Colonial Gardens Nursing Home

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to inform Physician 1 and Conservator 1 of an abuse allegation for one of three sampled residents (Resident 5).This deficient practice resulted in a delay in potential medical and psychiatric evaluations and resulted in Conservator 1 being unaware of Resident 5's well-being.Findings:During a review of Resident 5's admission Record (Face Sheet), the Face Sheet indicated Resident 5 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included nontraumatic chronic subdural hemorrhage (a slow collection of blood on the surface of the brain that develops over time, without being caused by a severe head injury), 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).During a review of Resident 5's Minimum Data Set (a resident assessment tool), dated 9/14/2025, the MDS indicated Resident 5's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to report an abuse allegation to the State Agency (California Department of Public Health [CDPH]), the ombudsman (an advocate for residents of nursing homes, board and care centers, and assisted living facilities), and local law enforcement for one of three sampled residents (Resident 5).This deficient practice resulted in a delayed notification to CDPH, the ombudsman, and law enforcement and also resulted in a delay of an onsite inspection This deficient practice had the potential to result in potential abuse to all residents in the facility.Findings:During a review of Resident 5's admission Record (Face Sheet), the Face Sheet indicated Resident 5 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included nontraumatic chronic subdural hemorrhage (a slow collection of blood on the surface of the brain that develops over time, without being caused by a severe head injury), schizophrenia (a mental illness that is…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop a person-centered care plan for one of three sampled residents' (Resident 5) after Resident 5 informed Licensed Vocational Nurse (LVN) 11 of an abuse allegation.This deficient practice had the potential to negatively affect Resident 5's physical, mental, and psychosocial well-being, delay the delivery of necessary care and services.Findings:During a review of Resident 5's admission Record (Face Sheet), the Face Sheet indicated Resident 5 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included nontraumatic chronic subdural hemorrhage (a slow collection of blood on the surface of the brain that develops over time, without being caused by a severe head injury), 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).During a review of Resident 5's Minimum Data Set (a resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement the Care Plan for one out of five sampled residents (Resident 2), who had a diagnosis of schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior) and exhibited increased in behaviors.This failure had the potential to result in Resident 2 having ongoing behaviors which could lead to altercations that endanger himself, other residents, and staff at the facility.During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was admitted to the facility on [DATE] and readmitted on [DATE]. The admission Record indicated Resident 2's diagnoses included schizoaffective disorder.During a review of Resident 2's Minimum Data Set ([MDS] a resident assessment tool), dated 7/21/2025, the MDS indicated Resident 2 had severe cognitive impairment (problems with the ability to think and reason). Resident 2's MDS indicated Resident 2 required supervision or touching assistance (Helper provides verbal…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This is a Repeat Deficiency at F609 from 6/24/2025 investigation. Based on interview and record review, the facility failed to report abuse allegations to the State Agency (California Department of Public Health [CDPH]), the ombudsman (an advocate for residents of nursing homes), and local law enforcement for three of seven sampled residents (Residents 5, 6, and 7) when Certified Nursing Assistant (CNA) 5 allegedly was rough with Residents 5, 6 and 7. This repeat deficient practice of delayed notification to CDPH, the ombudsman, and law enforcement resulted in a delay of an onsite inspection and had the potential to result in abuse to all residents in the facility.During a review of the facility's Plan of Correction / In-Service Training titled, Reporting Alleged Violations, dated 6/25/2025 and 6/26/2025, presented by the Director of Staff Development (DSD), the In-Service indicated the Director of Nursing (DON), the Administrator (ADM), Certified Nursing Aide (CNA) 3, and CNA 4 were all educated to report any…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This is a Repeat Deficiency at F610 from 6/24/2025 investigation. Based on interview and record review, the facility failed to thoroughly investigate an allegation of abuse for one of seven sampled residents (Resident 7), when Resident 7 informed Social Services (SS) 1, on 7/22/2025, that Certified Nursing Assistant (CNA) 5 was rough during facial shaving. This deficient practice resulted in CNA 5 not being suspended pending the investigation of the allegation and placed Resident 7 and all the residents in the facility at risk for further potential abuse.Cross Reference F609Findings:During a review of Resident 7's admission Record (Face Sheet), the admission Record indicated Resident 7 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including encephalopathy (a medical condition where the brain does not function properly), schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), and anxiety disorder (mental health condition characterized by…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of seven sampled resident (Resident 4's) care plan was reviewed and revised with updated interventions to address Resident 4's behavior of pocketing medications. This deficient practice resulted in Resident 4 having medication in his possession without staff knowledge and an increased risk for adverse medication reactions. Cross Reference F755.Findings:During a review of Resident 4's admission Record, the admission Record indicated Resident 4 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including paranoid schizophrenia (a subtype of schizophrenia with prominent delusions and hallucinations often involving false beliefs of being watched or targeted), and anxiety disorder (feeling of fear, dread and uneasiness that can be a normal reaction to stress). During a review of Resident 4's care plan titled, Behavior Problem, revised 6/13/2025, the care plan indicated Resident 4 had a behavior…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure medications were administered to meet the needs of each resident and in accordance with professional standards of practice for one of seven sampled residents (Resident 4). Resident 4 was observed with two medications in hand, without staff knowledge. This deficient practice resulted in Resident 4 not receiving the correct dose of medication, and the potential for other residents to receive medications not prescribed to them.Cross Reference F657Findings:During a review of Resident 4's admission Record, the admission record indicated Resident 4 was readmitted to the facility on [DATE] with diagnoses including paranoid schizophrenia (a subtype of schizophrenia with prominent delusions and hallucinations often involving false beliefs of being watched or targeted) and anxiety disorder (feeling of fear, dread and uneasiness that can be a normal reaction to stress). During a review of Resident 4's Minimum Data Set (MDS- a 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.

Based on interview and record review, the facility failed to ensure the Quality Assurance and Performance Improvement (QAPI) Committee / Quality Assessment and Assurance (QAA) implemented action plans to correct previously identified abuse allegation deficiencies from June 2025. This repeat deficient practice caused an increased risk in the safety and dignity of the residents of the facility. Findings: During a review of the facility's Plan of Correction from a previous abuse deficiency dated June 2025 and the In-Service Training titled, Reporting Alleged Violations, dated 6/25 and 6/26/2025, presented by the Director of Staff Development (DSD), the In-Service indicated the Director of Nursing (DON), the Administrator (ADM), Certified Nursing Aide (CNA) 3, and CNA 4 were all educated to report any abuse allegations immediately and for up to two hours to the CDPH, the ombudsman, and law enforcement. During a review of the facility's Performance Improvement Plan - Abuse Investigation and Reporting dated 7/1/2025, the plan indicated the root cause was communication when an incident…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 inform one of three sampled residents' (Resident 1) physician of the resident's Responsible Party's (RP 1) decision to not have a Computed Tomography (CT- a medical imaging procedure to create detailed images of the head) done after Resident 1 was found to have discoloration on his forehead. This deficient practice resulted in Physician 1 being unaware of RP 1's decision which resulted in no further ordered interventions. Findings: During a review of Resident 1's admission Record (Face Sheet), the admission Record indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included metabolic encephalopathy (condition when the brain's function is impaired due to a chemical imbalance in the body), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), and generalized muscle weakness. During a review of Resident 1's Minimum Data Set (MDS- a resident 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 interview and record review, the facility failed to report an injury of unknown origin to the State Agency (California Department of Public Health [CDPH]), the ombudsman (an advocate for residents of nursing homes, board and care centers, and assisted living facilities), and local law enforcement for one of three sampled residents (Resident 1) when Resident 1 was found to have discoloration on the right side of his forehead. This deficient practice of delayed notification to CDPH, the ombudsman, and law enforcement resulted in a delay of an onsite inspection. This deficient practice had the potential to result in further injury to Resident 1. Cross Reference F610. Findings: During a review of Resident 1's admission Record (Face Sheet), the admission Record indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included metabolic encephalopathy (condition when the brain's function is impaired due to a chemical imbalance in the body), depression…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 thoroughly investigate an injury of unknown origin for one of three sampled residents (Resident 1) when Resident 1 was found to have discoloration on the right side of his forehead. This deficient practice resulted in the facility being unaware of the cause of Resident 1's injury. Cross Reference F609. Findings: During a review of Resident 1's admission Record (Face Sheet), the admission Record indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included metabolic encephalopathy (condition when the brain's function is impaired due to a chemical imbalance in the body), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), and generalized muscle weakness. During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool), dated 6/9/2025, the MDS indicated Resident 1's cognitive skills (process of thinking) for daily decision making 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 one of three sampled residents (Resident 1) was free of accidents and hazards after falling on 4/10/2025 by failing to: 1. Complete Resident 1's 72-Hour Neurological Check (Neuro Check- series of tests over a 72-hour period to assess for changes in neurological function). 2. Complete Resident 1's post-fall Fall Risk Assessment. 3. Compete the documentation for the Interdisciplinary Team (IDT, a group of healthcare professionals with various areas of expertise who work together towards the goals of the residents) meeting on 4/11/2025. These deficient practices had the potential to result in Resident 1 sustaining undetected neurological changes which could have resulted in delay in treatment. These deficient practices also had the potential to result in the risks and root cause of Resident 1's fall to be unaddressed which increases the potential for reoccurrence of further falls and injury. Findings: During a review of Resident 1's admission…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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: 1. Remove one bottle of expired cetirizine hydrochloride (medication to relieve allergy symptoms) 5 milligrams (mg- metric unit of measurement, used for medication dosage and/or amount) inside one of two inspected medication carts (Main St Medication Cart). 2. Remove one bottle of expired haloperidol decanoate (antipsychotic medication [to treat psychosis- a severe mental illness where individuals experienced a distorted perception of reality) in one of two inspected medication rooms (Medication Room Nursing Station 2). These deficient practices increased the risk that residents could have received medications that had become expired and/or ineffective, possibly leading to health complications such as uncontrolled allergy symptoms and uncontrolled mental behaviors such as delusions (having false or unrealistic beliefs). Findings: 1. During a concurrent observation and interview on 5/21/2025 at 2:26 p.m. with Licensed Vocational Nurse (LVN) 2, observed one bottle of expired cetirizine hydrochloride 5 mg…

