North Bay Post Acute

Based on observations, interviews and record reviews, the facility failed to ensure two out of two sampled residents (Residents 37 and 80's) received care to maintain grooming when fingernails were long with brownish material underneath.This failure could negatively affect the resident's sense of dignity and be an infection control concern.Findings:A review of Resident 37's face sheet (front page of the chart that contains a summary of basic information about the resident) indicated an admission date in 4/2025 with a diagnosis of Hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and muscle weakness.A review of Resident 37's Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 10/29/25, section GG Functional Abilities and Goals, indicated Resident 37 needed moderate assistance from staff for personal hygiene tasks.A review of Resident 80's face sheet indicated an admission date in 1/2019 with a diagnosis of Traumatic Brain Injury (TBI, a disruption in the normal function of the brain that can be caused by a bump, blow, 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.

Based on observations, interviews, and record review, the facility failed to ensure the bed cane (a type of bed rail that is a bar that attaches to the side of a bed, to help a person get in and out of bed) for one of 24 sampled residents (Resident 8), was in proper use when:it was installed without completed assessment of risk of entrapment;Informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered) was not obtained prior to installation; andIt was installed incorrectly.These failures increased the risk of resident injury, including falls or entrapment, which could result in serious harm or death.Findings:A review of Resident 8's admission record indicated she was last admitted to the facility in 8/2018 with the diagnosis of unspecified dementia (a progressive state of decline in mental abilities).A review of Resident 8's physician order, dated 9/21/24, indicated, Bed cane x 1as an enabler to assist with bed mobility. (non-restraint)1. A review of Resident 8's bed rail (bars attached…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 observations, interviews and record review, the facility failed to maintain accurate records of controlled medications (medications that the use and possession of are controlled by the federal government) for one out of 92 residents of the facility (Resident 24), when a dose of Resident 24's Oxycodone Hydrochloride (Oxycodone, a controlled medication that treats pain) was not documented as administered in the Medication Administration Record (MAR a daily documentation record used by a licensed nurse to document medications and treatments given to a resident).This failure had the potential for a medication error to occur, which could cause Resident 24 to experience increased sedation (increased sleepiness), respiratory depression (condition where breathing becomes dangerously slow and shallow) and/or hospitalization. Findings:A review of Resident 24's Order Summary Report, an order dated 11/7/25, indicated Oxycodone 5 milligrams (mg, a unit of measure) to be given one tablet by mouth every six hours as needed (PRN) for severe pain (pain level 7-10 on a number pain scale [ A…

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

Based on observation, interview, and record review, the facility failed to ensure that one of one sampled resident for dental services (Resident 6) received timely and appropriate dental evaluation and treatment, when the resident had broken teeth, and a history of uncompleted dental referrals with no follow-up or treatment plan.This failure resulted in Resident 6 not being able to eat effectively, placing the resident at risk for decreased nutritional intake and potential further decline.Findings:A review of Resident 6's admission record indicated she was admitted in 5/2021 with the diagnosis of dementia (a progressive state of decline in mental abilities).A review of Resident 6's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 9/26/25, indicated she had no memory impairment.A review of Resident 6's progress notes, dated 12/8/25 to 12/9/25, indicatged Resident 6 was being monitored for unplanned weight loss. A review of Resident 6's weights summary, dated 8/4/25, indicated Resident 6's weight was 109 lbs. (pounds, an unit of measurement) and on 12/8/25…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 observations, interview, and record review the facility failed to properly maintain the residents' food refrigerator for a census of 92 when a food item was not properly labeled and another food item was past the expiration date.These failures had the potential to result in residents consuming spoiled or contaminated food, increasing the risk of foodborne illness and adverse health outcomes.Findings:During an observation on 1/7/26 at 1:06 p.m., the resident refrigerator contained an open pack of string cheese with five pieces remaining, labeled with the resident's room and bed number, and, Date in 9/30/25. The five pieces of string cheese were marked with an expiration date of 12/26/25. The freezer unit of the resident refrigerator also contained one quart of cookie butter ice cream only labeled with, Date in 11/25.During an interview on 1/9/26 at 10:30 a.m. with the Director of Nursing (DON), the DON stated he expected items placed in the resident refrigerator were labeled properly with dates and who the items belonged to, otherwise resident food could be shared with…

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

Based on observations, interviews and record reviews, the facility failed to ensure smoking safety was practiced for one out of four sampled residents who smoke when:1.a smoking evaluation was not completed upon Resident 72's admission,2. quarterly smoking assessments were not completed for Resident 72, and3.Resident 72 kept a pack of cigarettes at his bedside.These failures increased safety risks for Resident 72 and other residents who could have gained access to Resident 72's cigarettes.Findings:A review of Resident 72's face sheet (front page of the chart that contains a summary of basic information about the resident) indicated an admission date in 9/2024 with a diagnosis of Schizophrenia (a mental illness that is characterized by disturbances in thought) and Depression (a mood disorder that causes a persistent feeling of sadness and loss of interest that could interfere with daily activities).A review of Resident 72's care plan (a detailed, written document that outlines a resident's individual needs, goals, and how their care will be managed) titled [Resident 72] is a smoker,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 physician orders for one resident (Resident 1) when licensed nurses did not remove a transdermal medicated patch (an adhesive patch that delivers a specific dose of medication through the skin and directly in to the bloodstream over a controlled period of time) before a new one had been applied.This failure had the potential to cause unwanted side effects due to a higher than prescribed dose of the medication being absorbed through the skin.Findings:During an observation on 12/30/25 at 11:52 a.m., Resident 1 was noted to have a transdermal medication patch on the skin near his right ear and an identical second transdermal medication patch on the skin near his left ear. The patch near his right ear had the date 12/28 written on it and the patch near his left ear had writing which was smudged and unreadable.A record review of Resident 1's physician (MD) orders indicated, Scopolamine [a medication used to control excess secretions] Transdermal Patch 72 Hour, 1MG [milligram, a unit of measurement] /…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 observations, interviews and record reviews, the facility failed to ensure the provision of a sanitary environment that would prevent the development and transmission of infections for one out of four residents (Resident 2) when:1. Resident 2's foley catheter (FC, a hollow tube inserted into the bladder to drain or collect urine also known as a urinary catheter) bag (a drainage bag connected to the FC) was touching the floor.2. Staff did not wear a gown, in accordance with enhanced barrier precautions (EBP, an infection control intervention, that involves the use of gowns and gloves during high-contact care activities to reduce the transmission of Multidrug-Resistant Organisms [MDRO, microorganisms (germs), that are resistant to one or more antibiotics]) while handling Resident 2's FC.These failures had the potential to cause and spread infections among residents and staff. Findings:1. During a concurrent observation and interview on 7/15/25 at 1:44 p.m. Unlicensed Staff A verified Resident 2's FC drainage bag was touching the floor. Unlicensed Staff A stated the FC…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, interviews and record review, the facility failed to ensure a call light (a communication tool used in healthcare settings to allow patients/residents to request assistance from staff) was provided to one out of three sampled residents (Resident 2) when the call light was not within Resident 2's reach.This failure could result in late provision of care, unmet needs and increases the risk of accidents.Findings:During a concurrent observation and interview on 7/15/25 at 1:38 p.m., Resident 2's call light was tangled with a red string by the wall and near the foot of his bed. Resident 2 stated when he needed help he would use his call light but added, it was not where he could reach as it was too far [away].During a concurrent observation and interview on 7/15/25 at 1:44 p.m., in Resident 2's room, Unlicensed Staff A verified Resident 2's call light was tangled with red string by the wall, near the foot of his bed, and was not within Resident 2's reach. Unlicensed Staff A stated Resident 2's call light should be within his reach so he could ask for assistance when…

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

Based on interview and record review, the facility failed to implement its abuse policy when Certified Nursing Assistant B (CNA B) was allowed to return to work after a physical and sexual abuse allegation was made against him, and prior to the facility completing their abuse investigation. This failure caused Resident 1 to feel unsafe, and potentially placed other residents, who were cared for by CNA B, at risk of abuse. Findings: During an interview on 4/25/25 at 2:50 p.m., the Administrator stated Resident 1 had reported that CNA B had pushed her and had jumped on her roommate. The Administrator stated the facility's investigation into the incident was in process (not finished). The Administrator stated Resident 1's roommate (Resident 2) screamed when CNAs provided ADL (Activities of Daily Living; care such as eating, dressing, bathing, and toileting) care and Resident 1 may have inferred she was being abused. When asked how Resident 1 and Resident 2 were being protected during the investigation, Administrator stated he had immediately suspended CNA B. Review of Resident 1's 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.

