The Californian Pasadena Healthcare

Based on observation, interview, and record review, the facility failed to ensure medications were administered and supervised as ordered when Licensed Vocational Nurse 3 (LVN 3) left medications on the bedside table for one (1) of 23 sampled residents (Resident 2). This failure had the potential to result in diversion (medications being misused, stolen, or not given to the right person as prescribed) or accidental ingestion of the medications by other residents that could lead to adverse outcomes and compromise the residents' health and safety.Findings: During a review of Resident 22's admission Record by, the admission Record indicated the facility admitted Resident 22 on 1/30/2026 with diagnoses that included but not limited to chronic obstructive pulmonary disease (lung disease causing restricted airflow and breathing problems), presence of prosthetic heart valve (a man-made or tissue valve that helps the heart pump blood the right way when the original valve no longer works), and rheumatoid arthritis (a long-term disease where the body's immune system attacks the joints,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure an accurate Medication Regimen Review (MRR, review is a thorough, systematic evaluation of a patient's entire medication list) for one (1) of 23 sampled residents (Resident 38) by failing to reflect the correct diagnosis for the resident's use of valproic acid (a prescription medication used primarily to prevent and treat seizure [a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness] and a mood stabilizer) on the December 2025 and January 2026 MRR reports, which were in the resident's medical records. This deficient practice had the potential for the facility's pharmacy consultant (PC, perform medication regimen reviews based on a patient's health history to evaluate the appropriateness, safety, benefits, risks, and cost-effectiveness of medication therapy), to fail to identify irregularities (refers to use of medication that is inconsistent with accepted…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 pancake style call light (soft touch call light - a specialized patient-assistance button designed for individuals with limited mobility, poor dexterity, or weak grip strength and only requires minimal, gentle pressure to activate) for one (1) of three (3) sampled residents (Resident 44) reviewed for environment was functioning properly.This failure had the potential to put Resident 44 at risk for experiencing a delay in receiving assistance from facility staff which could lead to a fall or accident.During a review of Resident 44's admission Record, the admission Record indicated the resident was initially admitted to the facility on [DATE] with diagnoses of hemiplegia (severe or complete paralysis affecting one vertical side of the body, often including the arm, leg and face) and hemiparesis (partial weakness or reduced motor function affecting one entire side of the body) following cerebral infarction (stroke - the death of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop a baseline care plan within 48 hours of admission for one of three sampled residents (Resident 1), who was admitted with a peripherally inserted central catheter (PICC line - a long flexible catheter inserted through a vein in the upper arm). This deficient practice resulted in Resident 1 not receiving appropriate care, monitoring and assessment specific to her PICC line. Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including obstructive hydrocephalus (when excess fluid builds up in the brain, normal pathways that drain the fluid are blocked, often by a tumor, infection), type 2 diabetes mellitus without complications (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing), and malignant neoplasm of the brain (a dangerous growth of cancerous cells in the brain that invades and destroys health tissue).…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 peripherally inserted central catheter (PICC line- a long flexible catheter that is inserted through a vein in the upper arm) care and dressing was provided in accordance with professional standards of practice for one of three sampled residents (Resident 1). Resident 1's PICC line was not changed every seven days as indicated in the facility's policy. This deficient practice had the potential to result in Resident 1 developing an infection on the PICC line insertion site. Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including obstructive hydrocephalus (when excess fluid builds up in the brain, normal pathways that drain the fluid are blocked, often by a tumor, infection), type 2 diabetes mellitus without complications (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing), and malignant neoplasm…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY S483.25(d) Accidents. The facility must ensure that - S483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and S483.25(d)(2) Each resident receives adequate supervision and assistance devices to prevent accidents. Based on interview and record review, the facility failed to provide adequate supervision for one of four sampled residents (Resident 1) who was assessed as high risk for falls by failing to develop a comprehensive resident-centered care plan (a care plan developed and implemented to meet his or her preferences and goals, and addressed the resident's medical, physical, mental, and psychosocial needs) after Resident 1's fall on 8/10/2025. This deficient practice resulted in Resident 1's repeated fall on 8/12/2025 at 6:19 PM. Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was initially admitted on [DATE] and was readmitted on [DATE] with diagnoses that included non-traumatic intracerebral hemorrhage (the bleeding…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 2 sampled residents (Residents 222 and 11) were treated with respect and dignity in accordance with the facility policy by failing to ensure: 1. Resident 222 had a dignity bag (urine drainage bag holder to prevent public view) over the resident's indwelling catheter (a hollow tube inserted into the bladder to drain or collect urine). 2.Resident 11 did not have any food crumbs (small pieces of food that have broken off from a larger piece) on the resident's shirt on 12/16/2024. These deficient practices have the potential to negatively affect Residents 222 and 11's self-worth, self-esteem, and psychosocial well-being. Findings: 1. During a review of Resident 222's admission Record, the admission Record indicated Resident 222 was admitted to the facility on [DATE] with diagnosis of pneumonia (an infection that affects one or both lungs and causes them to fill up with fluid or pus), chronic obstructive pulmonary disease…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure two of two residents (Resident 70 and Resident 71) reviewed for closed records had a discharge care plan. This failure had the potential to result in Resident 70 and Resident 71 increasing their risk of preventable readmissions due to not focusing on their discharge plan and goals, not actively preparing and effectively transitioning to post discharge care. Findings: 1. During a review of Resident 70's admission Record, the admission Record indicated that the facility admitted Resident 70 on 8/22/2024 with diagnoses including type 2 diabetes mellitus (a disorder characterized by difficulty in blood sugar control), muscle weakness, abnormalities of gait and mobility, depression, hypertensive (high blood pressure) heart disease, atrial fibrillation (an irregular and often very rapid heart rhythm), congestive heart failure (a heart disorder causes the heart to not pump the blood efficiently), dysphagia (difficulty swallowing), and cognitive…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure two of two sampled residents (Resident 122 and Resident 22) on hemodialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidneys have failed) treatment received communication records from the hemodialysis center when the residents returned to the facility. This failure had the potential to result in Resident 122 and Resident 22's health status not being communicated in a timely manner and not receiving appropriate post dialysis care. Findings: 1. During a review of Resident 122's admission Record, the admission Record indicated the facility admitted Resident 122 on 12/3/2024 with diagnoses including chronic kidney disease (a progressive damage and loss of function in the kidneys), hyperkalemia (high potassium levels in blood), thrombocytopenia (low platelet count in blood), hypo-osmolality (levels of electrolytes, proteins, and nutrients in the blood are lower than normal), hyponatremia…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 dry food items that had been removed from their original packaging were labeled with use by date, and refrigerated foods that had expired were discarded. This deficient practice resulted in exposing residents to expired food items, affecting the quality, taste, and texture of food, and potentially harming residents if they consumed expired food. Findings: During a concurrent observation in the facility's kitchen and interview on 12/16/2024 at 8:16 AM with the Dietary Supervisor (DS), the DS picked up a package of assorted sugar free beverage crystals and stated the package was not labeled with a use by date to indicate when the product expired/ will expire. The DS added, It was no longer good for human consumption. The DS stated the package had been taken out of its original packaging and should have been labeled with use by date by the person who removed it from the original package. The DS stated it was important to label the food with use by date to ensure it was safe for human consumption and…

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

Based on observation, interview, and record review, the facility failed to ensure garbage was disposed properly for one of two dumpsters as indicated on the facility policy. 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) that could potentially infiltrate the facility, affect the resident care areas and pose a disease threat to the residents and staff of the facility. Findings, During a concurrent observation and interview on 12/17/2024 at 1:19 PM with Infection Prevention Nurse (IPN), there were two dumpsters in a corner outside the facility by the facility parking lot. One dumpster was observed not covered and another dumpster was not covered and was overflowing with garbage. IPN stated both dumpsters needed to be covered because the garbage could harbor pests. IPN stated it could cause the spread of infection and affect staff and the residents. During an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to accommodate the needs for two of 14 sampled residents (Residents 222 and 126) by failing to ensure the resident's call light (device used by residents to call staff) was within the resident's reach. This deficient practice had the potential for delayed provision of care to Residents 222 and 126, which could negatively affect the residents' overall wellbeing. Findings: 1. During a review of Resident 222's admission Record, dated 12/18/2024, the admission Record indicated Resident 222 was admitted to the facility on [DATE] with diagnosis