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

Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen when: 1. Two containers that contained personal food were stored inside Refrigerator 1. 2. One opened bottle of chocolate syrup, one opened bottle of caramel drizzle, one opened can of whipped cream and one container of white chopped onions were stored and unlabeled in the walk-in refrigerator. 3. One opened carton of ice cream was stored in the walk-in freezer unlabeled. These failures had the potential to result in harmful bacterial growth and cross contamination (transfer of harmful bacteria from one place to another) that could lead to foodborne illness (a disease caused by consuming food or drinks that are contaminated by germs or chemicals) in 95 of 99 medically compromised residents who received food from the kitchen. Findings: 1. During a concurrent interview and observation on 5/19/2025 at 8:24 a.m. with Dietary Aide (DA) 1, in the facility kitchen, Refrigerator 1 was observed. Refrigerator 1 had two personal plastic…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the safe medications administrations for two of six residents (Resident 17 and Resident 76) when the following occurred: 1. 40 out of 40 doses of oyster shell calcium (a dietary supplement) 500 milligrams (mg- metric unit of measurement, used for medication dosage and/or amount) were not administered to Resident 17 from 5/1/2025 to 5/20/2025. 2 a. Two out of 38 doses of tramadol HCl (a strong painkiller from a group of medicines called opiates, or narcotics) 50mg for Resident 76 on North Station, North Medication Cart on 5/21/2025 were not accurately accounted for and documented. b. Two out of 19 doses of lorazepam (a controlled medication [had a high potential for abuse] could be used to aid in the management of agitation) 1mg for Resident 76 on North Station, North Medication Cart on 5/21/2025 were not accurately accounted for and documented. c. One out of 11 doses of hydrocodone-acetaminophen (a strong painkiller from a group of…