Based on observation, interview, and record review, the facility failed to ensure one resident (Resident 1) of three sampled residents received care which met services provided to meet professional standards when nursing assessments related to changes in Resident 1's skin integrity (skin health) was not documented in Resident 1's medical record. This failure resulted in inaccurate assessment documentation which had the potential to prevent Resident 1's skin integrity from further impairment. Findings: A review of Resident 1's admission record indicated admission to the facility in April 2024 with diagnosis of syncope (fainting or passing out) and collapse, muscle weakness, abnormalities of gait (a manner of walking) and mobility, presence of right and left artificial knee joint (knee replacement), and schizophrenia (a mental illness that is characterized by disturbances in thought). A review of a Minimum Data Set (MDS- a federally mandated resident assessment tool), dated 4/9/25, indicated Resident 1: · No memory impairment, · Risk of developing pressure ulcers/injuries (localized…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain a sanitary (clean manner that prevents the spread of diseases), safe, and comfortable environment when: 1. All 21 residents' bathrooms were in disrepair. 2. Resident 54's privacy curtain (curtain used as divided between residents' beds) was not kept in a sanitary manner. 3. Comfortable water temperatures were not maintained in the bathrooms for 5 Residents' rooms (room [ROOM NUMBER], 114, 141, 143 and 146). These failures violated the residents' rights to live in a sanitary, safe, comfortable, homelike environment and had the potential to result in injury and illness in a medically compromised population. The facility census was 94. Findings: 1. During a concurrent observation and interview on 1/13/25 at 12:46 p.m. with Resident 23 in the shared bathroom for room [ROOM NUMBER] and room [ROOM NUMBER], the flooring going into the shower had an uneven surface with multiple large multilayer cracks, exposing old cement and flooring…

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

Based on interview and record review, the facility's abuse program failed to protect the residents when: 1. Resident 54's transfer request after a resident-to-resident altercation was not completed. (Cross Reference F745) 2. Reports of abuse were not reviewed and analyzed by QAPI (QAPI, data-driven approach to improving quality in healthcare facilities) per the facility's policy ad procedure. 3. There was no policy and procedure developed to prohibit and prevent retaliation (act of revenge that causes harassment or harm) against residents, families, and visitors who report incidents of abuse, neglect, or other similar violations. These failures had the potential to compromise the safety of all residents, staff, and visitors. The facility census was 94. Findings: 1. During an interview on 1/13/25 at 9:03 a.m. with Resident 54, Resident 54 stated she was involved in a resident-to-resident altercation on 12/13/24 and has been trying to leave the facility. Resident 54 stated, I don't feel safe here. During an interview on 1/16/25 at 9:26 a.m. with Resident 54, Resident 54 stated she did…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 five out of five licensed nurses (Registered Nurse 3, 4, 5, 6 and Licensed Vocational Nurse 2) were competent (having the necessary ability, knowledge, or skill to do something successfully) in medication administration. This failure resulted in a medication error rate of 24% and had the potential to result in significant adverse events (any undesirable or harmful effects that occur as a result of medical treatment including medications) to a medically compromised population. The facility census was 94. (Cross-reference F759) Findings: During multiple observations on 1/15/25 at various times with Registered Nurse (RN) 3, RN 4, RN 5, RN 6, and Licensed Vocational Nurse (LVN) 2, medications were administered to Resident 36, 39, 71, 81, 193, and 291. The medication error rate was 24%. During an interview on 1/15/25 at 12:55 p.m. with the Director of Nursing (DON), the DON stated nurses were evaluated for medication administration competency upon hire and if there were any errors with competency during…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 medication error rate did not exceed 5 percent when five out of five licensed nurses were observed and made the following medication errors: 1. Potassium (medication used to treat low amount of potassium in the blood) was not administered in accordance with physician order to Resident 36. 2. Resident 81 was not instructed to stay sitting in upright position after being administered Potassium-Phosphate (supplement to increase potassium and phosphate in the blood,) despite manufacturer guidelines to not lie down for 10 minutes after to prevent stomach irritation and discomfort. 3. Resident 81 was administered twice the ordered dose of cholecalciferol (Vitamin D-medication). 4. A powdered medication, polyethylene glycol (laxative- medication that draws more water into bowels to facilitate a bowel movement), was not mixed with enough water per manufacturer's guidelines and administered to Resident 291. 5. Insulin (medication 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.

Based on interview and record review, the facility's Quality Assurance Performance Improvement (QAPI, data-driven approach to improving quality in healthcare facilities) committee failed to maintain documentation and demonstrate evidence that the QAPI program was sustained during transitions in leadership when there were no follow-ups for medication administration audits (observations to help identify potential and actual medication errors at different stages) conducted by Pharmacy (Cross-reference F658, F726, F759, F760). These findings resulted in a medication error rate of 24%, including one considered significant, and had the potential to result in severe adverse effects for all residents. The facility census was 94. Findings: During a review of the facility's QAPI Minutes (a written record of a QAPI meeting that documents topics discussed, decisions made, and actions taken), dated January to December 2024, the minutes indicated that for January and February of 2024, Medication Administration Audits by the Pharmacist (PHARM) were planned to be completed monthly and reported to…

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

Based on interview and record review, the facility's Quality Assurance and Performance Improvement (QAPI, data-driven approach to improving quality in healthcare facilities) program failed to identify, address, and evaluate the following systemic quality deficiencies (issues that fall below the standards of quality for a facility's care, which QAPI programs were designed to identify and fix): 1. Nursing Medication Administration Competency (Cross-reference F658, F726, F759, F760) 2. Infection Control (Cross-reference F880, F881) 3. Abuse Program (Cross-reference F606, F607, F943) 4. Incomplete Resident's Records (Cross-reference F842) 5. Social Services (Cross-reference F607, F685, F742, F745, F791) These failures resulted in a lack of oversight over these necessary care services and had the potential to negatively affect the safety and quality of care provided to all residents. The facility census was 94. Findings: During a review of the facility's QAPI Minutes (a written record of a QAPI meeting that documents topics discussed, decisions made, and actions taken), dated January 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 prevention and control measures were implemented when: 1a. Water testing was not done to identify the presence of Legionella bacteria (can cause severe pneumonia [inflammation and fluid in the lungs]) in the building water system (cold and hot water distributed through the water pipes). 1b. Policies and Procedures (P&P) were not revised annually and updated as needed. 1c. Toilet plungers (used to free waste outlets of obstruction) located on the floor next to toilets in restroom of rooms 124, 130, 132, and 146. 1d. Four unlabeled urinals were in the restroom of rooms [ROOM NUMBERS]. 1e. One House Keeping staff did not know the dwell time (the amount of time the disinfectant needed to sit on the surface) of the [name of manufacturer] disinfectant. 2. Resident 83's used urinal with no lid cover was observed on the edge of his bedside table for approximately one hour. 3. Certified Nurse Assistant (CNA) 1 was observed not…