of pneumonia (an infection that affects one or both lungs and causes them to fill up with fluid or pus), chronic obstructive pulmonary disease (COPD- lung disease causing restricted airflow and breathing problems), and neurogenic bladder (a lack of bladder control due to a brain, spinal cord, or nerve problem). During a review of Resident 222's History and Physical, dated 12/5/2024, the H&P indicated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 54), had the head of bed (HOB) elevated at minimum 30 degrees during tube feeding infusion in accordance with the facility policy. This deficient practice had the potential for Resident 54 aspirating (feeding could enter the windpipe and lungs) and result in complications such as aspiration pneumonia (an inflammation of the lungs and bronchial tubes that occurs after foreign matter was inhaled), hospitalization, and death. Findings: During a review of Resident 54's admission Record, the admission Record indicated Resident 54 was admitted on [DATE] with diagnosis of dysphagia (difficulty or discomfort in swallowing) and a gastrostomy tube (G-tube, tube inserted through the belly that brings nutrition directly to the stomach). During a review of Resident 54's History and Physical (H&P, a term used to describe a physician's examination of a resident), dated 11/8/2024, the H&P indicated Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of 14 sampled residents (Resident 34), received Apixaban (medication to prevent blood clots) as indicated on the physician's order. This deficient practice had the potential to cause Resident 34 serious problems such as heart attack (a condition when blood flow to the heart muscle is suddenly blocked), deep vein thrombosis (DVT- a condition where a blood clot forms in a deep vein, usually in the legs, leading to serious complications), pulmonary embolism (a condition where a blood clot travels to and blocks an artery in the lungs), and stroke. Findings: During a review of Resident 34's admission Record, the admission Record indicated Resident 34 was admitted to the facility on [DATE] with diagnosis of atrial fibrillation (A-fib, an abnormal heart rhythm characterized by rapid and irregular beating) and history of myocardial infarction (MI-a condition when blood flow to the heart muscle is suddenly blocked). During a review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure the physician addressed the medication regimen review (MRR/Drug Regimen Review - a thorough evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medication) on 6/10/2024 to consider a gradual dose reduction (GDR - a periodic attempt to manage a resident's behavioral issues with a lower dose of medication) related to the use of Seroquel (a medication used to treat psychosis) or document a clinical rationale as to why an attempt would be contraindicated for one of five sampled residents (Resident 52). The deficient practice increased the risk for Resident 52 to experience adverse effects (unwanted, uncomfortable, or dangerous effects that a drug may have) related to Seroquel therapy possibly leading to impairment or decline in the resident's mental, physical, and /or psychosocial status. Findings: During a review of Resident 52'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 interview and record review, the facility failed to perform a gradual dose reduction (GDR - a periodic attempt to manage a resident's behavioral issues with a lower dose of medication) related to the use of Seroquel (a medication used to treat psychosis) or document a clinical rationale as to why an attempt would be contraindicated for one of five sampled residents (Resident 52.) The deficient practice increased the risk for Resident 52 to experience adverse effects (unwanted, uncomfortable, or dangerous effects that a drug may have) related to Seroquel therapy possibly leading to impairment or decline in the resident's mental, physical, and /or psychosocial status. Findings: During a review of Resident 52's admission Record (a document containing diagnostic and demographic information), dated 12/18/0224, the admission Record indicated Resident 52 was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease (a progressive disease that destroys memory and other important 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 ensure standard infection prevention control practices (a set of practices that prevent or stop the spread of infections and /or diseases in the healthcare setting) were followed in accordance with the facility's policy and procedure for two of 14 sampled residents (Residents 126 and 273) in accordance with the facility policy by failing to ensure: 1. Resident 126's used urinal with urine was not placed next to the uncovered cup of water and a cup of oatmeal on the resident's bedside table. 