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

Based on observation, interview, and record review, the facility failed to ensure that resident bedrooms accommodated no more than four residents in four of 42 bedrooms (Rooms A, B, C, and D). This deficient practice could adversely affect the adequacy of space, nursing care, comfort, and privacy to the residents and their visitors residing in Rooms A, B, C, and D. Findings: During a review of the facility's census, dated 5/19/2024, the census indicated Rooms A, B, C, and D had the capacity to accommodate six residents in the room. During a review of the facility's Client Accommodation Analysis (undated), the Client Accommodation Analysis indicated the following measurements for Rooms A, B, C, and D: 1. Rooms A and B measured 478.33 square feet ([sq. ft.]- unit of measurement). 2. Room C measured 487.44 sq. ft. 3. Room D measured 479.79 sq. ft. During the initial tour of the facility, on 5/19/2025 at 9:30 a.m., it was observed Rooms A, B, C, and D were occupied by six residents in each room. During observations made throughout the course of the survey from 5/19/2025 to 5/22/2025,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 choices were honored for one of three residents (Resident 74) when the resident was not permitted to take requested smoke breaks. This failure interfered with Resident 74's right to make choices about his routine and preferences. Findings: During a review of Resident 74's admission Record, the admission record indicated Resident 74 was initially admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses which included chronic obstructive pulmonary disease (COPD - a chronic lung disease causing difficulty in breathing), alcohol abuse, hypertension (HTN - high blood pressure), bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), and depression (mood disorder that causes a persistent feeling of sadness and loss of interest in life). During a review of Resident 74's History and Physical (H&P), dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to obtain informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered) from the residents prior to treatment of psychotropic (medications that affect brain activities associated with mental processed and behavior) medications for two of six sampled residents (Residents 40, and 64) by failing to: 1. Obtain informed consent from Resident 40, for the use of Quetiapine Fumarate (an antipsychotic medication [a medication that effects the mind, emotion, and behavior]). 2. Ensure Resident 64's informed consent for Depakote (an anticonvulsant medication used to treat behavioral disorders), Risperdal (an antipsychotic medication), and Seroquel (an antipsychotic medication) were complete. The deficient practice of failing to obtain informed consent prior to initiating treatment with psychotropic medications could have prevented Residents 40 and 64 from exercising 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 observation, interview, and record review, the facility failed to ensure a call light device was within reach for one of eight sampled residents (Resident 47). This deficient practice resulted in Resident 47 being unable to summon staff for assistance in a timely manner and had the potential to compromise Resident 47's safety and care. Cross Reference F919 Findings: During a concurrent observation and interview on 5/19/2025 at 10:07 a.m., with Resident 47, Resident 47 was observed in his room, lying in bed awake and alert. Resident 47's call light was observed hanging from a hook on the wall out of reach. Resident 47 stated that he was cold and asked if he could be covered with his blanket. Resident 47 stated he could not reach his call light, and the call light had not worked for months. During a review of Resident 47's admission Record, the admission Record indicated Resident 47 was initially admitted on [DATE] and readmitted on [DATE] with diagnoses which included bilateral (on both sides)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 Ombudsman (an advocate for residents of nursing homes, board and care centers, and assisted living facilities) and one of two residents (Resident 98) was provided a notice of discharge prior to the resident's discharge on [DATE]. This deficient practice increased the risk of potential harm to Resident 98 and breach of the resident's rights. Findings: During a review of Resident 98's admission Record, the admission Record indicated Resident 98 was admitted to the facility on [DATE]. Resident 98's diagnoses included generalized muscle weakness, dementia (a progressive state of decline in mental abilities), and diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 98's Minimum Data Set (MDS- a resident assessment tool), dated 12/26/2024, the MDS indicated Resident 98 had mild cognitive impairment (ability to think and reason). The MDS indicated Resident 98…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 the Minimum Data Set (MDS - a federally mandated resident assessment tool) for significant change in status within the required time frame for one of six sample residents (Resident 40). This failure had the potential to negatively affect Resident 40 receiving the necessary care services that would have been required due to their significant change in status. Findings: During a review of Resident 40's admission Record dated 11/1/2024 the admission Record indicated the facility initially admitted Resident 40 on 11/1/2024, and re-admitted Resident 40 on 3/28/2025 with diagnoses that included dementia (a progressive state of decline in mental abilities) metabolic encephalopathy (a condition that affects the brain due to problems with the body's metabolism), diabetes mellitus (DM - a disorder characterized by difficulty in blood sugar control and poor wound healing). Resident 40 also had a gastrostomy feeding tube (a surgical opening fitted with 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 accurately complete the minimum data set (MDS - a comprehensive resident assessment tool) assessment Section I (active diagnoses) by failing to include a diagnosis of depression (a mental disorder characterized by depressed mood, poor appetite, difficulty sleeping, and lack of interest in normal enjoyable activities) per information in the medical record for one of six sampled residents (Resident 54). The deficient practice of failing to accurately assess active diagnoses and complete MDS Section I increased the risk that Resident 54 may not have received care planning and treatment according to his needs possibly leading to a decline in his overall health and well-being. Findings: During a review of Resident 54's admission Record, the admission Record indicated Resident 54 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included depression (a mental disorder characterized by depressed mood, poor…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 following for three of 12 sampled residents (Resident 17, 54, and 61): 1. Develop and implement a care plan for Resident 17's diagnosis of vitamin D deficiency (low levels of vitamin D in the body), and the administration of oyster shell calcium (a dietary supplement), Trazodone (a medication used to treat depression [mental health disorder]), and Buspirone (a medication used to treat anxiety [a feeling fear, and worry]). 2. Develop and implement a care plan addressing Resident 54's diagnosis of depression. 3. Implement Resident 61's care plan addressing the resident's oxygen therapy and diagnosis of chronic obstructive pulmonary disease (COPD- a chronic lung disease causing difficulty in breathing). These deficient practices placed Residents 17, 54, and 61 at risk of not receiving care and resident-centered interventions to meet and address their needs and had the potential to result in oxygen toxicity (lung damage from too much extra…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 provide safe enteral nutrition (the delivery of liquid nutrients through a feeding tube directly into the gastrointestinal tract) for one of six sampled residents (Resident 40), when Resident 40's head of bed was not maintained in an elevated 30 to 45 degrees (refers to an angle of position) position while receiving enteral nutrition by gastrostomy tube (GT - a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems). This failure had the potential for resident harm and or death, as the provision of enteral feedings without elevating Resident 40's resting position increased the risk for vomiting and aspiration pneumonia, which may be caused when liquid nutrition and/or other stomach contents enter a person's airway and/or lungs. Findings: During a review of Resident 40's admission Record. dated 11/1/2024, and re-admitted Resident 40 on 3/28/2025, with diagnoses that included gastrostomy status, dementia (a progressive state…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 respiratory care was provided according to physician's orders and professional standards of practice for one of three residents reviewed for oxygen therapy (Resident 61) when the following occurred: 1. Staff administered continuous oxygen at a rate of 4.5 liters per minute (LPM- a unit of measurement), exceeding the prescribed rate of two liters per minute as needed. 2. Resident 61 was observed unmonitored in the facility patio with increased respirations without his supplemental oxygen. 3. Staff failed to ensure the amount of oxygen administered to Resident 61 was documented from 4/29/2025 to 5/20/2025. These failures had the potential to place Resident 61 at risk for oxygen toxicity (lung damage from too much extra oxygen) and respiratory distress, and compromise Resident 61's safety. Findings: During a review of Resident 61's admission Record, the admission Record indicated Resident 61 was originally admitted to the facility on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure residents were monitored for medication side effects or efficacy of medication for two of 12 sampled residents (Residents 17 and 29), by failing to: 1. Monitor signs and symptoms of bleeding for Resident 17, who was receiving Eliquis (an anticoagulant medication, used to prevent blood clots forming in the blood vessels and the heart). 2. Monitor Resident 17's sleep hours, who was receiving Trazadone (a medication used to treat depression [-a mental health disorder], and insomnia [-a sleep disorder]). 3. Monitor Resident 17's episodes of physical restlessness (behaviors such as agitation, inability to sit still) constantly trying to get up unassisted, who was receiving Buspar (a medication used to treat anxiety [-a feeling fear, and worry]). 