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

Based on interview and record review, the facility failed to provide procedures for reporting incidents of abuse and training for seven staff members (Social Services Director (SSD), Registered Nurse (RN) 2, Licensed Vocational Nurse (LVN) 3, Certified Nurse Assistants (CNA) 3, 4, 5, and 6). These findings resulted in staff ineffectively identifying the facility's procedure for reporting incidents of abuse and had the potential to compromise the safety of all residents, staff, and visitors. Findings: During an interview on 1/13/25 at 12:32 p.m. with Resident 23, Resident 23 stated he has heard staff members at night being verbally abusive to his roommate, and he reported it to staff. Resident 23 stated, nothing happened after he reported the incident. During an interview on 1/14/25 at 1:47 a.m . with LVN 3, LVN 3 stated that if there was an abuse incident, she would report it during the next shift to the Director of Nursing (DON) because she's night shift and she wouldn't want to wake the DON up. During an interview on 1/14/25 at 1:48 a.m. with CNA 5, CNA 5 stated that if there was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the Minimum Data Sets (MDS- a standardized assessment and care planning tool) were accurate for two of 23 sampled residents (Residents 25 and Resident 391). This failure had the potential to adversely affect the provision of care for Residents 25 and Resident 391. Findings: 1. During an interview on 01/15/25 at 3:26 p.m. the Medical Record Director (MRD), MRD stated Resident 391 was discharged home. During a concurrent interview and record review on 01/16/25 at 9:25 a.m. with the Minimum Data Set Coordinator (MDSC), Resident 391's MDS, dated [DATE], was reviewed. Resident 391's quarterly MDS Section A2105 indicated Resident 391 was discharged to a Short-Term General Hospital. MDSC stated Resident 391's MDS was inaccurate because she went home, not to the hospital. During a review of Resident 391's Discharge Summary, dated 11/27/24, the Discharge Summary indicated Resident 391 was to be discharged to home on [DATE]. During a review of Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2. During a review of Resident's 191's Face Sheet (demographics), the Face Sheet indicated Resident 191 was admitted on [DATE], with diagnoses including cellulitis of right lower limb (swelling and skin infection of the lower leg); unspecified fracture of shaft of right tibia (a break in the lower leg bone below the knee); initial encounter for closed fracture (the first time a resident is seen by a healthcare provider for a broken bone where the skin is intact), and burn of unspecified degree of right lower leg (the burn cannot be definitely determined at the time of assessment). During a concurrent observation and interview on [DATE] at 9:00 a.m. with Resident 191 in room [ROOM NUMBER] C, there was one collagenase (Santyl) ointment tube located on top of Resident 191's bedside cabinet. Resident 191 was alert and oriented. Resident 191 stated he has had the Santyl ointment tube stored in the bedside cabinet since [DATE]. During a concurrent interview and record review on [DATE] at 8:59 a.m. with Infection…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the antibiotic stewardship (monitors the effective use of antibiotics) monitored the effective use of Amoxicillin-Pot Clavulanate (antibiotic to treat urinary tract infections-[UTI- infection in your urinary system]) for the month of October 2024 and November 2024 for Resident 84. This failure had the potential to result in an inappropriate use of antibiotics for Resident 84. Findings: During a review of Resident 84's Face Sheet (demographics), the Face Sheet indicated Resident 17 was admitted on [DATE] with diagnoses to include a UTI. During a review of Resident 84's Physician Orders, dated 10/27/24, the Physician Order indicated, Amoxicillin-Pot Clavulanate tablet 875-125 milligram (unit of measurement), give 1 tablet by mouth two (2) times a day for urinary tract infection for 14 days. During a concurrent interview and record review on 1/15/25 at 10:48 a.m. with Infection Preventionist (IP), the facility's binder of Monthly Infection Control…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide adequate space for all 24, three residents residing rooms. This failure resulted in 23 Residents (Resident 1, 5, 11, 21, 23, 31, 51, 54, 56, 59, 61, 64, 65, 68, 69, 70, 74, 79, 81, 190, 191, 193, and 345) not having the required amount of usable living space and had the potential to compromise the safety of residents due to limited space. Findings: During a concurrent observation and interview on 1/13/25 at 9:03 a.m. with Resident 54 in room [ROOM NUMBER], the room had three residents residing in it. Bed C's individual living space was visibly smaller than Bed A and B's living spaces. Resident 54 in Bed C, stated, Look how small this is; I can't even get by. Resident 54 used a walker for an assistive device. During a concurrent observation and interview on 1/15/25 at 4:06 p.m. with Maintenance (MAIN) in room [ROOM NUMBER], MAIN measured Bed C's individual living space, the result was 11.5 feet by 6.5 feet, the Maintenance Director…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 resident hand-outs (weekly menu, activities calendar, guide for translation services) were provided in Resident's preferred language for two of 23 sampled residents (Resident 342 and Resident 8). This failure resulted in Resident 342 and Resident 8 being uninformed on menu options, activities, and how to obtain a translator. Findings: a. During a concurrent observation and interview on 1/13/25 at 3:22 p.m. with Resident 342, through the translation services provided from the facility, in Resident 342's room , posted on the walls were the weekly menu, activity calendar, interpretive services-reference guide and instructions for accessing interpreter, all written in English. Resident 342 stated he did not understand the signage because it was written in English. Resident 46 further stated he only spoke and read in Spanish. During an interview on 1/14/25 at 10:48 a.m. with Registered Nurse (RN) 2, RN 2 stated she has not seen any papers or forms in other languages. The forms were all written in English.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the call light was within reach for Resident 46. This failure resulted in Resident 46 being unable to contact staff for assistance. Findings: During a review of Resident 46's Face Sheet (demographics) dated 1/16/25, the Face Sheet indicated Resident 46 was admitted to the facility on [DATE] with diagnoses of hemiplegia (complete paralysis to one side of the body) following cerebral infarction (stroke- serious condition that occurs when blood flow to the brain is blocked) affecting right dominant side, aphasia (unable to communicate verbally) and weakness. During an observation on 1/14/25 at 4:02 p.m. in Resident 46's room, Resident 46 was reclined in a geriatric chair (padded chair that is designed to help seniors with limited mobility) in the middle of the room without a call light. Resident 46 threw one pillowcase, in the direction of the door, and waved multiple times. Resident 46 grunted and pointed at the call light, on 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 interview and record review, the facility failed to ensure one of 23 sampled residents (Resident 83) and/or their legal representatives were informed and/or provided written information about Advance Directives (AD, legal document that provides instructions regarding medical care according to the resident's wishes and only goes into effect if the resident can no longer communicate their wishes). This failure had the potential to result in lack of knowledge regarding care and treatment decision making for Resident 83. Findings: During a review of Resident 83's admission Record (AR), the AR indicated the facility admitted Resident 83 on 11/12/2024 with multiple diagnoses including hypertension (high blood pressure) and muscle weakness. The AR indicated Resident 83 had a Responsible Party 1 (RP) 1 as the emergency contact. During a review of Resident 83's Minimum Data Set (MDS - a resident assessment tool used to identify resident cognitive and physical function) Assessment dated 11/19/24, indicated Resident 83's Brief Interview for Mental Status (BIMS -assessment of memory…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 proper screening and follow-up for Registered Nurse (RN) 3 who had been found guilty of neglect by a court of law. This finding had the potential to compromise the safety of all residents, staff, and visitors. The facility census was 94. Findings: During a review of RN 3's employee files titled, CALIFORNIA BOARD OF REGISTERED NURSING- BRN (Board of Registered Nursing) LICENSING DETAILS, dated 1/16/25 and 12/19/23, the documents indicated RN 3 had an administrative disciplinary action against RN 3's license posted on 12/12/23. During a review of a public court document (legal document available to the public and is part of the court record) titled, BEFORE THE BOARD OF REGISTERED NURSING DEPARTMENT OF CONSUMER AFFAIRS STATE OF CALIFORNIA, dated 11/30/23, the document indicated, .[RN 3] was convicted by a plea of guilty to: (1) child endangerment . felony . During an interview on 1/17/25 at 8:31 a.m. with the Administrator (ADMIN), the ADMIN identified himself as the facility's abuse coordinator (designated staff…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 send a copy of the resident's transfer notification to the Office of the State Long-Term Care Ombudsman (resident advocacy agency) for two of 23 sampled residents (Resident 77 and 84) when: 1. Resident 77 was transferred to General Acute Care Hospital (GACH) on 11/10/24, and a transfer notification was not sent to the Ombudsman. 2. Resident 84 was transferred to General Acute Care Hospital (GACH) on 11/15/24, and a transfer notification was not sent to the Ombudsman. These failure resulted in the Office of the State Long-Term Care Ombudsman not being aware of Resident 77 and 84's transfers to GACH. Findings: 1. During a review of Resident 77's Face Sheet (demographics), the Face Sheet indicated Resident 77 was admitted to the facility on [DATE] with a diagnosis of chronic obstructive pulmonary disease (lung disease that makes it difficult to breathe). During a review of Resident 77's Progress Notes, dated 11/10/24, the notes indicated .running high…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 identify a mental illness (MI- medical disorder that affects a person's thinking, emotions, or behavior) and subsequently failed to refer one of 23 sampled residents (Resident 71) for a Level II PASRR (Preadmission Screening and Resident Review- used to ensure individuals are placed in an appropriate setting and receive needed mental health services) screening. This failure resulted in Resident 71 not receiving specialized mental health services to meet her needs. Findings: During a review of Resident 71's PASRR, dated 7/14/23, the PASRR indicated Level 1 screening was negative. PASRR indicated Resident 71 was not diagnosed with a mental disorder such as anxiety disorder (mental health condition that involves excessive and persistent feelings of fear, worry, dread and uneasiness that can cause physical symptoms) and panic disorder (mental health condition that experiences unexpected and repeated episodes of intense fear accompanied by physical symptoms like chest pain), and not prescribed psychotropic (a drug that affects…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 interventions were implemented to reduce the risk of injuries from falls for one of 23 sampled residents (Resident 25). This failure resulted in the potential for the resident to suffer an injury during a fall. Findings: Review of Resident 25's admission Record indicated Resident 25 was admitted to the facility on [DATE] with diagnoses which included malignant neoplasm of the temporal lobe (brain tumor). During an interview on 1/13/25 at 10:50 a.m. with Resident 25's Responsible Party (RP) 1, RP 1 stated facility staff called her on 1/12/25 and informed her that Resident 25 had rolled out of his bed. During an observation on 1/13/25 at 9:00 a.m. in Resident 25's room, Resident 25 was in bed asleep. No fall mat was observed on the floor at his bedside. During an observation 1/13/25 11:58 a.m. in Resident 25's room, Resident 25 was in bed asleep. No fall mat observed at bedside. During an interview on 1/15/25 at 8:45 a.m. with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to revise and implement a person centered comprehensive care plan for one of 23 sampled residents (Resident 28), when Resident 28 fell on 1/12/25 and care plan interventions were not revised and updated. This failure placed Resident 28's health and safety at risk when fall care plan interventions were not revised. Findings: During a review of Resident 28's Face Sheet (demographics), the Face Sheet indicated Resident 28 was admitted to the facility on [DATE] with diagnoses including repeated falls, muscle weakness and dementia (impaired ability to remember, think, or make decisions). During an observation on 1/14/25 at 8:56 a.m. in Resident 28's room, Resident 28 was observed seated in his wheelchair self-propelling himself out of his room. During a review of Resident 28's Minimum Data Set (MDS - a resident assessment tool used to identify resident cognitive and physical function) Assessment, dated 12/19/24, the MDS indicated Resident 28's…