2. Resident 273's urinary catheter (a hollow tube inserted into the bladder to drain or collect urine) drainage bag was not touching the floor. This deficient practice placed the Resident 126 at risk for potential infection. Findings: 1. During a review of Resident 126's admission Record, the admission Record indicated Resident 126 was admitted to the facility on [DATE] with diagnoses including hyperlipidemia (a condition in which there are high levels…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 their policy and procedure for norovirus (also often called food poisoning. It is the most common cause of diarrhea [watery stool] and vomiting [throwing up]) prevention and control for three of three sampled residents (Resident 1, 2 and 3) when facility did not cohort (a group of people with a shared characteristic) their staff assignment after they received a positive norovirus result for Resident 1 on 10/27/2024. This deficient practice placed all the other residents in the facility, facility staff and visitors at risk for contacting (exposure to contagious disease) norovirus. Findings: 1. During a review of Resident 1's admission Record, indicated Resident 1 was originally admitted to the facility on [DATE] with diagnoses that included gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for residents with swallowing problems), sepsis (a life-threatening…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one (1) of four (4) sampled residents (Resident 1) was not left unattended by facility staff while the resident is sitting on the bedside commode (a portable toilet) for long period of time. This deficient practice had a potential to result in skin breakdown and accidents that can lead to injury. Findings: During a review of the admission record indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included but not limited to acquired deformities of left lower leg (any abnormality in the normal alignment of the leg occurring either within the bone or at the level of a joint), enterocolitis due to clostridium difficile (an inflammation of the colon caused by an overgrowth of the C. diff bacterium [a type of bacteria that can cause diarrhea and colitis, an inflammation of the colon]), abnormality of gait and mobility, severe protein-calorie malnutrition (a nutritional condition that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement its abuse policy and procedure for one of three (3) sampled residents (Resident 1) by failing to thoroughly investigate an allegation of sexual abuse (non-consensual sexual contact of any type with a resident. This deficient practice had the potential to place Resident 1 at risk for elder abuse. Findings: A review of Resident 1's admission Record indicated resident was admitted on [DATE] with the diagnoses of dementia (long term and often gradual decrease in the ability to think and remember severe enough to affect a person's daily functioning) and aphasia (a language disorder that affects how a resident communicates). A review of Resident 1's History and Physical, dated 6/20/2024, indicated resident has the capacity to understand and make decisions. A review of Resident 1's Minimum Data Set (MDS, a standardized care screening and assessment tool), dated 6/26/2024, indicated resident was moderately impaired with cognitive ((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 ensure infection prevention control practices (a set of practices that prevent or stop the spread of infections and or diseases in the healthcare settings) were followed in accordance with the facility ' s policy and procedure by failing to ensure the Certified Nursing Assistant 3 (CNA 3) wore an isolation gown while passing water pitcher inside a residents room with a resident (Resident 2) who was positive for Coronavirus-19 (Covid-19, an acute respiratory illness in humans caused by a coronavirus, capable of producing severe symptoms and in some cases death, especially in older people and those with underlying health conditions). This deficient practice had a potential to spread infection to all residents, staff, and visitors in the facility. Findings: A review of Resident 2's admission Record indicated the resident was admitted to the facility on [DATE] with a diagnosis that included Klebsiella Pneumoniae (a type of bacteria that can…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 to administer medication in a safe and timely manner for two of two sampled residents (Resident 1 and 2) by ensuring: 1a. Resident 1 did not receive Tobramycin-Dexamethasone ophthalmic suspension (used to treat bacterial eye infections) 30 days after the open date as indicated in their policy. 1b. Resident 1 received Timolol Maleate (a medication used to treat glaucoma [eye disease that can cause vision loss and blindness by damaging a nerve in the back of the eye]) in accordance with the physician ' s order. 2. To administer Tylenol (a medication used to treat pain) according to pain parameters as ordered by the physician for Resident 2. These failures had the potential to result in worsening of Resident 1's glaucoma, had the potential to negatively impact Resident 1 ' s health and well-being, and ineffective management of pain for Resident 2. Findings: 1a. During a review of Resident 1 ' s admission Record (Face Sheet) dated…

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

Based on observation, interview, and record review the facility failed to follow infection prevention procedure during medication administration for one of two sampled residents (Resident 1) by failing to ensure Licensed Vocation Nurse (LVN) 1 washed hands before administering Resident 1's oral medication, washed hands before wearing gloves and administering ophthalmic (pertaining to eye) medications as indicated in the facility policy. This failure had the potential to transmit infectious microorganisms and increase the risk of infection for Resident 1. Findings: During a review of Resident 1 ' s admission Record (Face Sheet) dated 5/20/2024, the Face Sheet indicated the facility admitted Resident 1 on 01/17/2019 with diagnoses which include history of falling, difficulty in walking, muscle weakness, hypertension (elevated blood pressure), glaucoma (eye disease that can cause vision loss and blindness by damaging a nerve in the back of the eye), hyperlipidemia (increased levels of lipids or fat in their blood), and benign prostatic hyperplasia (a noncancerous enlargement 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.