4. Monitor signs and symptoms of bleeding for Resident 29, who was receiving Apixaban (an anticoagulant medication). These deficient practices placed Residents 17 and 29 at increased risk for preventable…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 physician ordered therapeutic diets were provided for one of six sampled residents (Resident 90), when Resident 90 did not receive their Magic Cup (a frozen dessert used for providing additional calories and protein to those experiencing involuntary weight loss). This failure could have resulted in insufficient food intake, unintentional weight loss, and a deterioration of Resident 90's overall health condition. Findings: During a review of Resident 90's admission Record, dated 11/8/2024, the admission Record indicated the facility initially admitted Resident 90 on 11/8/2024 and re-admitted Resident 90 on 2/6/2025, with diagnoses that included cerebral infarction (loss of blood flow to a part of the brain), dysphagia (difficulty swallowing), depression ( a common and serious medical illness that can significantly impact how a person feels, thinks, and acts). During a review of Resident 90's Minimum Data Set (MDS - a resident assessment tool), dated 2/14/2025, the MDS indicated Resident 90's cognition…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement infection (the invasion and multiplication of microorganisms [like bacteria, viruses, etc.] in body tissues, potentially causing illness or harm) control practices for one of six residents (Resident 40) when Resident 40's urinary catheter (a hollow tube inserted into the bladder to drain or collect urine) drainage bag was observed touching the floor on 5/20/2025. This deficient practice placed Resident 40 at risk for infection which could increase the resident's and other residents morbidity (the amount of disease in a population) and mortality (the state of being subject to death). Findings: During an observation on 5/20/2025 at 11:47 a.m. in Resident 40's room, Resident 40 was observed lying on the bed. The urinary catheter drainage bag was touching the floor. During an observation on 5/20/2025 at 1:27 p.m. in Resident 40's room, Resident 40 was observed lying on the bed. The urinary catheter drainage bag was touching the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the call system was functional for two of eight sampled residents (Resident 47 and Resident 78). This deficient practice resulted in Resident 47 being unable to summon staff for assistance in a timely manner and had the potential to result in Resident 47's and Resident 78's needs to go unmet and compromise the residents' safety and cause bodily injury from a fall. Findings: a. During a concurrent observation and interview on 5/19/2025 at 10:07 a.m., with Resident 47, Resident 47 was observed in his room, lying in bed awake and alert. Resident 47's call light was observed hanging from a hook on the wall. Resident 47 stated he was cold and asked if he could be covered up with his blanket. Resident 47 stated he could not reach his call light device. Resident 47 stated the call light device was hanging on the wall because it had been working for months. Resident 47 was handed the call light to push at 10:08 a.m. Observed the light on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to: 1. Ensure a seven-day bed hold was maintained for two of two sampled residents (Resident 1 and Resident 3) after they were transferred to the General Acute Care Hospital (GACH). This deficient practice resulted in the resident ' s rights being violated by not allowing them to return to their assigned beds in the facility per State and Federal regulations. Findings: A. During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 1 ' s diagnoses included schizophrenia (a mental illness that is characterized by disturbances in thought), hypertension (HTN-high blood pressure), and obesity (condition of having excess body weight). During a review of Resident 1 ' s Minimum Data Set ([MDS] a resident assessment tool), dated 2/7/2025, the MDS indicated Resident 1 ' s cognition (ability to reason and understand) was severely impaired. Resident 1…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure safety was maintained for one of four sampled residents (Resident 3), by not ensuring her call light was maintained within reach. This deficient practice placed Resident 3 at risk for harm and injury related to a fall. Findings: During an observation on 4/2/2025 at 11:51 a.m., at Resident 3 ' s bedside, Resident 3 was observed lying in bed. Resident 3 ' s call light was observed on the floor behind the head of her bed. During a review of Resident 3 ' s admission Record (a document containing a summary of basic information about the resident), the admission record indicated Resident 3 was admitted on [DATE] and most recently re-admitted on [DATE]. Resident 3 ' s admitting diagnoses included unspecified abnormalities of gait (walking pattern) and mobility, generalized muscle weakness, osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage) to both hips, history of falling, dementia (a progressive…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop a comprehensive, resident-centered care plan, with interventions, after the two episodes of choking (when airway is blocked by a foreign object, such as food, preventing oxygen from reaching the lungs, leading to a life-threatening situation) on 1/6/2025 and 1/15/2025 for one of five residents (Resident 2). The facility failed to provide interventions for staff to implement at dinner time for Resident 2 ' s safety. These failures left Resident 2 unsupervised during dinnertime and had potentially caused Resident 2 to aspirate (when food, liquid, or other substances entered the airway and the lungs) on 3/5/2025 and other complications such as, choking, loss of consciousness (state of being awake and aware of one ' s surroundings), apnea (not breathing) and death. Findings: During a review of Resident 2 ' s admission Record, the admission Record indicated, Resident 2 was originally admitted to the facility on [DATE] and readmitted on [DATE] with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to reassess the respiratory status on one of five residents ' (Resident 2), who had an oxygen saturation of 86% ([O2 sat] amount of oxygen in the blood- normal range 95 per cent (%)-100%) on 3/5/2025 at 5:28 p.m. As a result of this failure, Resident 2 ' s respiratory status worsened and potentially contributed to the resident ' s loss of consciousness (pass out), apnea (not breathing) and death. Findings: During a review of Resident 2 ' s admission Record, the admission Record indicated, Resident 2 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including metabolic encephalopathy (a change in how the brain works due to an underlying condition), dysphagia (difficulty swallowing), Parkinson ' s Disease (a progressive disease of the nervous system marked by a tremor, muscular rigidity, and slow, imprecise movements) and Acute Respiratory Failure ([ARF], when the lungs cannot release enough oxygen into the blood).…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide adequate supervision to one of five residents (Resident 2), after the two choking (when airway is blocked by a foreign object, such as food, preventing oxygen from reaching the lungs, leading to a life-threatening situation) incidents on 1/6/2025 and 1/15/2025. This failure left Resident 2 unsupervised while eating dinner on 3/5/2025, and had potentially caused Resident 2 to aspirate (when food, liquid, or other substances entered the airway and the lungs) and caused other complications such as, choking, loss of consciousness (state of being awake and aware of one ' s surroundings), apnea (not breathing) and death. Findings: During a review of Resident 2 ' s admission Record, the admission Record indicated, Resident 2 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including metabolic encephalopathy (a change in how the brain works due to an underlying condition), 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 ensure one of five residents (Resident 1), who was admitted to the facility with Carbapenem-Resistant Enterobacterales ([CRE], a group of bacteria resistant to carbapenem [an antibiotic]), was placed on contact precautions (measures that are intended to prevent transmission of infectious agent which are spread by direct or indirect contact with the resident or the resident's environment). This failure had the potential to spread the organisms to other residents and staff and can potentially cause infections. Findings: During a review of Resident 1 ' s admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses of Parkinson ' s disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements) without dyskinesia (uncontrolled, involuntary muscle movement) without mention of fluctuations. During a review of Resident 1 ' s Minimum Data Set ([MDS] a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow an infection prevention and control program for scabies (a contagious skin condition caused by tiny insects called mites that infest and irritate skin causing intense itching, inflammation, and red patches) for six out of six sampled residents (Resident 1, 2, 3, 4, 5, and 6) by failing to: 1. Place Residents 1, 2, 3, 4, 5, and 6 on Contact Precautions (refer to measures that are intended to prevent transmission of infectious agents which are spread by direct or indirect contact with the resident or the resident ' s environment) immediately. Resident 1 was diagnosed with scabies in the general acute care hospital (GACH) and returned to the facility on [DATE]. Resident 1, 2, 3, 4, 5, and 6 was placed on Contact Precautions on 11/5/2024, 2 days after Resident 1 returned to the facility. 2. To provide prophylactic (a medicine or course of action used to prevent disease) treatment immediately to Residents 2, 3, 4, 5, and 6 (Resident 1 ' s roommate),…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 Resident 1 ' s responsible party (RP 1), Resident 2, and Resident 2 ' s responsible party (RP 2) of their rights to participate in the resident care conference to discuss the plans of care and discharge goals for two of two sampled residents (Resident 1 and Resident 2). This deficient practice violated RP 1, Resident 2, and RP 2 ' s rights to be active participants in their care. Findings: 1. During a review of Resident 1 ' s admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE]. Resident 1 ' s diagnoses included generalized muscle weakness, anemia (a common blood disorder that occurred when the body had fewer red blood cells than normal), Type 2 diabetes mellitus (a disease that occurred when blood sugar was too high), dementia (the impaired ability to remember, think, or make decisions that interfered with doing everyday activities), schizoaffective disorder (a serious mental illness that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to notify the physician for one of two sampled residents (Resident 1) following Resident 1 sustaining a five (5) pound (lb., unit of measurement) weight loss between May 2024 and June 2024, and again following a nine (9) lb. weight loss between May 2024 and August 2024. This deficient practice placed Resident 1 at risk for delayed intervention and care plan adjustments, possibly resulting in further avoidable unplanned weight loss and not meeting her nutritional needs. Findings: During a review of Resident 1 ' s admission Record, the admission record indicated Resident 1 was originally admitted to the facility on [DATE] and was most recently re-admitted on [DATE]. Resident 1 ' s admitting diagnoses included anemia (a problem of not having enough healthy red blood cells or hemoglobin to carry oxygen to the body's tissues), dementia (group of thinking and social symptoms that interferes with daily functioning), and generalized muscle weakness.