 2. Contact isolation (interventions used and intended to prevent spreading of infectious agents by direct or indirect contact) was initiated and implemented for Resident 81 while resident had Methicillin-resistant Staphylococcus Aureus (MRSA, a type of bacteria that is resistant to several antibiotics) infection. 3. Resident 294's oxygen tubing remained off the floor during oxygen administration. 4. Resident 11's oxygen nasal cannula (a medical device that delivers oxygen to the nose through a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to maintain a safe and sanitary environment by failing to: 1. Empty the sharps container (made of rigid puncture resistant plastic which is used to ensure safe containment and disposal of items such as needles, scalpels, and other sharp medical instruments and prevent needlestick injuries) located in residents' restroom per facility policy. This failure resulted in unsafe conditions putting residents and staff at risk for injury. 2. Ensure unused toilet tissue rolls were clean, unopened, and stored in a sanitary manner. This failure resulted in unsanitary conditions putting residents at risk for urinary tract infection (UTI, an infection in any part of the urinary tract, the system of organs that makes urine) with the use of contaminated toilet tissue. Findings: 1. During a concurrent observation and interview on 4/29/2024 at 11:10 AM with Central Supply (CS) in Resident Restroom [ROOM NUMBER] (RR 1), the sharps container was observed with sharps products…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to revise a Foley catheter (or urinary catheter is a flexible tube that is inserted into the bladder to empty it and collect urine in a drainage bag) care plan for one (1) of 1 sampled resident (Resident 84) by not updating Resident 84's Foley catheter care plan to include the resident's behavior of placing the resident's Foley catheter drainage bag on the floor. This failure resulted in the facility staff not implementing interventions to prevent Resident 84 from placing his urinary catheter drainage bag on the floor and placed Resident 84 at risk for infection. Findings: A review of Resident 84's admission Record indicated the resident was initially admitted to the facility on [DATE] with diagnoses of aphasia (a language disorder that makes it difficult to understand, express, read, and write) and type two (2) diabetes (a disease that occurs when your blood sugar is too high). A review of Resident 84's History and Physical Examination…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 two (2) of 20 sampled residents (Residents 44 and 290) were provided care and services by failing to provide: 1. A communication board (a device that displays photos, symbols, or illustrations to help people with limited language skills express themselves) to Resident 44 that was readily accessible with the language the resident was able to understand in accordance with the facility policy. This failure had the potential to result in Residents 44 to experience a delay in receiving appropriate care and treatment and feeling lonely and isolated due to the staff not being able to properly communicate with the resident. 2. A shower to Resident 290 as scheduled and as requested. This failure resulted in violation of Resident 290's right to be showered, receive person centered care (services delivered in a setting and manner that is responsive to individuals and their goals, values and preferences) and potential to decline her ability to carry out…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 residents Coban wrap (a self-adherent elastic wrap that provides a reliable hold while maintaining mild compression) and Unna boot dressing (medicated moist gauze with zinc oxide) was applied to the resident's bilateral lower extremities (BLE, both legs) as indicated on the physician's order for one (1) of two (2) sampled residents (Resident 20). These deficient practices had the potential for unresolved and worsening edema (swelling caused by fluids trapped in the body's tissues) to Resident 20's BLE affecting the resident's physical comfort and well-being. Findings: A review of Resident 20's admission Record indicated the resident was admitted to the facility on [DATE] with diagnosis that included chronic kidney disease (CKD, a condition characterized by a gradual loss of kidney function over time) and congestive heart failure (CHF, a serious condition in which the heart doesn't pump blood as efficiently as it should). A…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide the necessary respiratory care service for one (1) of five sampled residents (Residents 34) in accordance with the facility's policy and procedure when an oxygen humidifier (a device designed to increase the moisture in the air and avoid dryness of the nasal passage [nose to lungs]) being used was empty and did not have sterile water (water that is free of any microbes [tiny living things that are found all around us and are too small to be seen by a naked eye], used to prevent growth of organisms and bacteria in the water). This deficient practice had the potential