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

Based on observation, interview and record review, the facility failed to ensure services provided met professional standards of practice when Licensed Vocational Nurse (LVN) 2 prepared two unsampled residents' (Resident 39 and Resident 193) medications and did not observe Resident 39 and Resident 193 ingest medications. This failure had the potential to result in Resident 39 and Resident 193 receiving the wrong medications. Findings: During an observation on 1/15/25 at 12:35 p.m. in the hallway of Station 1, LVN 2 was standing in front of the medication cart. LVN 2 had two medicine cups on top of the medication cart with unidentified pills: the first medicine cup, labeled 22A in black marker, had one long yellow pill. The second medicine cup, labeled 22C in black marker, had one round blue pill and one round white pill. LVN 2 went into the medication cart and dispensed a third pill into the medicine cup labeled 22C. LVN 2 then walked down the hallway, approximately 65 feet, holding the two medicine cups. LVN 2 entered Resident 39 and 193's room and placed the medicine cup labeled…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 Resident 290 received an assistive device for his vision needs when Resident 290 did not receive assistance with making an appointment to get new eyeglasses. This failure resulted in negatively affecting Resident 290's ability to enjoy his favorite hobbies such as crossword puzzles. Findings: During a review of Resident 290's Face Sheet (demographics), the Face Sheet indicated Resident 290 was admitted on [DATE] with diagnoses including diabetic retinopathy (eye condition that damages the eye's blood vessels due to high blood sugar). The Face Sheet included a picture of Resident 290 wearing eyeglasses. During a concurrent observation and interview on 1/14/25 at 4:25 p.m. with Resident 290 in his room, Resident 290 was holding up the crossword puzzle very close to his face. Resident 290 stated that he has been unable to do his crossword puzzles which he loved to do because he did not have eyeglasses for more than two weeks.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 physician visits were conducted once every thirty days for Resident 25. This failure had the potential to result in an undetected decline in Resident 25's health and/or potential delays in treatment or services. Findings: During a review of Resident 25's Face Sheet (demographics), the Face Sheet indicated Resident 25 was admitted to the facility on [DATE] with diagnoses including malignant neoplasm of the temporal lobe (brain tumor), iron deficiency anemia (fewer red blood cells in the body due to a lack of iron), type 2 diabetes mellitus (condition that causes the level of sugar in the blood to become too high), and dysphasia (difficulty swallowing). During an interview on 1/15/25 at 3:20 p.m. with Medical Director (MD), MD stated she visited the facility daily and saw the residents who need medication changes. MD stated she was unaware of the requirements for physician's visits, but she tried to see all residents monthly. MD stated, Sometimes…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 mental health services to Resident 71. This failure had the potential to negatively affect Resident 71's psychosocial (the mental, emotional, social and spiritual effects of a disease) well-being. Findings: During a review of Resident 71's Face Sheet (demographics) dated 1/16/25, the Face Sheet indicated Resident 71 was admitted to the facility on [DATE], with diagnoses of depression, panic disorder (mental health condition that experiences unexpected and repeated episodes of intense fear accompanied by physical symptoms like chest pain), generalized anxiety disorder (mental health condition that involves excessive and persistent feelings of fear, worry, dread and uneasiness that can cause physical symptoms), and chronic post-traumatic stress disorder (a condition of persistent mental and emotion stress occurring because of injury or severe psychological shock). During a review of Resident 71's Minimum Data Set (MDS-an 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to: 1. follow up on facility transfer for one of 23 sampled residents (Resident 54) 2. properly screen for Preadmission Screening and Resident Review (PASARR- used to ensure individuals are placed in an appropriate setting and receive needed mental health services) for one of 23 sampled residents (Resident 71) 3. arrange and provide mental/psychosocial counseling services for one of 23 sampled residents (Resident 71) These failures resulted in the delay of Resident 54 and Resident 71's care to maintain their well-being. Findings: 1.During a concurrent observation and interview on 1/13/25 at 9:03 a.m. with Resident 54 in room [ROOM NUMBER], Resident 54's privacy curtain was drawn, Resident 54 was sitting on edge of the bed, and watching television. Resident 54 stated she was involved in a resident-to-resident altercation on 12/13/24 and had been trying to leave the facility and stated, I don't feel safe here. During an interview on 1/16/25 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 ensure Monthly Medication Reviews (MMR- a comprehensive review of all medications a resident receives) were conducted for Resident 61. This failure resulted in the potential for Resident 61 to receive unnecessary medications. Findings: During a review of Resident 61's Face Sheet (demographics), the Face Sheet indicated Resident 61 was admitted to the facility on [DATE] with diagnoses including Lewy body dementia (brain disease that causes a gradual decline in thinking, movement, and behavior) and major depressive disorder (a mental disorder causing low mood, lack of interest and feelings of hopelessness). During an interview on 1/16/25 at 3:14 p.m. with Pharmacist (PHARM), PHARM stated that he should conduct a MMR every month to look for any medication concerns such as duplicate therapy or medication interactions and email the results to the Director of Nursing (DON) so that any issues with the resident's medications could be addressed. 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 interview and record review, the facility failed to attempt a Gradual Dose Reduction (GDR- an attempt to reduce the dose of medications which affect the nervous system to treat mental illness to achieve the lowest dose possible) for one of 23 sampled residents (Resident 61). This failure had the potentialto result in Resident 61 receiving psychotropic medications which were unnecessary and in excessive dose. Findings: During a review of Resident 61's Face Sheet (demographics), the Face Sheet indicated Resident 61 was admitted to the facility on [DATE] with diagnoses which included Lewy body dementia (brain disease that causes a gradual decline in thinking, movement, and behavior) and major depressive disorder (a mental disorder causing low mood, lack of interest and feelings of hopelessness). During an interview on 1/15/25 at 8:45 a.m. with Certified Nurse Assistant (CNA) 6, CNA 6 stated Resident 61 has shown no aggression to staff or other residents. During an interview on 1/15/25 at 9:00 a.m. with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the correct dosage of insulin (medication that lowers the level of glucose [sugar] in the blood) was in the prefilled pen injector per physician's sliding scale order for Resident 291. This failure had the potential to result in hypoglycemia (medical condition where blood sugar level is too low) and death for Resident 291. Findings: During a review Resident 291's Face Sheet (demographics), the Face Sheet indicated Resident 291 was admitted on [DATE] with diagnoses including diabetes mellitus type 2 (disease that causes high blood sugars). During a review of Resident 291's Face Sheet (demographics), the Face Sheet indicated Resident 291 was admitted on [DATE] with diagnoses including diabetes mellitus type 2 (disease that causes high blood sugars). During a concurrent observation and interview on 1/15/25 at 4:15 p.m. with Registered Nurse (RN) 3 in Resident 291 ' s room, RN 3 checked Resident 291's blood sugar with a glucometer…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 routine dental services for Resident 71 for 16 months. This failure had the potential to result in a decline in oral health for Resident 71. Findings: During a concurrent observation and interview on 1/16/25 at 9:35 a.m. with Resident 71, Resident 71 had multiple teeth missing. Resident 71 stated she had only seen the dentist one time since admission. Resident 71 further stated she verbally requested a dental visit multiple times. During an interview on 1/16/25 at 9:46 a.m. with Social Services Director (SSD), SSD stated Resident 71 was admitted on [DATE] and was not seen by dental until 11/14/24. SSD stated the resident should have been seen every 6 months and as needed. During a review of Resident 71's Minimum Data Set (MDS-an assessment tool), dated 12/26/24, the MDS indicated, Resident 71's Oral/Dental Status is no natural teeth or tooth fragment(s) (edentulous-lacking teeth). The MDS indicated Care Area Triggered was Dental…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 protect equipment from contamination via dust and grease. This failure posed the risk for food borne illness in a medically fragile resident population of 98 facility residents who received food prepared in the kitchen. Findings: During a concurrent observation and interview on 1/13/25 at 8:21 a.m., with the Dietary Supervisor (DS) a white powdery (dusty) substance was noted on top of the dishwasher. The dishwasher was also noted to have a thick greasy buildup up on the bar going across the bottom of the equipment. The DS agreed that the equipment was dirty and needed to be cleaned. During a review of the facility's policy and procedure (P&P) titled, Shelves, Counters, and Other surfaces Including Sinks (Handwashing, Food Preparation, ETC.), dated 2023, the P&P indicated, Remove any large debris and wash surface with warm detergent solution .Rinse with clear water using a clean sponge or cloth. Wipe dry with a clean cloth.