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to revise the nutritional care plan for one of two sampled residents (Resident 1) following Resident 1's five (5) pound (lb., unit of measurement) weight loss between May 2024 and June 2024, and again following a nine (9) lb. weight loss between May 2024 and August 2024. This deficient practice placed Resident 1 at risk for not receiving the required interventions to prevent further avoidable unplanned weight loss and inability to meet her nutritional needs. Findings: During a review of Resident 1 ' s admission Record, the admission record indicated Resident 1 was originally admitted to the facility on [DATE] and was most recently re-admitted on [DATE]. Resident 1 ' s admitting diagnoses included anemia (a problem of not having enough healthy red blood cells or hemoglobin to carry oxygen to the body's tissues), dementia (group of thinking and social symptoms that interferes with daily functioning), and generalized muscle weakness. During a review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of two sampled residents (Resident 1) was referred to the facility ' s Nutrition Weight Variance Committee following a five (5) pound (lb., unit of measurement) weight loss between May 2024 and June 2024, and again following a nine (9) lb. weight loss between May 2024 and August 2024. This deficient practice resulted in Resident 1 sustaining an additional one (1) lb. weight loss in August 2024, and placed her at increased the risk sustaining further avoidable unplanned weight loss and not meeting her nutritional needs. Findings: During a review of Resident 1 ' s admission Record, the record indicated Resident 1 was originally admitted to the facility on [DATE] and was most recently re-admitted on [DATE]. Resident 1 ' s admitting diagnoses included anemia (a problem of not having enough healthy red blood cells or hemoglobin to carry oxygen to the body's tissues), dementia (group of thinking and social symptoms that interferes…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 monitor for aggressive behaviors for one out of three residents (Resident 2) after the resident had consecutive and ongoing refusals of Zyprexa (an antipsychotic medication used to treat mental health conditions) for angry outbursts. This deficient practice had the potential to exacerbate Resident 2's aggression and cause harm to Resident 1. Findings: During an interview on 8/5/2024 at 9:10 a.m., Resident 2 refused to talk and stated, I don't want to talk to you . During a review of Resident 2's admission Record, the admission record indicated Resident 2 was admitted to the facility on [DATE]. Resident 2's admitting diagnosis included schizophrenia (a disorder accompanied by false beliefs, disorganized thinking, and seeing or hearing stimuli that is not real), anxiety disorder (characterized by feelings of excessive worry and fear about everyday situations), and major depressive disorder (a condition that causes persistently low 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 observation, interview, and record review the facility failed to ensure safe and sanitary food storage practices in the kitchen that placed 99 out of 99 sampled residents at risk for food borne illness (an illness that comes from eating contaminated food) when the facility failed to ensure: 1. The walk -in refrigerator contained food with no in date (the date when the food was placed in the refrigerator) and no use by date (date the food item must be consumed by). 2. The walk-in refrigerator contained expired food. 3. The walk-in freezer had food items that was not labeled with in date and a use by date. 4. The dry storage room had food bins that were not labeled with an in date and a use by date. 5. The Kitchen staff did not ensure thawing meat was placed on the lowest shelf in the refrigerator. 6. The Kitchen staff did not ensure washed dishes and utensils were free of old food. 7. The Kitchen staff did not ensure food scoopers (utensil, shovel shaped in design, this utensil is made to easily transfer bits of food) were cleaned, contained, and every bin had a scooper. 8.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 an effective and comprehensive Quality Assurance Performance Improvement (QAPI) program was implemented and maintained for all 99 residents by not performing the following: 1. Ensure that the Infection Prevention Nurse (IPN) was a participant in the facility's QAPI meetings. 2. Ensure a method tracking and monitoring of measurable outcomes were in implemented to record the progress of each QAPI action plan. This deficient practice had the potential to negatively impact patient care, safety, and satisfaction, and to allow facility-identified patient care issues or concerns to reoccur within the facility. Cross reference F867. Findings: During a concurrent record review and interview, on 6/27/2024, at 2:22 p.m., with the Director of Nursing (DON), the facility's QAPI Plan and Sign-In Sheet, dated 4/1/2024 to 4/30/2024, was reviewed. The plan indicated that the facility planned to improve immunizations, enhanced barrier precautions, and closed discharge charts. The sign in sheet did not include the IPN's name 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 interview and record review, the facility's Quality Assessment and Assurance Committee (QAA) failed to implement measures to effectively collect and use data to monitor the effectiveness of Quality Assurance Plan Improvement (QAPI) plans and track overall performance for all 99 residents. This deficient practice had the potential to negatively impact resident care, safety, and satisfaction, and had the potential to allow facility-identified resident care issues or concerns to reoccur within the facility. Cross reference F865. Findings: During a concurrent record review and interview, on 6/27/2024, at 2:22 p.m., with the Director of Nursing (DON), the facility's QAPI Plan, dated 4/1/2024 to 4/30/2024, was reviewed. The plan indicated that the facility planned to improve immunizations, enhanced barrier precautions, and closed discharge charts. There were no documents that indicated an outline of specific interventions and there was no indication that progress was monitored. During a concurrent record review and interview, on 6/27/2024, at 2:22 p.m., with the DON, 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 implement an effective infection prevention control program for all residents by failing to maintain and complete the infection surveillance documentation. This deficient practice had the potential to cause the spread of infection causing organisms amongst all staff and/or residents. Findings: During a concurrent interview and record review on 6/25/2024 at 9:46 a.m., with the Infection Preventionist Nurse (IPN), the facility's Infection Surveillance Binder, dated 2024, was reviewed. The binder indicated there was no infection surveillance completed for the month of June 2024. The IPN stated she got behind on the month of June 2024 and had to catch up. The IPN stated she was responsible for keeping up with the infection surveillance every day to be aware of what was going on in the facility. The IPN stated falling behind on the infection surveillance had the potential be to be unaware of a resident having symptoms of an infection and could delay informing the resident's physician, which would cause a delay in treatment.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 maintain complete antibiotic stewardship documentation for the facility for June 2024. This deficient practice had the potential for residents to be administered and prescribed antibiotics (medication to treat infections) inappropriately and unnecessarily. Findings: During a concurrent interview and record review on 6/25/2024 at 9:46 a.m., with the Infection Preventionist Nurse (IPN), the facility's Antibiotic Stewardship Binder, dated 2024, was reviewed. The binder indicated there was no antibiotic stewardship documentation completed for the month of June 2024. The IPN stated she got behind on the month of June 2024 and had to catch up. The IPN stated she was responsible for keeping up with the antibiotic stewardship every day to keep track of the residents who were taking antibiotics. The IPN stated falling behind on the antibiotic stewardship had the potential for residents to be given antibiotics and would not be followed up to ensure the antibiotics were appropriate and necessary to treat the infection. During an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to: 1. Obtain informed consent (process of communication between resident/responsible party and health care provider that often leads to agreement or permission for care, treatment, or services) prior to initiation and administration of psychotropics medications (medications that affect the mind, emotions, and behavior) for two out of eight sampled residents (Resident 6, and Resident 52). 2. Obtain informed consent for a bed alarm and a wheelchair alarm (bed exit alarms that warn caregivers when patients leave or attempt to leave their beds or wheelchairs) for one out of eight sampled residents (Resident 33). 3. Obtain informed consent for one of one sampled resident's (Resident 81) bed bolster (an alternative to side rails that helps prevent residents at risk for falls from rolling out of bed). These deficient practices violated Resident's 6, 52, 33, and 81's and/or their responsible party's right to make an informed decision regarding the use of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to: 1. Ensure behaviors of rummaging through other's belongings related to the use of Clozaril (a medication used to treat mental illness) were monitored in the resident's Medication Administration Record (MAR - a resident's record of all medications administered, and monitoring done) between 6/1/2024 and 6/26/2024 in one of five sampled Residents (Resident 6.) 2. Ensure adverse effects (ASE - unwanted side effects of medication therapy) related to the use of Clozaril, Depakote (a medication used to treat mental illness), Lexapro (a medication used to treat mental illness), and Zyprexa (a medication used to treat mental illness) were monitored in the residents' MARs between 6/1/2024 and 6/26/2024 in two of five sampled residents (Resident 6 and Resident 60.) The deficient practices of failing to monitor target behaviors and adverse effects related to the use of psychotropic medications (medications that affect brain activities associated with mental…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that its medication error rate was less than five percent (%). Four medication errors out of 25 total opportunities contributed to an overall medication error rate of 16 % affecting two of eight residents observed for medication administration (Resident 66 and Resident 69.) The medication errors noted were as follows: 1. Omitted one dose of Lactulose (a medication used to treat high levels of ammonia in the blood). 2. Omitted one dose of vitamin C (a supplement). 3. Omitted one dose of vitamin D (a supplement). 4. Omitted one dose of aspirin (a medication used to prevent blood clots). The deficient practice of failing to administer medications in accordance with the physician' s orders, including any required time frame, increased the risk that Residents 66 and 69 may have experienced medical complications possibly resulting in hospitalization. Findings: During an observation on 6/25/2024 at 8:11 a.m., Resident 69 was observed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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: 1. Ensure two expired insulin (a medication used to control high blood sugar) pens were removed from the medication cart affecting Residents 31 and 148 in one of four inspected medication carts (Station 1 AM Medication Cart). 2. Ensure two unopened insulin pens were stored in the refrigerator according to the manufacturer's requirements affecting residents 14 and 40 in two of four inspected medication carts (Station 1 AM Medication Cart and Station 2 AM Medication Cart). The deficient practices of failing to store medications per the manufacturers' requirements and remove expired medications from the medication carts increased the risk that Residents 14, 31, 40 and 148 could have received medication that had become ineffective or toxic due to improper storage possibly leading to health complications resulting in hospitalization or death. Findings: During a concurrent observation and interview on 6/25/2024 at 1:13 p.m. of Station 1 AM Medication Cart with licensed Vocational Nurse (LVN 6), the following…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to offer and administer the pneumococcal vaccine (medication that trains the body's immune system so that it can fight pneumonia [an infection that inflames the air sacs in one or both lungs]) to four of five sampled residents (Resident 54, 60, 62, and 70), who were eligible to receive the vaccine. This deficient practice had the potential to result in the development and spread of pneumonia. Findings: a. A review of Resident 54's admission Record (Face Sheet), indicated Resident 54 was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses that include but not limited to acute kidney failure (the sudden and rapid loss of kidney's ability to filter waste and balance fluid in blood), dementia (a condition characterized by progressive or persistent loss of intellectual functioning), and major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest 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.