to create discomfort and dryness to Resident 34's nasal passages which can lead to serious complications. Findings: A review of Resident 34's admission Record indicated the resident was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses which included chronic respiratory failure with hypoxia (a condition that occurs when the lungs…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to accurately record and implement the food preferences for one of four sampled Residents (Resident 25). This failure resulted in a violation of Resident 25's right to have preferred meal choices, with the potential for decreased food intake and inadequate nutrition. Findings: A review of Resident 25's admission Record indicated Resident 25 was readmitted to the facility on [DATE] with diagnoses that included hemiplegia (inability to move one side of the body) and hemiparesis (weakness one side of the body), acute respiratory failure (a sudden condition in which not enough oxygen passes from the lungs into the blood) with hypoxia (low levels of oxygen in body tissues, causing confusion, bluish skin, and changes in breathing and heart rate), dysphagia (difficulty swallowing) and gastro esophageal reflux disease (chronic digestive disease where the contents of the stomach refluxes and irritates the esophagus). A review of Resident 25's Minimum Data Set…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the call light (an alerting device for nurses or other nursing personnel to assist a resident when in need) was within the resident's reach (arm's length) for two (2) out of 20 sampled residents (Residents 18 and 34) as indicated on the facility's communication-call system policy. This deficient practice had the potential for Residents 18 and 34 not being able to call the facility's staff for help or assistance especially during an emergency. Findings: 1. A review of Resident 18's admission Record indicated the resident was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included chronic kidney disease (a condition in which the kidneys are damaged and cannot filter blood as well as they should), blindness on one eye, and history of fall. A review of Resident 18's History and Physical (H&P), dated 11/14/2023, indicated Resident 18 does not have the capacity to understand and make decisions.…

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

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 (a set of practices that prevent or stop the spread of infections and or diseases in the healthcare setting) were followed for two (2) of 2 sampled residents (Resident 1 and 3) in accordance with the facility ' s policy and procedure when: 1. Resident 1 ' s oxygen humidifier (a device used to make supplemental oxygen moist) was not dated to indicate it was changed every 7 days. 2. 2. Resident 3 ' s oxygen humidifier was found sitting on the floor instead of on top of the oxygen concentrator (a medical device that gives extra oxygen by taking and filtering air from the surroundings). These deficient practices had the potential for residents ' medical devices to be contaminated and placing residents at risk for infection. Findings: 1. A review of Resident 1 ' s admission Record indicated the resident was admitted to the facility on [DATE] with diagnosis that included interstitial pulmonary disease (disease…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to offer pneumococcal vaccine (prevents infection by Streptococcus (bacterium that causes one of the most common and severe forms of pneumonia) to one (1) of six (6) sampled residents (Resident 2) in accordance with the facility ' s policy and procedure. This deficient practice placed Resident 2 at a higher risk of acquiring and experiencing complications from pneumococcal pneumonia disease (bacterial lung disease) including transmitting pneumonia to other residents in the facility. Findings: A review of Resident 2 ' s admission Record indicated the resident was admitted to the facility on [DATE] with diagnosis that included pulmonary hypertension pulmonary hypertension (increase of blood pressure in the lungs) and chronic bronchitis (a lung condition that develops over time in which the large air passages that lead to the lungs become inflamed and scarred). A review of Resident 2 ' s History and Physical (H&P), dated 11/23/23, indicated Resident 2 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 meet resident's need of medications upon admission for one of three sampled residents (Resident 1). The facility did not administer Resident 1's seven (7) medications due to be given on 1/26/2024 at night (usually scheduled at 9 PM). This deficient practice had a potential of causing a decline in resident's health condition. Findings: A review of Resident 1's admission record indicated Resident 1 was admitted at the facility on 1/26/2024 with the diagnoses that included but not limited to hemiplegia (paralysis of one side of the body), chronic respiratory failure (severe problem in breathing), chronic obstructive pulmonary disease (COPD, a group of lung diseases that block airflow and make it difficult to breathe) and chronic