Based on observation, interview, and record review, the facility failed to provide three of five sampled residents (Resident 54, 56, and 341) a designated refrigerator to store personal, perishable food items. This failure resulted in Resident 56, unsafely storing perishable personal food items in her bedside drawer, which had the potential to result in a foodborne illness for Resident 56. This failure resulted in a non-homelike environment for Residents 54 and 341. Findings: During a concurrent observation and interview on 1/13/25 at 10:57 a.m., in Resident 56's room, Resident 56 was observed opening her bedside bottom drawer and pulling out a container of butter and jar of pickled beets. Resident 56 stated she knew the food items needed to be refrigerated but there was no available refrigerator. During an interview on 1/14/25 at 2:54 p.m. with Dietary Manager (DM), DM stated residents were encouraged to eat food brought from outside within two hours. DM stated the facility did not have a separate refrigerator to store food for residents. During an interview on 1/14/25 at 3:21 p.m.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 Physician's Progress Notes were documented in the medical record for 3 of 23 sampled residents (Resident 25, 61, and 75). This failure resulted in the potential for communication delays and potential delays in coordination of care. Findings: 1. During a review of Resident 25's Face Sheet (demographics), the Face Sheet indicated Resident 25 was admitted to the facility on [DATE] with diagnoses including malignant neoplasm of the temporal lobe (brain tumor) and urinary tract (organs that make urine) infection. During a concurrent interview and record review of Resident 25's medical record on 1/14/25 at 4 p.m. with the Director of Nursing (DON), the medical record review indicated there were no documented Physician's Progress Notes. DON stated he was unaware how often the Medical Director (MD) examined the residents and confirmed there were no documented Physician's Progress Notes. DON stated MD had her own charting system and did not document…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 interviews and record reviews, the facility failed to ensure a sexual abuse allegation between Unlicensed Staff B (ULS B) and Resident 1 was reported within the 2 hour abuse reporting time frame. Findings: A review of the facility ' s initial report indicated an abuse allegation was reported to the state on 12/9/24. A review of the Summary-Staff-to-Resident Allegation indicated that on 12/9/24, ULS D reported that Resident 1 told him she was having inappropriate texts and inappropriate interactions with ULS B. A review of the staffing assignment sheet indicated ULS D was assigned to work on 12/8/24 on afternoon shift and Resident 1 was under his care at that time. ULS D reported to the ADM on 12/9/25 the sexual abuse allegation between ULS B and Resident 1. A review of the written statement by ULS D, undated, confirmed he was working with Resident 1 on 12/8/24. During an interview on 12/23/24 at 12:30 p.m., LN A stated it was important that abuse allegations were reported timely to ensure interventions to keep residents safe were in place immediately. During a concurrent…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to follow a physician ' s order in obtaining a Keppra (medication to treat seizures), blood level for one of two sampled Residents, (Resident 10), by not having the laboratory company come to the facility to obtain the sample and the nursing Department did not follow up on the missed opportunity for four months. This failure had the potential to result in Resident 10 experiencing subsequent seizures in October and November of 2024 causing pain, distress, and a higher level of care to ensure no further damage to Resident 10 ' s brain. Findings: During a review of Resident 10 ' s admission Record indicated Resident 10 was admitted to the facility on [DATE] with a history of Parkinson ' s (a chronic brain disorder that causes movement problems, mental health issues and other health concerns), epileptic seizures (a chronic brain disorder which causes seizures by an abnormal electrical activity in the brain), muscle weakness and dysphagia (difficulty swallowing…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on Interview and Record Review the Facility failed to allow residents, who were smokers at time of their admission, the right to self-determination when the facility made the decision to enforce the Smoking Policy without considering the rights of the residents to choose their schedules. Residents, who were smokers, were not allowed input about the changes in the Policy including the timing of smoking breaks. Residents were not given guidance for managing the restrictions nor alternatives to smoking. This change in Policy infringed on the rights of the Residents who smoked, and affected nine of the thirteen residents, who identified as smokers in the facility, among them Resident 3, Resident 11, Resident 2, Resident 7, and Resident 12. Findings: During an interview on 10/29/24 at 2:30 p.m., Resident 3 stated she did not want to quit smoking and this change in policy infringed on her rights as a Resident. Resident 3 stated it was not right to change the door code to the exit by station 2, preventing her…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the Facility failed to follow transfer and discharge requirements when nine of thirteen residents, who at the time they were admitted to the facility, identified as smokers, were given a Notice of Transfer and Discharge for endangering the health of safety of individuals in the facility, all on 10/23/24. The facility did not have appropriate documentation to support that the residents were noncompliant with the smoking policy or that their smoking behavior was a safety risk for the other residents at the facility. The failure to identify and document in each of the nine residents records the behavior that caused the need for the facility to initiate a resident discharge could result in unfair and unsafe discharges. Findings: During a review of Resident 2's clinical record, the admission record documented Resident 2 was admitted [DATE]. Resident 2's Smoking-Safety Screen, dated 8/14/24 assessed Resident 2's ability to smoke safely. The assessment determined that Resident 2 was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to implement the interventions to reduce the risk of elopement (leaving the facility without knowledge of the staff) for one of one sampled resident (Resident 1), who left the facility, undetected, and was found on a busy street. A bystander stayed with him until the emergency responders arrived. This failure had the potential to result in serious injuries, including bruises, lacerations, head injury and broken bones. Findings: During a review of Resident 1's admission Record, printed 9/16/24, the admission Record indicated Resident 1 was originally admitted to the facility on [DATE], and was readmitted to the facility on [DATE]. This record indicated Resident 1's most recent hospital stay was 4/26/24 to 7/24/24. Resident 1's principal diagnosis was Unspecified dementia, unspecified severity, with other behavioral disturbance (impaired memory and judgement). During a review of Resident 1's medical records, on 9/16/24, a SBAR (Situation, Background,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 the responsible party (decision maker) (wife) for one of two samepled residents (Resident 1) of the intention to transfer the resident to the hospital. Resident 1's Responsible Party stated she did not know her husband was at the hospital until he called her (with help from the hospital staff.) This failure to notify the Responsible Party in writing and in advance of the reason for transfer disregarded Resident/Responsible Party's right to be informed and to participate in the resident's care. Findings: During a review of Residents 1's medical record on 5/15/24, Resident 1's admission Record, dated 5/15/24, indicated Resident 1 was a veteran with medical coverage from the Veterans Administration (VA.) Resident 1's diagnosis included dementia with other behavioral disturbance, diabetes, hypertension, and unspecified mood disorder. During an interview on 5/15/24 at 3:00 p.m., Infection Preventionist (IP) stated that they had an unscheduled meeting…