Based on observation, interview, and record review, the facility failed to ensure the call light device (one of the major communication technologies that link nursing home staff to the needs of residents) was answered for one (1) of four 4 sampled residents (Resident 1). On 5/7/24, Resident 1's call light was on, and it was not answered by Licensed Vocational Nurse (LVN) 1 who was standing across the resident's room, Certified Nurse Assistant (CNA) 2 and Registered Nurse (RN) 1 who passed by the room. This had the potential to result in a delay in care for Resident 1 not to receive the necessary care and services which can lead to illness or serious injury. Findings: A review of Resident 1's admission record indicated the facility admitted Resident 1 on 4/29/24 with diagnosis which include difficulty in walking, muscle weakness, hypertension (when the pressure in your blood vessels is too high). During a review of Resident 1's care plan date initiated 4/29/24 indicated Resident 1's at risk for fall. Care plan goal indicated Resident 1 will consistently use call light for assistance.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 ensure the safety and prevent fall (unintentionally coming to rest on the ground, floor, or other lower level, but not as a result of an overwhelming external force) of two (2) of three (3) high fall risk sampled residents (Resident 2 and 3) by: 1. The facility failed to update care plan interventions and to reassess Resident 2's fall risk assessment after the resident's fall on 4/25/2024. 2. The facility failed to update Resident 3's care plan after resident had a fall on 4/9/2024. This deficient practice resulted to Resident 2 had another fall on 5/4/2024 and was sent to General Acute Care Hospital (GACH 1) and placed Resident 3 at risk for another fall incident. Findings: 1. A review of Resident 2's admission record indicated the facility admitted Resident 2 on 4/22/24 with diagnosis which include muscle weakness, difficulty in walking, traumatic subarachnoid hemorrhage (traumatic head injury, resulting in bleeding) A review of Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility's licensed nursing staff failed to provide care in accordance with facility's policy and procedures (P&P) titled, Psychotropic Medication (drugs that affect the person's mental state) Use, and Dementia (a general term for the impaired ability to remember, think, or make decisions that interferes with doing everyday activities) - Clinical Protocol, to ensure three of five sampled residents (Residents 10, 13 and 291) for unnecessary medication care area. Residents prescribed with psychotropic medications included clear, clinical indications for use or continued use to treat a specific condition. The deficient practices had the potential for adverse effect (unwanted, unintended result) on resident's psychosocial wellbeing, risk for falls, constipation, confusion, excessive sedation, and increased agitation, and receiving more medication than needed for three out of five sampled residents (Resident 10, 13, 291). Cross reference with F758. Findings: 1. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record reviews, the facility failed to provide services and treatment to prevent urinary tract infection (UTI, clinically detectable condition associated with invasion by disease causing microorganisms of some part of the urinary tract, including the urethra, bladder, ureters, and/or kidney) for two of four sampled residents (Resident 290 and 13) who have indwelling catheter (tube that drains urine from the bladder into a bag) by failing to: 1. Monitor and document signs and symptoms of UTI for Resident 290 on 1/30/2024. 2. Change Resident 13's indwelling catheter on 1/23/2024 as ordered by the physician. Theses deficient practices resulted in Resident 290 developing cloudy urine, worsening gross hematuria (blood in urine that can be seen with naked eye) and possible UTI. In addition, it may result to Resident 13 developing UTI. Findings: 1. A review of Resident 290's Face Sheet indicated the resident was admitted to the facility on [DATE], with diagnoses that included gross…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 oxygen therapy (treatment that provides supplemental, or extra oxygen) and necessary respiratory care services for two (2) of 2 sampled residents (Resident 289 and 243) for oxygen care area in accordance with the facility's policy and procedure when: 1. Resident 289 did not receive three (3) liters of oxygen continuously per physician's order. 