pulmonary edema (water accumulated in the lung). A review of the facility's census list indicated Resident 1 was admitted to the facility on [DATE] at 8 PM. A review of Resident 1's list of medications ordered printed on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide a functioning call light (device to call for assistance from staff) for one of three sampled residents (Resident 1) as indicated in the Call System Communication facility policy. This failure had the potential to result in Resident 1 not being able to call the facility staff for assistance, which could result in a fall, injury or delayed provision of care. Findings: During a review of Resident 1 ' s admission Record indicated Resident 1 was admitted to the facility on [DATE]. Resident 1 ' s diagnoses included hemiplegia (unable to move only one side of the body) and hemiparesis (one-sided muscle weakness) after a cerebral infarction (a condition that disrupts blood flow to the brain) affecting the left dominant side, absence of a right forearm below the right elbow, diabetes mellitus (a condition when the body cannot properly store or use glucose [sugar]), hypertension (high blood pressure), chronic kidney disease (a condition in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to treat one of four sampled residents (Resident 1) with respect and dignity when Certified Nurse Assistant (CNA) 1 called Resident 1 fat. This deficient practice had the potential to result in psychological harm. Findings: A review of Resident 1's admission Record, indicated Resident 1 was originally admitted at the facility on 7/1/2020 and was readmitted on [DATE] with the following diagnosis of muscle weakness and unsteadiness on feet. A review of Resident 1's History and Physical (H&P), dated 4/13/2023, indicated Resident 1 had the capacity to understand and make decisions. A review of Resident 1's Minimum Data Set (MDS; a standardized assessment and care screening tool), dated 10/20/2023, indicated resident is moderately cognitively impaired for daily decision making. MDS also indicated resident required set up or clean up assistance (helper sets up or cleans up; resident completes activity. Helper assists only prior to or following the activity)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to develop a comprehensive person-centered care plan for the use of oxygen therapy (a treatment that delivers oxygen for you to breath) or two (2) of four (4) sampled residents (Resident 4 and Resident 32) in accordance with the facility policy and procedure. This deficient practice had the potential to result in a lack of or delay in delivery of necessary care and services for Resident 4 and Resident 32. Findings: 1. A review of the admission Record indicated Resident 4 was admitted on [DATE] with diagnoses including metabolic encephalopathy (a chemical imbalance of the blood in the brain), chronic obstructive pulmonary disease (COPD, a constriction of the airway making it hard and uncomfortable to breathe), acute respiratory failure with hypoxia (low level of oxygen in the body tissues), and congestive heart failure (CHF, a serious condition in which the heart doesn't pump blood as efficiently as it should). A record review of Resident 4's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure a resident receiving enteral feeding (gastrostomy [GT] feeding) received appropriate care and services to prevent complications of enteral feeding for two of two sampled residents (Resident 55 and 30). Resident 55's gastrostomy (GT) feeding tube did not have a date and time label, in accordance with the facility's policy on Enteral Feeding. This deficient practice had the potential to cause GT associated complications such as infection to the gastrostomy site. Findings: 1. A review of Resident 55's Face Sheet (a document that gives a patient's information at a quick glance) indicated the facility admitted the resident on 1/20/2021with diagnoses of sequelae of cerebral infarction (residual conditions produced after disrupted blood flow to the brain due to problems with supply the blood vessels), Type 2 diabetes mellitus (body failure to regulate and uses sugar as a fuel), hypertension (high blood pressure), major depressive disorder…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide the necessary respiratory care service for two (2) of four sampled residents (Residents 4 and 32). 1. For Resident 4, the facility failed to change the resident's oxygen humidifier (a device used to make supplemental oxygen moist) every three (3) days per physician's order. This deficient practice had the potential for the resident to develop a respiratory infection. 