Based on observation, interview, and record review, the facility failed to ensure that resident bedrooms accommodated no more than four residents in four of 32 bedrooms (Rooms A, B, C, D). This deficient practice could adversely affect the adequacy of space, nursing care, comfort, and privacy to the residents and their visitors residing in Rooms A, B, C, and D. Findings: A review of the facility census, dated 6/24/2024, indicated Rooms A, B, C, and D had the capacity to accommodate six residents in the room. A review of the facility's Client Accommodation Analysis (undated), indicated the following measurements for Rooms A, B, C, and D: 1. Rooms A and B measured 478.33 square feet ([sq. ft.]- unit of measurement). 2. Room C measured 487.44 sq. ft. 3. Room D measured 479.79 sq. ft. During the initial tour of the facility, on 6/24/2024 at 10:07 a.m., it was observed Rooms A, B, C, and D were occupied by six residents in each room. During observations made throughout the course of the survey, from 6/24/2024, to 6/27/2024, there were no adverse effects that pertained to the adequacy of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to accommodate the needs for one of eight sampled resident's (Resident 66) by: 1. Failing to place the call within reach. 2. Failing to provide an appropriate call light device. These deficient practices prevented Resident 66 from communicating with staff and had a potential to delay and receive appropriate care, treatment, and services when needed for Resident 66. Findings: During an observation on 6/25/2024 at 8:50 a.m. with Resident 66, Resident 66 was awake and alert, observed sitting in a wheelchair next to her bed in her room. Resident 66's call light was observed not within reach and resting on the floor. A review of Resident 66's admission Record, dated 5/2/2024, indicated Resident 66 was initially admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses which included metabolic encephalopathy (an alteration in consciousness due to brain dysfunction caused by another health condition), dementia (a loss…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure Resident 6, who had impaired cognition for daily decision making, had a representative that acted on behalf of the resident for medical decision-making. This deficient practice placed Resident 6 at risk for all health care decisions, risk and benefits of medications and treatments, and of other available treatment alternatives. Findings: A review of Resident 6's admission Record, indicated Resident 6 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 6's diagnoses included schizophrenia (a mental health disorder, with symptoms of hallucinations or delusions, and mood disorder symptoms) and dementia (the loss of cognitive functioning, thinking, remembering, and reasoning, to such an extent that it interferes with a person's daily life and activities). The admission Record indicated Resident 6 was self-responsible. A review of Resident 6's History and Physical (H&P), dated 11/7/2023, indicated Resident 6 was not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to notify the physician and responsible party (RP) of an unplanned significant weight loss of 14 pounds (6.6 percent [%] weight loss) for one of five sampled residents (Resident 4). This failure had the potential to place Resident 4 at risk for further weight loss. Findings: A review of Resident 4's admission Record (Face Sheet), indicated Resident 4 was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE]. Resident 4's diagnoses included schizoaffective disorder (mental illness that affects mood), chronic kidney disease (longstanding disease of the kidneys leading to renal failure), and bipolar disorder (a mental illness that causes unusual shifts in mood, energy, and concentration). A review of Resident 4's Minimum Data Set (MDS, a standardized screening and assessment tool), dated 4/3/2024, indicated Resident 4 was usually understood and usually understood others. The MDS indicated Resident 4's cognition (process of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of one sampled resident (Resident 81), was free from unnecessary physical restraints (any mechanical or physical material, device, or equipment that is attached to or adjacent to a resident's body that restricts the resident's freedom of movement and cannot be easily removed by the resident) by: 1. Failing to attempt least restrictive measures before implementing a bed bolster (an alternative to side rails that helps prevent residents at risk for falls from rolling out of bed) for Resident 81 while in bed. 2. Failing to provide and document on-going monitoring for Resident 8l while implementing the use of a bed bolster to prevent falls. These deficient practices had the potential to result in entrapment (when a resident is caught between the mattress and bed rail or within the bed rail itself) and injury from lack of monitoring, and the potential to cause anxiety and isolation from Resident 81 not being treated with respect and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to accurately complete the Minimum Data Set (MDS - a comprehensive resident assessment tool) assessment Section I (active diagnoses) by failing to include accurate diagnoses per information in the medical record for three of five sampled residents Resident 3, 6, and Resident 60) when the facility failed to perform the following: 1. Ensure the accurate diagnosis of depression (a group of conditions associated with the elevation or lowering of a person's mood) for Resident 6 and Resident 60 were documented in the MDS Section I. 2. Ensure the accurate diagnosis of dementia (a group of thinking and social symptoms that interferes with daily functioning with behavioral disturbance) for Resident 3 was documented in the MDS Section I. These deficient practices of failing to accurately assess active diagnoses and complete MDS Section I increased the risk that Residents 3, 6, and 60 may not have received care planning and treatment according to their needs…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to develop and implement care plans (plans of care specific to a resident) for three out of six sampled residents (Resident 3, 33, and 65) by failing to: 1. Ensure an individualized care plan was developed for Resident 3's diagnosis of dementia (a group of thinking and social symptoms that interferes with daily functioning with behavioral disturbance). 2. Ensure an individualized care plan was developed for Resident 33's diagnosis of anxiety (intense, excessive, and persistent worry and fear about everyday situations). 3. Ensure an individualized care plan was developed for Resident 65's diagnosis of seizure (burst of uncontrolled electrical activity between brain cells that causes temporary abnormalities in muscle tone or movements (stiffness, twitching or limpness), behaviors, sensations, or states of awareness). These deficient practices had the potential to negatively affect the delivery of necessary care and services, and overall quality…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to revise a care plan (document that helps nurses and other team care members organize aspect of resident care) for one of five sampled residents (Resident 4), who had an unplanned significant weight loss of 14 pounds (lbs). This deficient practice had the potential to result in Resident 4 having further weight loss. Findings: A review of Resident 4's admission Record (Face Sheet), indicated Resident 4 was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE]. Resident 4's diagnoses included schizoaffective disorder (mental illness that affects mood), chronic kidney disease (longstanding disease of the kidneys leading to renal failure), and bipolar disorder (a mental illness that causes unusual shifts in mood, energy, and concentration). A review of Resident 4's Minimum Data Set (MDS, a standardized screening and assessment tool), dated 4/3/2024, indicated Resident 4 was usually understood and usually understood others. The…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement the policy and procedures for accurate assessment for two out of six sampled residents (Resident 55 and Resident 4) by failing to: 1. Ensure an accurate assessment was performed and documented every shift, as indicated by the Skin Integrity Care Plan, prior to Resident 55's development of bruising to the left chest and torso (the main part of the body that contains the chest, abdomen, pelvis, and back) for Resident 55. 2. Transcribe (copy from one place to another) a physician order of weekly weights and laboratory tests to the Physician Telephone Orders form for Resident 4. These failures placed Resident 55 at risk for an undetected injury or fracture (broken bone) and had the potential for changes in weight, laboratory blood levels for Resident 4, which could have led to delay in care and necessary treatment for both residents, Resident 55 and Resident 4. Findings: a. During an observation, on 6/25/2024, at 9:40 a.m., Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure one of eight residents (Resident 66) was provided a communication card (a set of icons that patients can use if they are having difficulty communicating their immediate needs, wants or concerns) with the language (Spanish) Resident 66 was able to understand. This deficient practice prevented Resident 66 from communicating effectively with the staff and had the potential to delay and receive appropriate care, treatment, and services for Resident 66. Findings: A review of Resident 66's Record of Admission, dated 5/2/2024, indicated Resident 66 was initially admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses, metabolic encephalopathy (an alteration in consciousness due to brain dysfunction caused by another health condition), cognitive communication deficit (difficulty with any aspect of communication that is affected by disruption of cognition [mental processes that take place in the brain,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY During an observation, interview, and record review the facility failed to practice pressure related injury preventive practices (interventions to prevent skin breakdown) for two out of eight residents (Resident 65, and Resident 77) when the facility failed to: 1. Ensure a low air mattress ([LAM], a mattress that provides airflow to help keep skin dry, as well as to relieve pressure, treat pressure sores and prevents pressure sores) was set according to Resident 65's weight of 106 pounds and the LAM was set between 150 pounds to 200 pounds. 2. Ensure the LAM was set according to Resident 77's weight of 135 pounds and LAM was set to 350 pounds. These deficient practices placed Resident 65 and Resident 77 at higher risk of developing a pressure injury (localized damage to the skin and underlying soft tissue, usually occurring over a bony prominence, or related to medical devices) due to incorrect weight setting on LAM and provided an uncomfortable bed for Resident 65 and Resident 77 to lie on. Findings: 1.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 provide adequate supervision and provide an environment free of accidents when the facility failed to ensure the following: 1. Adequate supervision was provided for a resident with a known history of falls and poor safety awareness and fell four times within the month (6/2024) for one out three sampled residents (Resident 16). 2. A cabinet that housed two cleaning solution spray bottles in Hallway A was secured and inaccessible to all residents. These deficient practices had the potential for Resident 16 to sustain bodily injury from another fall and for all residents to be subject to chemical injury if the contents of the cleaning solution were sprayed, ingested (consumed) or used to cause harm to other residents or staff members. Findings: 1. A review of Resident 16's admission Record indicated Resident 16 was originally admitted to the facility on [DATE] and re-admitted on [DATE]. Resident 16's diagnoses included lack of coordination,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of two sampled residents (Resident 58) received respiratory care consistent with professional standards of practice when the oxygen nasal cannula tubing (a device used to deliver supplemental oxygen), was not labeled. This deficient practice had the potential to result in unsafe use of oxygen equipment and potentially cause respiratory infection, and/or hospitalization for Resident 58. Findings: A review of Resident 58's Record of Admission, dated 4/29/2024 indicated Resident 58 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 58's diagnoses included acute respiratory failure (the lungs cannot release enough oxygen into the blood, which prevents organs from properly functioning), paroxysmal atrial fibrillation (an irregular heartbeat in the upper chambers of the heart), chronic pulmonary edema (a condition in which fluid builds up in the lungs, making it difficult to breathe) and pneumonia (an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents were free from significant medication errors by: 1. Failing to administer one dose of aspirin (a medication used to prevent blood clots) per the physician's order on 6/25/2024 to one of eight residents observed for medication administration (Resident 69). 2. Failing to administer one dose of Lactulose (a medication used to treat high levels of ammonia in the blood) per the physician's order on 6/25/2024 to one of eight residents observed for medication administration (Resident 66). The deficient practice of failing to administer medications in accordance with the physician's orders, including any required time frame, increased the risk that Residents 66 and 69 may have experienced medical complications possibly resulting in hospitalization. Findings: During an observation on 6/25/2024 at 8:11 a.m., Resident 69 was observed taking the following medications prepared by Licensed Vocational Nurse (LVN 4): 1. One tablet of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the kitchen staff served the correct diet for one of one sampled resident (Resident 48) by failing to: 1. To serve a therapeutic regular diet with chopped meat for Resident 48. This deficient practice had the potential for Resident 48 to receive food that was not palatable and may have caused Resident 48 not to eat her food resulting in possible weight loss. Findings: During an observation on 4/26/2024 at 12:05 p.m. in the kitchen, Resident 48's meal at lunch was observed with a mechanical chopped diet on the tray. A review of Resident 48's admission Record, indicated Resident 48 was admitted to the facility on [DATE] with a diagnosis of chronic obstructive pulmonary disease- ([COPD] group of chronic lung diseases that block airflow and make it harder to breathe air out of the lungs) and multiple sclerosis (a disorder of the central nervous system marked by weakness, numbness, a loss of muscle coordination, and problems with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to retain pneumococcal vaccine (medication that trains the body's immune system so that it can fight pneumonia [an infection that inflames the air sacs in one or both lungs]) administration records indicating the type of vaccine three of five sampled residents (Resident 45, 54, and 70) received. This deficient practice had the potential to result in the inappropriate administration of the pneumococcal vaccine. Findings: a. A review of Resident 45's admission Record (Face Sheet), indicated Resident 45 was initially admitted to the facility on [DATE] and readmitted to the facility with diagnoses that include but not limited to hyperlipidemia (an abnormally high concentration of fat particles in the blood), acute kidney failure (the sudden and rapid loss of kidney's ability to filter waste and balance fluid in blood), and schizoaffective disorder (mental illness that affects mood). A review of Resident 45's Minimum Data Set (MDS, a standardized screening and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to establish a comprehensive and person-centered plan of care, for one of three sampled residents (Resident 1) to address Resident 1's medical diagnosis of type 2 diabetes mellitus ([DM]-abnormal blood sugar). This deficient practice resulted in Resident 1 not receiving the interventions for elevated blood sugar levels. Findings: During areview of Resident 1's Face Sheet (admission record), the face sheet indicated Resident 1 was admitted to the facility on [DATE] with a diagnosis of hypertension (high blood pressure), DM, and schizophrenia (disorganized thinking and behavior). During a review of Resident 1's history and physical (H&P) dated 7/31/2023, the H&P indicated Resident 1 had the capacity to understand and make decisions. During a review of Resident 1's ([MDS] a standardized care assessment and care screening tool), dated 8/9/2023, the MDS indicated Resident 1's cognitive skills (thought process) was moderately impaired, and Resident 1 could…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 protect the health, welfare, and rights of 93 of 93 residents by failing to: a. Develop a policy that ensured the reporting of all alleged abuse (the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish) incidents to authorities as required by federal law. b. Screen potential employees for history of abuse, neglect (the failure to provide goods & services necessary to avoid physical harm, mental anguish, or mental illness), exploitation, or misappropriation of resident property (deliberate misplacement or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent) and maintain documentation that screening occurred. These deficient practices placed all 93 residents at high risk for abuse and neglect. Findings: a. During a review of the facility's undated policy and procedure titled, Resident Abuse, the P/P indicated the…