2. Resident 243's nasal cannula (a device that delivers extra oxygen through a tube and into your nose) was not properly placed on the resident's nostrils (two openings in the nose through which air moves when you breathe). These deficient practices had the potential to cause complications associated with oxygen therapy to Residents 289 and 243. Findings: 1. A review of Resident 289's admission Record indicated Resident 289 was admitted to the facility on [DATE] with diagnoses of methicillin resistant staphylococcus aureus infection Methicillin Resistant Staphylococcus Aureus Infection (MRSA…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 medications were administered in accordance with physician orders for two of six residents reviewed during medication administration pass. The facility failed to ensure: 1a. Resident 19's Metformin (a medication that treats type 2 diabetes (a long-term condition in which the body has trouble controlling blood sugar and using it for energy) was not administered over two hours after the scheduled administration time of 7:30 AM, with instructions to administer daily with breakfast. 1b. Resident 19's blood pressure (BP) was accurately assessed as a parameter ordered by the physician to determine whether to hold or administer resident's combination BP medication, Lisinopril 20 milligram (MG, unit of measure of weight) with Hydrochlorothiazide (HCTZ) 12.5 MG 2. Resident 239's ClearLax (also known as MiraLAX [polyethylene glycol 3350 powder, for solution] used to treat occasional constipation) was prepared in accordance with the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure three of five sampled residents (Residents 10, 13, 291), for unnecessary medication care area, were free from the use of unnecessary psychotropic drug (any medication capable of affecting the mind, emotions, and behavior) by failing to: 1. Identify specific, measurable target behaviors related to the use of Seroquel (antipsychotic [medications used to treat mental illness]) for Resident 10 2. Identify specific, measurable target behaviors related to the use of Abilify (antipsychotic) and Seroquel for Resident 13. 3. Identify specific, measurable target behaviors related to the use of Seroquel and Melatonin (medication to promote sleep) for Resident 291 This deficient practice had the potential to place Residents 10, 13, and 291 at risk for significant adverse consequence (unwanted, uncomfortable, or dangerous effects that a drug may have) from the use of unnecessary psychotropic drug, which could result to impairment or decline in the residents'…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow the facility's policy and procedure on storage of controlled refrigerated medication (a prescription medicine that is subject to strict legal controls) and disposal of expired supplies for one of one medication storage rooms when: 1. A bottle of liquid lorazepam (medication used to treat anxiety) was not stored inside a locked box inside the refrigerator. 2. One (1) unopened foley catheter insertion tray (a soft, thin tube used to pass urine from the body) with expiration date of [DATE] was stored in medication room [ROOM NUMBER] (MR 1). 3, 15 unopened needles (a small tube used for injecting or withdrawing liquids) with expiration date of [DATE] was stored in MR 1. 4. Two (2) unopened intravenous tubing's (Y-set, three-way connector sets made of connecting plastic tubes used for delivering intravenous drugs into the body from multiple fluid sources) for a resident who has been discharged was stored in MR 1. This deficient practice…

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

Based on observation, interview, and record review, the facility failed to follow proper food handling practices in accordance with their policy and procedure by: 1. Facility failed to label food in the kitchen with item name, date opened and expiration date, and failed to discard expired food. 2. Facility failed to ensure kitchen equipment were clean and in good condition. 3. Failed to ensure there was no blanket and personal belongings stored in the kitchen storage. 4. Failed to ensure Dietary Staff performs hand hygiene (is the act of cleaning the hands with soap or handwash and water to remove viruses/bacteria/microorganisms, dirt, grease, or other harmful and unwanted substances stuck to the hands) in between tasks. These deficient practices had the potential to result in pathogen (germ) exposure to residents, which could place the residents at risk for developing foodborne illness ([food poisoning] with symptoms including upset stomach, stomach cramps, nausea, vomiting, diarrhea, and fever) and can lead to other serious medical complications and hospitalization. Findings: 1.…

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