2. For Resident 32's oxygen tubing was not labeled according to the facility's policy and procedure. This deficient practice had the potential for Resident 32 not to receive the benefits of the supplemental oxygen ordered if the oxygen tubing was not in its optimal working condition. Findings: 1. A review of Resident 4's admission Record indicated that resident was admitted on [DATE] with diagnoses including metabolic encephalopathy (a chemical imbalance of the blood in the brain), chronic obstructive pulmonary disease (COPD, a constriction of the airway making it…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 obtain an informed consent for one of three sampled residents (Resident 55) after an increase in the dose of antidepressant drug (medication used to treat certain mental/mood conditions) dosage. This failure had the potential to violate Resident 55's rights to be informed and to choose the type of care or treatment to be received, or alternatives the resident or responsible party preferred. Findings: A review of Resident 55's face sheet indicated the facility admitted the resident on 1/20/2021 with diagnosis of sequelae of cerebral infarction (residual conditions produced after disrupted blood flow to the brain due to problems with supply the blood vessels), type 2 diabetes mellitus (body failure to regulate and uses sugar as a fuel), hypertension (high blood pressure), major depressive disorder (a common and serious medical illness that negatively affects how a resident feel, think and act). A review of Resident 55's Minimum Data Set (MDS, an assessment and care screening tool), dated 2/23/2023, indicated…

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

Based on interview and record review the facility failed to ensure that a current copy of a resident's advance directive was in the resident's medical record for one of two sampled residents (Resident 79). This deficient practice had the potential to result in misinformation of medical care and treatment and not honoring resident's wishes in cases where the resident and/or responsible party was unable to participate in making healthcare decisions. Findings: A review of Resident 79's admission Record indicated an admission to the facility on 2/7/2023 with diagnoses that included of encephalopathy (brain disease that alters brain function or structure), end stage renal disease (medical condition in which a person's kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis (procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly) or kidney transplant to maintain life), and dependence on renal dialysis. A review of Resident 79's History and Physical dated 2/7/2023 indicated the resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow professional standards of quality (means that care and services are provided according to accepted standards of clinical practice) during medical equipment sharing in between residents, by failing to clean and disinfect the sphygmomanometer (BP-equipment used to measure blood pressure) cuff and glucometer (an instrument for measuring the concentration of glucose in the blood) before and after each resident's use for four of seven sampled residents (Resident 81, 79, 57, and 192). This deficient practice had the potential to put residents at higher risk of health-care associated infections, where blood glucose monitoring equipment is shared and exposure to other infectious diseases during contaminated BP equipment sharing. Findings: 1. A review of Resident 81's admission Record indicated that Resident 81 was admitted to the facility on [DATE], with diagnoses including diabetes mellitus (a chronic condition that affects the way 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 prepare one of 18 sampled residents (Resident 77) for a colonoscopy procedure (examination of the inside of the colon using a colonoscope, inserted into the rectum) as indicated on the physician order. This deficient practice resulted to a rescheduled appointment to a later date, which could potentially cause a negative outcome and a delay in treatment. Findings: A review of Resident 77's admission Record indicated Resident 77 was admitted on [DATE] with diagnosis of malignant neoplasm (cancerous tumor) of the large intestine. A review of Resident 77's Minimum Data Set (MDS, a resident assessment and care screening tool), dated 1/16/2023, indicated Resident 77 had an intact cognitive (mental action or process of acquiring knowledge and understanding) status and required extensive assistance (resident involved in activity, staff provide weight-bearing support) with activities of daily living. A review of Resident 77'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 that residents receive proper treatment and assistive devices to maintain vision abilities that included arranging and making appointments to see an eye specialist since 2/15/2023 for one of two sampled residents (Resident 63). This deficient practice had the potential to result in further decline of Resident 63's vision. Findings: A review of Resident 63's admission Record indicated the resident was admitted to the facility on [DATE], discharged on 1/31/2023 and readmitted back to the facility on 2/3/2023 with diagnoses that included congestive heart failure (a type of heart failure in which the heart is unable to maintain adequate circulation of blood in the tissues of the body), diabetes (inadequate control of blood sugar levels), and dysphagia (swallowing difficulties). A review of Resident 63's History and Physical indicated the resident had the capacity to understand and make