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

Based on observation interview and record review the facility failed to store garbage in a manner that made it inaccessible to pests. This failure potentially contributed to a rat infestation in the kitchen. Finding: During an observation on 4/3/24 at 9:34 a.m., a dumpster on the side of the facility, approximately 20 feet from the kitchen door, had the lid propped open with a long stick. The facility's dumpster area was surrounded by extensive overgrowth of English ivy. A photo of the dumpster was obtained. During a phone interview on 4/3/24 at 11:20 a.m., the pest control company's customer service stated that during the last six months the facility had called in reports of rat activity in the kitchen on 11/27/23, 12/19/23, 2/20/24, 2/28/24, 2/29/24, 3/8/24, and 3/19/24. During an interview on 4/3/24 at 11:30 a.m., [NAME] C stated he had been noticing gnawed food in dry storage for two months. During an interview on 4/3/24 at 12:47 p.m., Pest Control Service Specialist D was on site and stated that he was assigned this account at the beginning of March 2024. He stated he was last…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 administrator failed to 1. Follow up on reports of rats in the facility kitchen to ensure the pest control company was controlling the rats, 2. Follow up on letters from the county health department requesting a plan to address code compliance issues in the kitchen (dating back to 8/2023), and 3. Ensure the staffing agency sent nurses to cover shifts as agreed upon. These failures resulted in the facility's kitchen closing for several weeks requiring food to be obtained from an outside source for the residents, and also resulted in nurses working 24-shifts to cover for registry nurses who did not report to work. Findings: 1. During an observation and concurrent interview on 4/3/24 at 9:36 a.m. in the facility kitchen, kitchen staff were preparing food. Several dark brown droppings were under the ware washing area (area of the kitchen for rinsing and washing pots, pans, and dishes). More droppings were under the two-compartment sink, the steam table (appliance used to keep food warm while it is being plated for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain an effective pest control program when signs of a rat infestation in the kitchen were not adequately addressed. This resulted in rats contaminating the residents' food and the kitchen where food was prepared. Findings: During an observation and concurrent interview on 4/3/24 at 9:36 a.m. in the facility kitchen, kitchen staff were preparing food. When queried, [NAME] A stated the dietary manager was in [NAME] for the past month. Several dark brown droppings were under the ware washing area (area of the kitchen for rinsing and washing pots, pans, and dishes). When queried, Director of Nursing (DON) stated they were droppings. More droppings were under the two-compartment sink, the steam table (appliance used to keep food warm while it is being plated for residents' meals), under the ice machine, and in the dry storage area under shelves of food and on food. Dietary Aide B stated the droppings were rat poop. She stated she had been…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 adequately staff the Noc shift (10:30 p.m. to 6:30 a.m.) when the registry nurses scheduled to work Noc shift did not report to work three nights in a row. This failure resulted in three nurses working a triple shift (three consecutive 8-hour shifts) for those three days, potentially putting residents at risk of medication errors or delay in care when nurses caring for the residents are too fatigued to accurately follow physician orders or provide care. Findings: During a record review and concurrent interview on 4/3/24 at 3:22 p.m., facility staffing assignment sheet for 3/17/24 revealed Licensed Nurse E worked AM shift (6:30 a.m. to 3:30 p.m.), PM shift (3:30 p.m. to 11:30 p.m.), and Noc shift. Review of staffing assignment sheet for 3/18/24 revealed Licensed Nurse F worked AM shift, PM shift, and Noc shift. Director of Nursing (DON) verified Licensed Nurses E and F worked 24-hours straight on those two days. DON stated Licensed Nurse G also worked 24 hours on 3/19/24. DON stated the nurses all worked double shifts (16…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 take precautions to prevent the development of a pressure ulcer for 1 of 4 sampled residents (Resident 1). This failure in not taking precautions, resulted in a Deep Tissue Injury (DTI, an injury to a patients underlying tissue below the skin's surface that results from prolonged pressure in an area of the body), to Residents 1 ' s sacrum (low back to upper buttock area). Findings: During a review of Resident 1 ' s records from her hospitalization over 6/13/23 to 6/14/23, she was triaged in the Emergency Department just before midnight on 6/13/23. Resident 1 was admitted to the hospital and transported to the nursing unit at 5:30 a.m. Pictures of Resident 1 ' s sacrum were taken on 6/13/23 at 5:33 a.m., because the nurses had identified a DTI. The picture of Resident 1 ' s sacrum showed two rounded areas of skin that were black in color with purple around one of the black areas, and the rest of her buttock was reddened. During a review of Resident 1 ' s Hospitalist Discharge summary from the hospital, dated 6/14/23,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 exercise reasonable care for the protection of residents ' property from loss for two of two residents (Resident 1 and 2) when the facility did not consistently mark the clothes and property of Residents 1 and 2. This failure placed the personal property of Residents 1 and 2 at risk for loss and misplacement. Findings: During an interview on 8/8/23, at 11:25 a.m., Resident 1 stated three pants and three sweaters have gone missing since his admission to the facility in May 2023. Resident 1 stated he often receives clothes from other residents and sees his clothes being worn by other residents. During an interview on 8/8/23, at 11:35 a.m., Resident 2 stated he has had clothes missing since arriving at the facility. During an interview on 8/8/23, at 2:20 p.m., the Social Services Director (SSD) stated she was responsible for the facility ' s theft and loss and program for resident property. The SSD stated a key interventions undertaken by the facility to prevent theft and loss of resident property were labeling…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 develop and implement a care to address the offensive behavior of one of one resident (Resident 3). This failure placed other residents at risk of having their quality of life at the facility disrupted by Resident 3 ' s offensive behavior. Findings: During an interview on 8/8/23, at 11:25 a.m., Residents 1 and 2, who are roommates, stated their former roommate defecated and urinated on the floor of the room a few weeks ago. Resident 1 and 2 stated the whole floor was covered with feces and urine, remained so until staff came to clean the room. In the meantime, Residents 1 and 2 stated they felt trapped in their beds because it was impossible to leave their beds without stepping onto feces and urine. Residents 1 and 2 also reported with they felt disgusted by the offensive sights and smells of Resident 3 ' s bowel and bladder incontinence in the room. A review of the facility census for June and July 2023 indicated Resident 3 shared the same room with Residents 1 and 2 until 6/29/23, after which he was transferred to…