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

Based on observation, interview, and record review, the facility failed to ensure the planned menu items and recipe was followed during meal preparation. This deficient practice had the potential for 90 out of 93 residents to not receive a proper therapeutic diet as ordered. Findings: During an observation of the food preparation area on 4/4/2022 at 8:45 a.m., there was pureed food observed at the steam table. During an interview on 4/4/2022 at 9:48 a.m. with [NAME] 1 (Ck 1), in the presence of the Dietary Supervisor (DSS), CK 1 stated that he prepared the pureed diet to be served for lunch at around 9 am and left it in the steam table. CK 1 stated that he was currently preparing lunch for the residents receiving regular and mechanical soft diets. CK 1 stated that he did not follow the recipe indicated on the menu because he defrosted pork meat instead of the beef. CK 1 stated that all he did was taste it and put pepper and salt and soy sauce so it would taste good. During an interview with DSS on 4/4/2022 at 12:45 p.m., DSS stated the cook on the afternoon shift dropped the recipe…

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

Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices were followed in the kitchen when the following was observed: a. A dirty can opener blade attachment was observed. b. [NAME] 1 did not follow standardized recipes when preparing food on 4/4/2022 and was not evaluated for competency related to food preparation. c. Reach-in freezer had several gaps on the temperature logs for the months of February and March 2022. d. Several food items and bulk items were not dated, labeled and sealed after opened in the food preparation area, walk-in freezer and dry storage area. e. Dishwasher 1 (DW 1) and Dietary Aide (DA 1) did not know which sanitizer test strip to use for the dish machine sanitizer and quaternary ammonium ([QUAT] a type of sanitizing solution) sanitizer. DA 1 did not know the concentration strength of the quaternary ammonium sanitizer and there was no sanitizing log for lunch time. f. Kitchen staff wore jewelry in the food preparation area. These deficient practices had the potential to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure: a. The facility's training program was implemented to ensure any training needs were met for all new and existing staff. b. The facility's evaluation of policies and procedure were revised or updated annually or as necessary in provision of care that meet current standards of practice. c. Develop and implement a policies and procedures addressing the way the Interdisciplinary Team ([group of different disciplines working together towards a common goal for a resident) authorized medical interventions for residents who were unable to provide informed consent and without a healthcare decision maker. These deficient practices placed the resident population at risk to not receive required care or necessary services needed. Findings: a. During an interview with Licensed Vocational Nurse 4 (LVN 4) on 4/6/2022 at 12:29 p.m., LVN 4 stated she did not remember when she was trained on how to apply physical restraints to residents, LVN 4 stated was hired…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure: a. Advance directives (written statement of a person's wishes regarding medical treatment made to ensure those wishes are carried out should the person be unable to communicate them to a doctor) was offered, discussed, and written information was provided to the residents and/or responsible party for one of 20 sampled residents (Resident 11). b. Medical records included a copy of the advance directives for one of 20 sampled residents (Resident 71). These deficient practices violated the residents' and/or the representatives' right to be fully informed of the option to formulate their advance directives and had the potential to cause conflict with the residents' wishes regarding alternatives in the provision of health care. Findings: a. A review of Resident 11's admission Record (Facesheet) dated [DATE], indicated the resident was originally admitted to the facility on [DATE] and readmitted to the facility on [DATE], with diagnoses not limited…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 any allegations of abuse (the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish), neglect and injuries of unknown source were reported to the state licensing agency, long term care ombudsman (agency to work with residents in long term care facilities with issues), and law enforcement agency within the time frame required for three of three sampled residents. The following incidents were not reported: a. Resident 21's allegations of abuse on 3/9/2022. b. Resident 90's fall incident on 2/25/2022 that resulted in a fracture (broken bone) of the Lumbar 1 (L1) to L3 (lower back) causing significant decline in activities of daily living ([ADLs] self-care activities performed daily such as dressing, personal hygiene, and grooming). c. Resident 93's unusual death on 3/11/2022. These deficient practices resulted in a delay of the state agencies and local authorities'…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide documented evidence that all alleged violations were thoroughly investigated, within five working days of the incident, for three of three sampled residents and results were reported to the state survey agency and other officials in accordance with California state law for the following incidents: a. Resident 21's allegations of abuse (the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish) on 3/9/2022. b. Resident 90's fall incident on 2/25/2022, that resulted in a fracture (broken bone) of the L1-L3 (injury that affect the lower back) causing significant decline in activities of daily living ([ADLs] skills required to independently care for oneself). c. Resident 93's unusual death on 3/11/2022. These deficient practices placed 93 of 93 residents residing in the facility at higher risk for further abuse or mistreatment. Findings: a. During a review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to develop and/or implement an individualized resident centered plan of care with measurable objectives, timeframes, and interventions for residents at risk for pressure sore (injury to skin and underlying tissue caused by prolonged pressure to the area) development and for the use of physical restraints for eight of 20 sampled residents (Residents 8, 21, 69, 80, 93, 6, 90, and 84). This deficient practice had the potential to negatively affect the delivery of necessary care and services. Findings: a. During a review of Resident 8's admission Record, the admission record indicated the resident was readmitted to the facility on [DATE]. Resident 8's diagnoses included paraplegia (impairment or loss of motor or sensory function in areas of the body served by the thoracic, lumbar, or sacral neurological segments owing to damage of neural elements in those parts of the spinal column), hypothyroidism (condition in which your thyroid gland doesn't…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to identify and provide needed care and services that were resident-centered with professional standards of practice for four of four sampled residents (Residents 36, 90, 93, and 345) This deficient practice had potential to cause a negative outcome for Resident 36, 90, 93 and 345. Findings: a. A review of Resident 36's admission Record indicated Resident 36 was admitted to the facility on [DATE]. Resident 36's diagnoses included low back pain, chronic obstructive pulmonary disease ([COPD] group of lung diseases that block airflow and make it difficult to breathe) and hypertension (high blood pressure). A review of Resident 36's Minimum Data Set (MDS), a comprehensive standardized assessment and screening tool, dated 2/7/2022, indicated Resident 36 had clear speech, was able to make himself understood and was able to understand others. The MDS indicated Resident 36 required limited assistance with one person assist with activities of daily…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure two of eight sampled residents (Residents 8 and 84) received care consistent with professional standards of practice, to prevent pressure ulcer development (are localized areas of injury that occur when skin and underlying tissue are compressed between a bony prominence and an external surface such as a mattress) and received necessary treatment and services to promote healing and prevent new pressure ulcers from developing. This deficient practice resulted in Resident 8 developing a Stage II pressure ulcer (partial thickness loss of dermis presenting as a shallow open ulcer with a red, pink wound bed) and deep tissue injury ([DTI] injury to the soft tissue under the skin due to pressure and is usually over bony prominence) on the coccyx (is a small, triangular bone resembling a shortened tail located at the bottom of the spine) area and Resident 84 developed a Stage I (non-blanchable redness of the skin ) on the left wrist…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 three of three sampled residents received adequate supervision to prevent accidents when: a. Resident 36 was physically restrained after multiple falls due to poor safety awareness related to dementia (progressive memory loss). b. Resident 90 had a fall incident on 2/25/2022 resulting in a L2-L3 fracture (broken bone of the second and third vertebrae of the lower spine). c. Resident 93 experience a choking incident resulting in left chest discoloration, the resident expired on 3/11/2022 These deficient practices placed all 93 residents currently residing in the facility at risk for any future accidents and/or death from inadequate staff supervision. Findings: a. During a review of Resident 36's admission Record, the admission record indicated the resident was admitted to the facility on [DATE]. Resident 36's diagnoses included low back pain, chronic obstructive pulmonary disease ([COPD] group of lung diseases that block airflow and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the following: a. All staff had an annual skills competency evaluation and annual performance evaluation. b. Staff was competent when administering single dose Ativan (medication used to treat anxiety [feelings of excessive worry, unease]) injections. c. Licensed Vocational Nurse 4 (LVN 4) maintained infection control (measures to prevent or control the spread of germs) when administering medications to three of three sampled residents (Resident 35, 55, and 4). These failures had the potential to negatively affect the quality of care received by the residents in the facility. Findings: a. During a record review of four staff personnel files (two certified nurse assistants (CNAs), one director, and one licensed vocational nurse (LVN), the files indicated there was no documented evidence of an annual skills competency and annual performance evaluation. During a concurrent interview with the Director of Staff Development (DSD) and…