decisions. A review of the Minimum Data Set (MDS,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to identify, implement, monitor, and modify interventions, consistent with the resident's assessed needs, choices, and preferences to maintain acceptable parameters of nutritional status for one of one sampled resident (Resident 63), who was assessed at risk for fluctuation in weights and malnutrition (the condition that develops when the body is deprived of vitamins, minerals and other nutrients it needs to maintain healthy tissues and organ function). This deficient practice had the potential to result in further significant weight loss, which can affect resident's well-being. Findings: During a concurrent observation and interview with Resident 63 in his room, on 4/10/2023 at 11:21 AM, Resident 63 stated I have lost many pounds here, I think it is because of my teeth, I am old some of my teeth are missing and the ones I have are rounded, I need dentures. Resident 63 stated the facility does not follow his meal preferences. Resident 63…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 provide pharmaceutical services to prevent consequences of medication-related adverse events for one of seven sampled residents (Resident 7) by failing to dilute GlycoLax Powder (a medication used to treat occasional constipation [difficulty emptying the bowels]) in six (6) to eight (8) ounces of water per physician's order. This deficient practice had the potential to result in ineffectively managed constipation and decrease the efficacy of the medication. Findings: A review of Resident 7's admission Record indicated that resident was originally admitted on [DATE] with diagnoses including other sequelae of cerebral infarction (residual effects from interruption of blood flow to the brain), chronic obstructive pulmonary disease (COPD, a lung disease characterized by long term poor airflow), and shortness of breath. A record review of Resident 7's Care Plan, initiated on 3/24/2023, indicated Resident 7 was at risk for constipation due 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 the safe drug storage by leaving a medication unattended on top of the medication cart for one of seven sampled residents (Resident 192) as indicated on the facility policy and procedure. This deficient practice had the potential to result in other residents having access to medications causing adverse consequences or possible hospitalization if ingested. Findings: A review of Resident 192's admission Record indicated that resident was originally admitted on [DATE] with diagnoses including hemiplegia and hemiparesis (mild to complete loss of strength), dysphasia (difficulty or discomfort in swallowing), and arteriovenous malformation (when arteries and veins are not formed correctly in an area of the body). A review of Resident 192's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 1/20/2023, indicated the resident had moderately impaired cognition (thought process and ability to reason or make…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to promptly provide dental services fort two of two sampled residents (Resident 63, and 56). This deficient practice had the potential to result in the inability to effectively chew foods and lead into weight loss for Resident 56 and 63. Findings: A review of admission Record indicated Resident 56 was initially admitted on [DATE] and readmitted on [DATE] with a diagnosis that included chronic obstructive pulmonary disease (COPD, a disease that damage the lungs in ways that make it hard to breath), dysphagia (difficulty swallowing), and spinal stenosis (when the spaces in the spine narrow and create pressure on the spinal cord and nerve roots). A review of Resident 56's History and Physical examination dated 8/6/2022 indicated Resident 56 has the capacity to understand and make decisions. A review of the Minimum Data Set (MDS, a comprehensive assessment and care screening tool) dated 2/14/2023 indicated Resident 56 requires extensive…

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

Based on observation, interview and record review, the facility failed to follow proper sanitation practices for 84 out of the 88 residents in the facility by failing to store the red sanitizing bucket (a designated container, for holding sanitizing solution used for cleaning equipment surfaces) away from clean, air-drying dishes, utensils, pots, pans, and equipment. This deficient practice has the potential to expose residents to pathogens (bacteria, viruses, or other germs which may cause disease), increasing the risk for developing foodborne illness (food poisoning); symptoms including upset stomach, stomach cramps, nausea, vomiting, diarrhea, and fever and can lead to other serious medical complications and hospitalization. Findings: On 4/10/2023 at 1:30 PM during an interview and concurrent observation with the Dietary Supervisor (DS), clean, air-drying dishes and utensils were observed on the drying rack, next to a red sanitizer bucked containing disinfecting agent. DS stated that the red bucket with disinfecting agent should not be stored next to clean