Based on observation, interview, and record review, the facility failed to clean the dryer lint trap for three (3) of 3 dryers located in the laundry room as indicated in the policy. This deficient practice had the potential to cause fire in the facility. Findings: During a concurrent observation in the laundry room and interview with Laundry Staff 1 (LS 1) and Licensed Vocational Nurse 3 (LVN 3) on 2/2/2024 at 5:35 PM, 3 dryers were observed in the laundry room. Lint f ound in the lint traps in all three dryers. LS 1 stated, Lint is removed from the lint traps twice a day, and it's been logged. LVN 3 verified that lint was found in the lint traps for all three dryers. LVN 3 stated leaving the lint in the lint traps can cause fires and was unsanitary. During a concurrent interview with LS 1 and record review on 2/2/2024 at 5:45 PM, the Lint logs, from January 2023 to present for dryers 1, 2, and 3 indicated two columns for time and two columns for initial, LS 1 stated that their practice is to clean dryer 1, 2, 3 twice a day, and LS 1 added I think our policy only stated to remove…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 promote dignity and respect for one of one resident (Resident 293) for dignity care area as indicated on the facility's policy when staff changed the resident's brief when the resident stated she was dry and did not need to be changed. This deficient practice had the potential to result in Resident 293's feelings of decreased self-esteem, self-worth, and experiencing distress. Findings: A review of Resident 293's admission Record indicated Resident 293 was admitted to the facility on [DATE], with diagnoses of recurrent major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), insomnia (inability to sleep), and fracture (break in the bone) of unspecified part of neck of right femur (the long bone of the bind or lower limb extending from the hip to the knee). A review of Resident 293's History and Physical (H&P, the initial clinical…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the call light (device used by residents to call staff) was within reach for one of two residents (Resident 292) for the environment care area. The call light was observed hanging on the back of the resident's bed, out of reach (more than the arm's length) of Resident 292. This failure had the potential to result in a delay in or in inability for Resident 292 to obtain necessary care and services. Findings: A review of Resident 292's admission Record indicated Resident 292 was admitted to the facility on [DATE], with diagnoses of central cord syndrome at 7th cervical vertebra (C7 - the largest and most inferior vertebra [the flexible column of bones extending neck to tail] in the neck region) level of cervical spinal cord (result of trauma that causes damage to the vertebrae in the neck leading to the spinal cord's ability to transmit some messages to or from the brain is damages or reduced below the site of injury to the spinal…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 notify one (1) of two (2) sampled residents (Resident 37) upon admission and periodically during the resident's stay, of services available in the facility and of charges for those services, including any charges for services not covered under Medicare (a federal health insurance for anyone age [AGE] and older/Medicaid (a joint federal and state program that gives health coverage to some people with limited income and resources) or by the facility's per diem (a payment rate determined for each day of the residents stay) rate, in accordance with the facility policy. This deficient practice resulted in payment of billed charges to Resident 37 which amounted to $21,420 prior to being discharged from the facility. Findings: A review of Resident 37's admission Record indicated the resident was admitted to the facility on [DATE] with a diagnosis of multiple sclerosis (the immune system attacks the protective sheath that covers nerve fibers and cause…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 baseline care plan within 48 hours of resident's admission for use of indwelling catheter (tube that drains urine from the bladder into a bag) for one of one sampled resident (Resident 13). This failure had the potential to result in Resident 13 not being provided with an effective and resident centered care which could result in urinary tract (urinary system) infection (UTI, condition in which bacteria invade and grow in any part the urinary system which includes the kidneys, bladder ureters [tube that carries urine from the kidney to the urinary bladder], and urethra [canal from the bladder]). Findings: During a review of Resident 13's admission record, the admission Record, indicated Resident 13 was admitted on [DATE] with diagnosis of Extended Spectrum Beta-Lactamase (ESBL) (bacteria in the urine), and urine retention (inability to urinate) with an indwelling catheter in place. During a review of Resident 13's Minimum Data…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive resident- centered care plan for eight (8) of 19 sampled residents (Residents 10, 13, 291, 289, 290, 15, 243, and 4), as indicated on the facility policy. 1. Resident 10 did not have a care plan to include non-pharmacological interventions (approaches to care that do not involve medications, generally directed towards stabilizing and/or improving a resident's mental, physical, and psychosocial well-being) to address psychosis (a mental disorder characterized by a disconnection from reality). 2. Resident 13 did not have a care plan for the use of Abilify (medication used to treat mental illness) and use of indwelling catheter (tube that drains urine from the bladder into a bag). 