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

Based on observation, interview and record review, the facility failed to: a. Accurately account for the administration of two controlled medications (medications with a high potential for abuse on the Narcotic Record (a log signed by the nurse with the date and time a controlled medication is given to a resident) for Residents 76 and 90. b. Accurately account the date for the use of one controlled substance on the Narcotic Drug Record for Resident 78. These deficient practices increased the facility's risk for the potential loss, diversion (transfer of a medication from a legal to an illegal use) or accidental exposure to controlled medications, and potential for harm to resident. Findings: a. During an inspection of the controlled medications awaiting disposition (destruction) and record review on 4/7/2022, at 8:38 a.m. with Director of Nursing (DON), there was a discrepancy between the medication card (a bubble pack from the dispensing pharmacy labeled with the resident's information that contains the individual doses of the medication) and the Narcotic Record. Resident 76's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure three of three sampled residents (Resident 69, 21, 84) were free from unnecessary psychotropic medications (medication which affects the brain activities associated with mental process and behavior) when the facility failed to ensure: a. Resident 69 had an informed consent, a comprehensive care plan, a stop date limited to fourteen days, a gradual dose reduction, and documented physician rationale for the use of Zolpidem (medication to induce sleep). b. Resident 21's Depakote (used to treat seizures and bipolar disorder), Haldol (used to treat certain mental/mood conditions) and Zyprexa (treat certain mental/mood conditions) had a legal informed consent from a responsible party. c. Resident 84's Remeron (treat symptoms of depression), Zoloft (used to treat depression, panic attacks, obsessive compulsive disorder, post-traumatic stress disorder, social anxiety disorder) and Zyprexa (used to treat certain mental/mood conditions) had an informed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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. Label opened date for one multiple-dose influenza vaccine (medication to protect against a viral infection that attacks the respiratory system) vial (a small glass container). 2. Label opened date for one multiple-dose tuberculin (medication used to diagnose tuberculosis [TB], a potentially serious infectious bacterial disease that mainly affects the lungs) vial. 3. Label with a complete opened date for one multiple-dose tuberculin vial. 4. Discard one multiple-dose tuberculin vial that had expired. 5. Reseal one emergency kit ([E-kit] box containing a small quantity of medications that can be dispensed when pharmacy services are not available) containing controlled substances (medications with a high potential for abuse) after opening. 6. Re-order and replace one E-kit after opening. 7. Store discontinued controlled substances with the Director of Nursing (DON) for disposition. These deficient practices increased the risk 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 observation, interview, and record review, the facility failed to ensure an updated policy and procedure was developed and implemented to determine underlying causes of problems in the facility. This deficient practice put the facility at risk for not maintaining an effective system to identify, collect and use data to improve services that could affect resident care during their stay in the facility. Findings: a. During an entrance conference with the Administrator (ADM) and Director of Nursing (DON) on 4/4/2022 at 8:44 a.m., the ADM was provided with a list of the needed documents including the abuse policy of the facility. During a record review of the facility's undated policy and procedure (P/P) titled, Resident Abuse, indicated for alleged resident to resident or other resident abuse a mandated reporter shall not be required to report a suspected incident of abuse if all of the following were indicated the elder or dependent adult has been diagnosed with a mental illness, defect, dementia or incapacity, or is subject of a court ordered conservatorship because of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure: a. Licensed Vocational Nurse (LVN) 4 performed hand hygiene prior to administering medications to three of three residents (Residents 35, 55, and 4) observed during medication administration. b. Single-dose Ativan (medication used to treat anxiety [feelings of worry, unease]) vials were not used more than once for Resident 30. c. Resident 69's bed was not placed directly on the floor. These deficient practices had the potential to place the residents, staff, and the community at risk for the spread of infection. Findings: a. A review of Resident 35's admission Record (Face sheet) dated 4/8/2022, indicated the resident was originally admitted to the facility on [DATE] and readmitted to the facility on [DATE]. Resident 35's diagnoses included cellulitis (bacterial skin infection) of the right upper limb, acute embolism (a sudden blocking of an artery [blood vessel that carry oxygen-rich blood from the heart to the body) and…

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

Based on observation, interview, and record review, the facility failed to provide care in a manner that maintained residents dignity and respect for one of 44 sampled residents (Resident 69) by placing the resident's mattress directly on the floor without a bed frame. This deficient practice had the potential to affect Resident 69's sense of self-worth and self-esteem. Findings: During a review of Resident 69's admission Record (face sheet), the face sheet indicated the facility admitted Resident 69 on 11/20/2021. Resident 69's diagnoses included hemiplegia (paralysis [inability to move] one side of the body), metabolic encephalopathy (damage or disease affecting the brain), muscle weakness, type 2 diabetes mellitus (impairment in the way body regulates and uses sugar [glucose] as fuel), anemia (condition in which not enough healthy red blood cells to deliver oxygen to the body tissues), and dementia (general term for loss of memory, language, problem-solving and other thinking abilities severe enough to interfere with daily living). During a review of Resident 69's Minimum Data…

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

Based on observation, interview, and record review the facility failed to protect one of three sampled residents (Resident 21) from abuse (the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish) by: a. Failing to ensure Licensed Vocational Nurse 8 (LVN 8) reported abuse allegations (staff to Resident 21) to the Director of Nursing (DON) or Administrator (ADM). b. Failing to comprehensively assess, monitor, and notify Resident 21's physician and responsible party after the the resident's abuse allegations was reported by Certified Nurse Assistant 16 (CNA 16). These deficient practices placed Resident 21 at further risk for abuse. Findings: During a review of the Resident 21's admission record (face sheet), the face sheet indicated the facility admitted Resident 21 on 1/7/2022. Resident 21's diagnoses included muscle weakness, cognitive communication deficit (difficulty with thinking and how someone uses language), lack of coordination, muscle wasting and atrophy ( decrease in size and wasting of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure self-reporting involving abuse (the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish), neglect, including injuries of unknown source to the state licensing agency, long term care ombudsman (agency to work with residents in long term care facilities with issues), and law enforcement agency within the time frame required was completed for three of three sampled residents by not reporting: a. Resident 21's allegations of abuse on 3/9/2022. b. Resident 90's fall incident on 2/25/2022 that resulted in a fracture (broken bone) of the Lumbar 1 (L1) to L3 (lower back) causing significant decline in activities of daily living ([ADLs] self-care activities performed daily such as dressing, personal hygiene, and grooming). c. Resident 93's unusual death on 3/11/2022. These deficient practices resulted in a delay of the state agencies and local authorities' investigation…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 pain management was provided for one of one sample resident (Resident 90). This deficient practice had the potential to result in lack of detection of unrelieved pain for Resident 90. Findings: A review of Resident 90's admission Record indicated the resident was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 90's diagnoses included wedge compression fracture (broken bone) of the first lumbar of spine (fracture usually occurs in the front of the vertebra, collapsing the bone in the front of the spine and leaving the back of the same bone unchanged, which results in the vertebra taking on a wedge shape), muscle weakness, malignant neoplasm of prostate (cancer in a man's prostate, a small walnut-sized gland that produces seminal fluid). A review of Resident 90's Minimum Data Set (MDS), a comprehensive standardized assessment and screening tool, dated 3/16/2022, indicated Resident 90 had clear…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 resident bedrooms accommodated no more than four residents in four of 32 bedrooms (Rooms A, B, C, D). This deficient practice could adversely affect the adequacy of space, nursing care, comfort, and privacy to the residents and their visitors residing in Rooms A, B, C, and D. Findings: During the entrance conference, on 4/4/2022 at 8:44 a.m., the Administrator (ADM) stated the facility had four resident rooms, Rooms A, B, C, and D, which had more than four residents in each of the rooms. A review of the facility census, dated 4/4/2022, indicated Rooms A, B, C, and D had the capacity to accommodate six residents in the room. During the initial tour of the facility, on 4/4/2022 at 9:42 a.m., it was observed Rooms A, B, C, and D were occupied by six residents in each room. Room Beds Square Feet (Sq. ft) Required Sq. Ft: A 6 478.33 480 B 6 478.33 480 C 6 487.44 480 D 6 479.79 480 During observations made throughout the course of the survey from April 4, 2022, to April 8, 2022, there were no adverse…

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