dishes and instead…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure two of two sampled residents (Resident 171 and 173) receive the treatment and care as indicated on the care plan and facility policy. a. Resident 171 did not have a documented evidence of physician notification for reevaluation of multiple use of Norco (opioid) ordered as needed (PRN). Resident 171 received PRN Norco once to two times a day since 1/12/2020. b. Resident 173 did not have a documented evidence of physician notification for reevaluation of multiple use of Norco. Resident 173 received PRN Norco once to three times a day since 1/3/20. Resident 173 did not receive pain medication (Acetaminophen) as ordered on 1/7/2020. These deficient practices had the potential to result in unmanaged pain that can affect the resident's quality of life. Findings: a. A review of the Face Sheet indicated Resident 171 was admitted to the facility on [DATE]. Resident 171's diagnoses included displaced fracture of the femur (break in the thigh…

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

Based on interview and record review, the facility failed to ensure discontinued non-narcotic medications were disposed in accordance with the facility's policy and procedures. There were multiple non-narcotic medications on multiple occasions, disposed without two licensed staff verifying the destruction of the medications, without the quantity of medication to be disposed and without a date. This deficient practice had the potential to result in medication diversion/loss. Findings: On 1/24/20 at 7:51 a.m., during a medication room inspection with Registered Nurse 1 (RN 1), the facility's Medication Return Record Log was reviewed and the following were observed: a) On 1/10/20, ten medications were disposed. The box to indicate the quantity of two medications (Hydralazine 10 milligrams and Atenolol 25 milligrams) were blank. b) There were 10 undated pages of Medication Return Record log (with 40 different medications disposed) without two licensed staff signatures. On 1/24/20 at 8:01 a.m., the above findings were confirmed by the facility's Director of Nursing (DON). According 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 infection control practices were maintained for one of 19 sampled residents (Resident 40) and during an inspection of the laundry room. a. For Resident 40, a gown and used linens were observed placed in the resident's wheelchair and bathroom sink. b. Clean linens in closed and opened bags were stored on the shelves in the laundry room next to the washer. These deficient practices had the potential to result in cross contamination and spread of infection. Findings: a. A review of Resident 40's admission Record (Facesheet) indicated the resident was readmitted on [DATE] with diagnoses that included pneumonia (infection that inflames air sacs in one or both lungs, which may fill with fluid), unspecified fracture of femur (breaks or ruptures in bone situated between the hip and the knee), and muscle weakness. A review of Resident 40's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 11/19/19, indicated the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of 19 sampled residents (Resident 40), wore a diaper while in bed and was not naked per her preference. This deficient practice did not maintain the resident's dignity and did not respect her preference. Findings: A review of Resident 40's admission Record (Facesheet) indicated the resident was readmitted to the facility on [DATE] with diagnoses that included pneumonia (inflammatory condition of the lung), unspecified fracture of femur (breaks or rupture in the bone situated between the hip and the knee), and muscle weakness. A review of Resident 40's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 11/19/19, indicated the resident had severely impaired cognitive skills (a mental action of acquiring knowledge and understanding). Resident 40 was always incontinent of bowel and bladder and she required extensive assistance with activities of daily living (ADL's). During an observation on 1/23/20, at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to: a. Ensure Advance Directive (a written statement of a person's wishes regarding medical treatment to ensure those wishes are carried out should the person be unable to communicate them ) education or information was provided and documented on the facility's Advance Directive Acknowledgement Form for Resident 59. b. Ensure Resident 60 had a Physician Orders for Life Sustaining Treatment (POLST) in the clinical record. These deficient practices had the potential for the residents' treatment wishes not to be carried out in the event the residents were unable to communicate or during an emergency. Findings: a. A review of Resident 59's admission Record (Facesheet) indicated the resident was readmitted to the facility on [DATE] with diagnoses that included personal history of urinary tract infections (an infection in any part of the urinary system), sepsis (a life-threatening complication of an infection), and contracture (limited movement of a