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

Based on interview and record review, the facility failed to provide speech therapy (treatment for speech, language, and swallowing disorders) in the frequency ordered of three times a week for two of two residents (Residents 1 and 4). This failure had the potential to impair Residents 1 and 4 swallowing and verbal communication abilities. Findings: During an interview on 7/14/23, at 2:20 p.m., Resident 1 stated he was not receiving speech therapy in the frequency ordered. A review of Resident 1 ' s physician ' s order indicated order dated 5/8/23 for speech therapy three times a week for four weeks. During an interview on 8/8/23, at 4:45 p.m., the Speech Language Therapist (SLT) stated she was treating Resident 1. The SLT stated Resident 1 was receiving speech therapy for aphasia (difficulty with sound production and language processing). The SLT stated Resident 1 had an order for speech therapy three times a week and had been receiving therapy continuously since his admission in May. The SLT stated thrice a week treatment was the standard for speech therapy. The SLT stated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and records review, the facility failed to ensure a Quarterly Minimum Data Set ((MDS - an assessment tool completed by clinical staff to identify potential resident problems, strengths, and preferences) was completed for 9 of 19 sampled residents (Resident 22, 41, 58, 14, 3, 23, 46, 33, and 36) and 2 randomly selected residents (Resident 178, and 176). This failure resulted in inadequate monitoring of Residents 22, 41, 178, 176, 58, 14, 3, 23, 46, 33, and 36's progress and decline, and the lack of resident specific information to CMS (Centers for Medicare & Medicaid Services) for payment and quality measure monitoring. Findings: During an electronic record review for Resident 178, the MDS Tracking indicated a quarterly MDS assessment for Resident 178 dated 11/26/2022. The assessment status indicated, In Progress. During an electronic record review for Resident 22, the MDS Tracking indicated a quarterly MDS assessment for Resident 22 dated 10/19/2022. The assessment status indicated, In…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide activities that met individual resident's needs and preferences, per facility Activity policy and procedure, when 1.a.) 5 of 5 Confidential Residents (CR 1, 2, 3, 4, and CR 5) and 1 of 3 Unsampled Resident (Resident 57) were not provided group/social activities per their liking, 1.b.) Leadership personnel (Infection Preventionist and Activity Director) canceled scheduled group/social activities despite State liberalization of Covid mitigation measures (interventions designed to decrease spread of COVID 19, viral pandemic (widespread disease epidemic over several countries) that began in 2020) and 2) 2 of 3 Unsampled Residents (Resident 172 and Resident 181) were not provided individual activities per their care plans. These failures contributed to Resident 57, CR 4, CR 2, and CR 5 feeling bored, prevented residents who desired organized group activities from socializing, and potentially caused Residents 172 and Resident 181 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, intervention and record review, the facility: 1). Failed to ensure the Registered Dietitian (RD) provided services to meet the needs of the residents when nutritional assessments (overall nutritional status of patients) were routinely done remotely, without direct observation of the resident and without resident (or responsible party) interviews; 2) Failed to ensure the Registered Dietitian (RD) provided adequate oversight in the kitchen, per job description, when a) dietary staff, did not have documented job related competencies (verified skills required to perform duties) in their employee file and b) the dietary manager was evaluated by the Administrator; and 3) Failed to ensure the RD addressed resident complaints regarding food quality/palatability. These failures potentially prevented accurate and timely resident nutritional assessments, contributed to inadequate oversight of dietary services, contributed to poor food quality and palatability, and potentially negatively affected…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 activities that met individual resident's needs and preferences when 2 confidential residents (CR 2 and and CR 5) were not provided social dining per their preference and the facility routinely closed the dining room despite State liberalization of Covid mitigation measures (interventions designed to decrease spread of COVID 19, viral pandemic beginning in 2020). These failures caused Confidential Residents 2 and 5 to feel isolated and prevented all residents desiring group dining from socializing in the dining room during meals. Findings: Review of facility document (untitled/undated; provided by facility upon survey entrance on 1/9/2023) indicated the facility had three dining rooms. The document indicated, Locations of Dining rooms . 1. Back Dining room [ROOM NUMBER]. RNA Dining room [ROOM NUMBER]. Station #3 Dining Room. The document was updated on 1/11/2023 and indicated, Locations of Dining Rooms .Large Dining Room = Station…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and records review, the facility failed to ensure the prescribing physician obtained informed consent for one of five sampled residents selected for unnecessary medication review (Resident 24) prior to the administration of a psychotropic medication (medications which affects mood or behavior). This failure did not provide Resident 24's Responsible Party the right to be fully informed regarding care and treatment in order to make health care decisions for the Resident 24. Findings: During a record review for Resident 24, the Face sheet indicated Resident 24 was admitted on [DATE] with diagnoses including Dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities) with Behavioral Disturbance and Psychosis (severe mental disorder). The Face sheet indicated Family Member Q was the responsible party for Resident 24. During a record review for Resident 24, the Minimum Data Set (MDS -health status screening and assessment tool used for all…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 records review, the facility failed to ensure residents' MDS assessments (Minimum Data Set - an assessment tool completed by clinical staff to identify potential resident problems, strengths, and preferences assessments) were transmitted within 14 days after completion for 7 of 19 sampled residents (Resident 14, 25, 28, 37, 52, 56, and 169) and 5 randomly selected residents (Resident 2, 30, 35, 179 and 180). This failure resulted in lack of resident specific information to CMS (Centers for Medicare & Medicaid Services) for payment and quality measure monitoring. Findings: During an electronic record review for Resident 169, the MDS Tracking indicated Resident 169's quarterly MDS assessment dated [DATE] was completed on 11/23/2022 with a submit by date of 12/07/2022. The assessment status indicated, Export Ready. During an electronic record review for Resident 28, the MDS Tracking indicated Resident 28's quarterly MDS assessment dated [DATE] was completed on 8/18/2022 with a submit by date…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and records review, the facility failed to ensure the Minimum Data Set (MDS - an assessment tool completed by clinical staff to identify potential resident problems, strengths, and preferences) was accurately completed for 6 of 19 sampled residents (Resident 17, 4, 39, 19, 9, and 118) and 6 randomly selected residents (Resident 2, 173, 24, 20, 174, and 175) when they did not receive the recommended Pneumococcal vaccine; however, Section O0300 of their MDS indicated their Pneumococcal vaccination was up to date. This failure resulted in residents not getting the recommended Pneumococcal vaccine and putting them at risk for increased respiratory infections. (Reference F883). Review of the Pneumococcal Vaccine Timing for Adults indicated, CDC recommends 1 dose of PPSV23 at age [AGE] years or older. Administer a single dose of PPSV23 at least 1 year after PCV13 was received. Their pneumococcal vaccinations are complete. https://www.cdc.gov/vaccines/vpd/pneumo/downloads/pneumo-vaccine-timing.pdf…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, investigation and record review, the facility failed to ensure 1) there were sufficient and competent nursing staff available to care for residents during both day to day operations and emergencies. 2) the licensed nurses had upon hire and annually, completed the nursing competency check to ensure they were competent to provide safe nursing care to the residents. 3) the call light (a means of communication for patients to their care providers that are outside of the patient's room) was within reach for eight out of eight sampled residents (Residents 9, 17, 34, 41, 49, 120, 218 and 220). This failure resulted in 1. the facility not meeting the nursing staffing needs based on the facility assessment for 30 out of 30 days for November 2022, 31 out of 31 days for the December 2022 and 10 out of 10 days for December 2023. 2. missing and incomplete nursing competency check for five out of five sampled licensed nurses (Licensed Staff E, F, G, H and ADON). 3. late provision of care due to long wait time for staff to answer call lights and residents fearing for their…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 records review, the facility failed to ensure that medication drug regimen for one of five sampled residents (Resident 24), who received psychotropic medication was reviewed for irregularities at least once a month according to facility policy. This failure had the potential to result in side effects that could go undetected by licensed staff and delay for the physician to act upon irregularities. Findings: During a record review for Resident 24, the Face sheet indicated Resident 24 was admitted on [DATE] with diagnoses including Dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities) with Behavioral Disturbance and Psychosis (severe mental disorder). The Face sheet indicated Family Member Q was the responsible party for Resident 24. During an electronic record review for Resident 24, the Current Order Medication History for Resident 24 indicated Resident 24 was started on Abilify 2 mg (a drug used to treat certain mental/mood…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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, interview and records review, the facility failed to ensure medication error rate was below 5% when three of four Licensed Nurses (Licensed Staff E, F and G) were observed for medication pass and did not follow the manufacturer's recommendations and doctor's order regarding administration of medication for three residents (Residents 176, 28, and 177) which resulted in seven medication administration errors out of 31 administration opportunities (21% error rate). This failure had the potential to compromise the absorption of the medication and the risk of compromising the resident's health and well-being for not getting the right medication and required dose of medication according to the doctor's order. Findings: Resident 176 During a record review for Resident 176, the Face sheet (A one-page summary of important information about a resident) indicated Resident 176 was admitted on [DATE] with diagnoses including Diabetes Mellitus (disease that result in too much sugar in the blood). During…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 records review the facility failed to: 1. Maintain medication room temperature according to manufacturer's guidelines when the facility's emergency kit (E-kit - contain a small quantity of medications that can be dispensed when pharmacy services are not available) containing antibiotics (a medicine that inhibits the growth of or destroys microorganisms) was stored above 77°F (77 degrees Fahrenheit). This failure had the potential risk of bacterial growth and sub-potent antibiotics which could lead to more serious illnesses and antibiotic resistance. 