3. Resident 291 did not have a care plan for the use of Melatonin (medication to regulate the body's wake-sleep cycle). 4. Resident 289 did not have a care plan for the use of oxygen therapy (a treatment that delivers oxygen…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to revise the care plan (a formal process that correctly identifies existing needs and recognizes a resident's potential needs or risks to achieve healthcare outcomes) for one of 19 sampled Residents (Resident 28) when Resident 28/ Responsible Party's (RP) request to have the resident's suprapubic catheter (medical device that drains urine from bladder) dressing change after breakfast to provide more time for resident activities was not reflected on the care plan. This deficient practice had the potential for inconsistency of care being rendered for Resident 28, which could affect resident's well being. Findings: A review of Resident 28's admission Record indicated Resident 28 was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses that included hypertension (high blood pressure), urinary retention and difficulty in walking. A review of Resident 28's Minimum Data Set (MDS, a standardized assessment 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 implement treatment for the prevention of pressure ulcer (painful wound caused as a result of pressure or friction) for three (3) of seven (7) sampled residents (Residents 289, 27, and 4) for pressure injury care area, in accordance with the facility's policy and procedure by failing to ensure: 1. The 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 for Resident 289. The facility also failed to ensure Resident 289's pressure ulcer was assessed with measurements and documented on 1/27/2024. 2. The LAL was on the correct setting for Resident 27. 3. Resident 4's pressure injuries/skin was not assessed upon admission on [DATE] and Resident 4's LAL mattress was not set according to weight. This deficient practice had the potential to place Residents 289 27, 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 label an intravenous (IV-administered into a vein) medication with the resident's name, medication name, dosage, route, and time administered and an IV tubing (plastic tubing that connects the set-up to a bag of fluid to the IV) was not labeled with date initiated, time, and initials (licensed nurse who started the IV) for one of two sampled resident (Resident 289) for antibiotic care area. This deficient practice had the potential for Resident 289 to receive an incorrect IV medication as ordered by the physician and infection control risks from using an unlabeled IV tubing. Findings: A review of Resident 289's admission Record indicated Resident 289 was admitted to the facility on [DATE] with diagnoses of methicillin resistant staphylococcus aureus infection Methicillin Resistant Staphylococcus Aureus Infection (MRSA - infections caused by specific bacteria that are resistant to commonly used antibiotics), urinary tract infection (UTI -…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to ensure one of one sampled resident (Resident 15) for pain care area, receive the treatment and care to address the resident's pain during rehabilitation exercise (aim to return full function following injury through re-building muscle strength, endurance, power and improving overall flexibility and mobility), in accordance with the facility's policy and procedure. This deficient practice had the potential to result in a delay of necessary care and treatment and unmanaged pain that could negatively affect the resident's quality of life. Findings: A review of Resident 15's admission Record indicated the resident was admitted to the facility on [DATE] and was re-admitted on [DATE]. Resident 15's diagnoses included liver cirrhosis (is permanent scarring that damages your liver and interferes with its functioning), cellulitis (a common bacterial skin infection that causes redness, swelling, and pain in the infected area of the skin) of right and left lower…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 system (the means of the initial communication between staff and residents) was functional on two out of two (2) sampled residents (Resident 10 and 292). This deficient practice had a potential in a delay in meeting the residents' needs for assistance and can lead to frustration, falls and accidents. Findings: 1. A review of Resident 10's admission Record indicated the resident was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses included subdural hematoma (a serious condition where blood collects between the skull and the surface of the brain), history of falling and hypertension (high blood pressure). A review of Resident 10's Minimum Data Set (MDS, a standardized assessment and care-screening tool), dated 10/4/2023, indicated Resident 10 has severely impaired cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision making. The MDS indicated,…

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