joint) of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not have a documented evidence that a baseline care plan summary was provided to the resident or representative for two of 19 sampled residents (Resident 171 and 172). This failure had the potential for the residents or representatives to be unaware and not be able to participate in the plan of care to address specific residents' needs. Findings: a. A review of the Face Sheet indicated Resident 171 was admitted to the facility on [DATE]. Resident 171's diagnoses included displaced fracture of the femur (break in the thigh bone), aftercare following joint replacement (damaged or diseased parts of a joint replaced with new, man-made parts), osteoporosis (progressive bone disease that weakens bones and makes them susceptible to bone fractures), hypertensive heart disease (heart conditions caused by high blood pressure), and depression (mood disorder that causes a persistent feeling of sadness and loss of interest). A review of the Minimum Data Set (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 develop a comprehensive person-centered care plan for two of 19 sampled residents (Resident 34 and 121). a. Resident 34 did not have a care plan to address hearing limitations as indicated on the Minimum Data Set (MDS, standardized assessment and care screening tool). b. Resident 121 did not have a care plan to address behavior of pulling nasal cannula. This failure had the potential for the resident not to receive interventions to address resident's specific needs, which could affect quality of life. Findings: a. A review of the Face Sheet indicated Resident 34 was admitted to the facility on [DATE]. Resident 34's diagnoses included humerus fracture (break in the long bone of the arm or forelimb that runs from the shoulder to the elbow), hypertensive heart disease (heart conditions caused by high blood pressure), and hearing loss. A review of the Minimum Data Set (standardized assessment and care screening tool), dated 11/20/19 indicated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to revise the care plan to include specific current interventions to address constipation (acute or chronic condition in which bowel movements occur less often than usual or consist of hard, dry stools that are painful or difficult to pass) for one of 19 sampled residents (Resident 172), as indicated on the facility policy. This deficient practice had the potential for Resident 172 not to receive specific interventions to address constipation, which can result to complications and affect Resident 172's well-being. Findings: A review of the Face Sheet indicated Resident 172 was admitted to the facility on [DATE]. Resident 172's diagnoses included chronic obstructive pulmonary disease (COPD, lung disease marked by permanent damage to tissues in the lungs which makes breathing difficult), diabetes mellitus (DM, persistently high levels of sugar in the blood), and generalized muscle weakness. A review of Resident 172's Resident admission Assessment, 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 provide treatment and services to prevent the development of a pressure ulcer (localized injury to the skin and or underlying tissue usually over a bony prominence as a result of pressure or pressure in combination with shear and/or friction) for two of six sampled residents (Resident 121 and 172). a. Resident 172, who was assessed as at risk for pressure ulcer was observed in bed with bilateral heels not offloaded (to suspend or take off pressure from the heels), as indicated on the care plan. This deficient practice had the potential to result in the deterioration of Resident 172's Stage 1 pressure ulcer (intact skin with a localized area of non-blanchable erythema, which may appear differently in darkly pigmented skin) on bilateral heels. b. For Resident 121, the facility's staff failed to implement the manufacturer's recommendations for the use of the low air loss mattress (LAL, special mattress that uses an air pump to reduce…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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, facility failed to make the necessary podiatrist (physician whose education and training was to diagnose and treat conditions affecting the foot, ankle, and related structures of the leg) appointment for toe nail care and treatment for one of 19 sampled residents (Resident 62), as indicated on the facility policy. This deficient practice had the potential to result in discomfort and decline in the resident's functional mobility. Findings: A review of the Face Sheet indicated Resident 62 was admitted on [DATE]. Resident 62's diagnoses included Stage 3 chronic kidney disease (slow loss of kidney function to remove wastes and excess water from the body) and generalized muscle weakness. A review of the Minimum Data Set (MDS, standardized assessment and care planning tool), dated 12/18/19, indicated Resident 62's brief interview of mental status (BIMS, screening that aids in detecting cognitive [mental action or process of acquiring knowledge and understanding]…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the