2. Remove an expired bottle of Prosight (eye supplement) with vitamins and minerals from the medication cart; expired acetaminophen (fever reducer) suppository and expired bottle of Stomahesive protective powder (intends to absorb moisture and protect skin from damage) from the shelf of the facility's central supply room. This failure resulted in a medication error and a potential risk for less effective medication. 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 interview, and facility document review, the facility's Quality Assurance and Performance Improvement Program (QAPI, a data driven and proactive approach to quality improvement. It combines two approaches - Quality Assurance (QA) and Performance Improvement (PI). QA is a process used to ensure services are meeting quality standards and assuring care reaches a certain level.) failed to identify quality deficiencies as evidenced by: 1) Residents smoking assessments were not being completed timely, the residents were smoking in a non-designated smoking area, by the side of the building a few feet away from the exit door and this area did not contain a fire extinguisher (Cross Reference F689); 2) The facility did not provide Trauma Informed Care in services so staff could provide appropriate and compassionate care specific to individuals who had experienced trauma (Cross reference F699) 3) The facility's Registered Dietician (RD) provided inadequate oversight in the kitchen/dietary department which resulted in dietary staff not knowing how to sanitize items adequately. 4) 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 observations, interviews, and record reviews, the facility failed to implement measures to reduce the risk of disease and infection transmission when: 1) Transmission based precautions (additional measures focused on the particular mode of transmission and are always in addition to standard precautions) were not followed for one resident (Resident 168) when Resident 168's wound was positive for MRSA (Methicillin resistant Staphylococcus aureus - infection is caused by a type of staph bacteria that's become resistant to many of the antibiotics used to treat ordinary staph infection) and his wound drain was intermittently opened and the drainage was not contained. This failure caused potential spread of MRSA in the environment. 2) Four residents (Resident 182, 169, 23 and 3) were not offered hand hygiene before meals. This failure had the potential risk for residents of getting sick from common germs including Escherichia coli (E. coli) which can cause stomach aches and vomiting. 3) Licensed Staff F did…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and records review, the facility failed to offer the pneumococcal vaccine recommended by the Advisory Committee on Immunizations Practices (ACIP- provides advice and guidance to the Director of the CDC [Centers for Disease Control] regarding use of vaccines and related agents for control of vaccine-preventable diseases in the civilian population of the United States.) for 6 of 19 sampled residents (Resident 17, 4, 39, 19, 9, and 118) and 6 randomly selected residents (Resident 2, 173, 24, 20, 174, and 175). This failure had the potential risk for residents to acquire and transmit pneumococcal bacteria that could result in serious respiratory infections. The Centers for Disease Control and Prevention (CDC) recommended revaccination of PPSV23 (Pneumococcal polysaccharide vaccine - also known as Pneumovax 23) at least 1 year after PCV13 (Pneumococcal conjugate vaccine) dose and at least 5 years after any PPSV23 dose for resident over [AGE] years old with underlying medical condition or other…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 1) residents who smokes cigarettes were allowed to smoke in the designated smoking area only for 3 out of 3 sampled residents (Resident 119, 28 and 53), and 2) residents who smoke have a smoking safety screen completed quarterly for six out of eight sampled residents (Resident 50, 53, 28, ,224, 225 and 226). These failures were a safety risk that could lead to unsafe smoking practices. Findings: During a smoking safety screen record review on 1/10/22 at 10:30 a.m., the following residents had late smoking safety screen assessment: Resident 53's last assessment was on 8/4/21, Resident 28's last assessment was 8/10/22, Resident 224 last smoking assessment was on 8/9/22, Resident 225's last assessment was on 8/9/22, Resident 50's last assessment was on 4/7/22 and resident 226's last assessment was on 8/10/22. During an observation on 1/10/23 at 11:30 a.m., Resident 53 was observed to be smoking in a non-designated smoking area, on the side of the facility building a few feet away from the exit door. This…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 comprehensive assessment for one of 19 sampled residents (Resident 24) when a Minimum Data Set (MDS - an assessment tool completed by clinical staff to identify potential resident problems, strengths, and preferences) was not completed within 14 days of Resident 24's admission to hospice services. This failure resulted in an inaccurate representation of Resident 24's current clinical status and had the potential to cause inadequate care based on a delinquent comprehensive assessment and care planning. Findings: During a record review for Resident 24, the Face sheet (A one-page summary of important information about a resident) indicated Resident 24 was admitted on [DATE] with diagnoses including Malignant Neoplasm of Right Ovary (cancer of the ovary [a female reproductive organ in which ova or eggs are produced, present in humans and other vertebrates as a pair]; Chronic Obstructive Pulmonary Disease (COPD - diseases that cause airflow…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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, interview, and record review, the facility failed to meet professional standards during medication pass observation for 2 of 19 sampled residents (Resident 28 and Resident 43) when: 1. Licensed Nurse administered Sodium Chloride tablet (also known as salt) to Resident 28 when there was no physician's order for the medication. 2. Licensed Nurse administered Prosight with vitamins and minerals to Resident 28 that was expired. 3. Licensed Nurse did not provide instruction to Resident 28 on how to properly administer the Albuterol oral inhaler (used to prevent and treat difficulty breathing, wheezing, shortness of breath, coughing, and chest tightness). 4. Licensed Nurse did not notify the physician when Resident 43's blood sugar was 416 Findings: Resident 28 During a medication observation on [DATE] at 8:47 a.m., Licensed Staff F prepared ten oral medications for Resident 28 which included Sodium Chloride tablet 1000 mg (also known as salt) and Prosight with vitamins and minerals. 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 records review, the facility failed to ensure that nutritional care and services were provided to one of two sampled residents (Resident 170). Resident 170 had a weight loss of eight pounds which yielded to 9.89 percent weight loss in a month from 12/05/2022 to 01/08/2023. This deficient practice had the potential to result in Resident 170's further unplanned weight loss. Findings: During an observation on 1/09/23 at 10:40 a.m. in Resident 170's room, Resident 170 was sitting in her wheelchair looking at the window. When Resident 170 was asked if she had any concern about her care, Resident 170 stated she was concerned about being thin and wanted to keep up with her weight. During a record review for Resident 170, the Face sheet (A one-page summary of important information about a resident) indicated Resident 170 was admitted on [DATE] with diagnoses including Left Femur Fracture (a break in the thigh bone), Chronic Obstructive Pulmonary Disease (COPD - diseases that 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 observations, interviews and record reviews, the facility failed to ensure residents received Trauma Informed Care (TIC, an intervention and organizational approach that focuses on how trauma may affect an individual's life and his or her response to behavioral health) which accounted for resident's experiences and preferences for two out of two sampled residents (Resident 220 and 171). This failure resulted in the facility's inability to identify possible triggers that could result in re-traumatization (the reactivation of trauma symptoms via thoughts, memories, or feelings related to the past torture experience). Findings: Resident 220 was [AGE] years old, initially admitted to the facility on [DATE]. His diagnoses include Post Traumatic Stress Disorder (PTSD, a mental health condition that's triggered by a terrifying event - either experiencing it or witnessing it. Symptoms may include flashbacks, nightmares and severe anxiety, as well as uncontrollable thoughts about the event), Diabetes Mellitus…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 Director of Nursing (DON) only worked as a charge nurse if the facility census was 60 and below. This resulted in the DON working as a charge nurse on the floor seven times between 10/2022 and 12/2022 on different shifts and there was no DON coverage at those times. Findings: During an interview on 1/17/23 at 12:52 p.m., the Staffing Coordinator verified the DON also works as a charge nurse to cover a shift if they were not able to find a nurse to work on the floor. The staffing coordinator verified the DON worked on these dates: 10/5, Wednesday morning shift, 10/16 Sunday afternoon shift, 10/19 Wednesday morning shift, 10/22 Saturday afternoon shift, 10/25 Tuesday night shift, 11/3Thursday morning shift and 12/24 Saturday afternoon and night shift. The staffing coordinator verified the census was above 60 during these days. During an interview on 1/17/23 at 12:55 p.m., the DON stated she does work as a charge nurse at times. She stated it could either be on the morning, afternoon or the night shift…

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