resident's environment remained free of accident hazards for two of six sampled residents (Resident 171 and 172). a. Resident 171, assessed as high risk for fall, was observed with only one floor mat instead of two, as indicated on the physician's order. This deficient practice had the potential to result in injury and harm to the residents in the event of a fall. b. Resident 172, assessed as high risk for fall, was observed not on a low bed as indicated on the care plan. This deficient practice had the potential to result in injury and harm to the residents in the event of a fall. One tiger balm ointment (pain reliever that contains ingredients such as camphor, menthol, and clove oil and is applied superficially to the area of pain and absorbed through the skin) and one bag of cough drops were observed unsecured on top of Resident 172's bedside table. This deficient practice had the potential for other residents to have access…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to complete a bowel and bladder (B&B) reassessment after completion of the toilet schedule program and discontinuance of urinary indwelling catheter (tube inserted into the bladder to drain urine to a collection bag) for one of 19 sampled residents (Resident 34), as indicated on the facility policy. This deficient practice had the potential for the resident not to receive interventions to restore or maintain continence to the extent possible. Findings: A review of the Face Sheet indicated Resident 34 was admitted to the facility on [DATE]. Resident 34's diagnoses included humerus fracture (break in the long bone of the arm or forelimb that runs from the shoulder to the elbow), hypertensive heart disease (heart conditions caused by high blood pressure), and overactive bladder (condition where there is a frequent feeling of needing to urinate to a degree that it negatively affects a person's life). A review of the Minimum Data Set (standardized assessment…

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

Based on observation, interview, and record review, the facility failed to ensure one of one sampled residents (Resident 121) received oxygen (O2, a colorless, odorless reactive gas) as prescribed by the physician. This deficient practice had the potential to cause respiratory complication to Resident 121 due to lack of oxygen. Findings: A review of Resident 121's admission Record indicated the facility admitted the resident on 1/03/20 with diagnoses that included unstageable pressure ulcer (bedsore whose severity cannot be determined with a visual exam) to the sacral region and heart disease. A review of Resident 121's Minimum Data Set (MD, a resident assessment and care-screening tool), dated 1/10/20 indicated the resident had impairment in cognitive skills for daily decision making and required extensive assistance (resident involved in activity, staff provide weight-bearing support) for bed mobility, transfer and personal hygiene. A review of Resident 121's Physician's Order, dated 1/20/20, indicated for staff to administer continuous O2 at 2 liters per minute (L/min) and may…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure two of five sampled residents (Residents 59 and 121), who were on psychotropic medication (medications that affect brain activities associated with mental processes and behaviors) had specific indication and continuous monitoring for the side effects of the medication. a. For Resident 121, the resident did not have a specific indication for the use of Lorazepam (antianxiety medication) as needed (PRN). b. For Resident 59, the nursing staff failed to monitor the side effects of Remeron (antidepressant medication) per physician's orders. These deficient practices had the potential to place Residents 121 at risk for receiving unnecessary psychotropic medications, and placed Resident 59 at risk to experience adverse effects from the use of antidepressant without appropriate interventions. Findings: a. A review of Resident 121's admission Record indicated the facility admitted the resident on 1/3/20 with diagnoses that included…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 therapeutic diet (a meal plan that controls the intake of certain foods or nutrients as part of the treatment, includes diet in which the texture of a diet is altered or modified) was served per physician's order for one of two sampled residents (Resident 58). Resident 58, who was on nectar-thick liquids (liquids with nectar like consistency), received milk that was not thickened as nectar like consistency. This deficient practice had the potential to result in aspiration (liquids entering airway and into lungs), coughing, shortness of breath and pneumonia (lung infection). Findings: A review of Resident 58's admission record indicated the resident was admitted to the facility on [DATE] and readmitted on [DATE]. Resident 58's diagnoses included dysphagia, oropharyngeal phase encompasses problems with the oral preparatory phase of swallowing (chewing and preparing the food) and hemiplegia (paralysis of one side of the body). 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.