El Rancho Vista Health Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure licensed nursing staff followed professional standards of practice by failing to obtain an accurate and timely blood pressure assessment prior to the administration of a blood pressure medication for one of five sampled residents (Resident 24) This deficient practice had the potential to result in a hypotensive (low blood pressure) episode for Resident 24.Findings: During a review of Resident 24's admission Record, the admission Record indicated Resident 24 was initially admitted to the facility on [DATE]. Resident 24's diagnoses included chronic subdural hemorrhage (severe brain bleeding), hypertension (high blood pressure), and compression of the brain. During a review of Resident 24's Minimum Data Set ([MDS], a resident assessment tool), dated 2/6/2026, the MDS indicated Resident 24's cognitive skills (ability to think and reason) for daily decision making were intact. The MDS indicated Resident 24 required maximal assistance…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to perform weekly weights for one of two sampled residents' (Resident 70), after Resident 70 experienced a three-pound (lb, unit of weight measurement) weight loss in one week.This deficient practice resulted in the uncertainty whether Resident 70's 4 lb weight loss in a month period was gradual or sudden.Findings:During a review of Resident 70's admission Record, the admission Record indicated Resident 70 was admitted to the facility on [DATE]. Resident 70's diagnoses included dysphagia (difficulty swallowing), gastroesophageal reflux disease (GERD- a chronic digestive condition where the stomach acid frequently flows back up the esophagus [tube connecting the mouth to the stomach]), and type 2 diabetes mellitus (a disorder characterized by difficulty in blood sugar control and poor wound healing).During a review of Resident 70's Minimum Data Set (MDS- a resident assessment tool), dated 2/13/2026, the MDS indicated Resident 70'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 interview and record review, the facility failed to ensure licensed nursing staff demonstrated competency to prioritize and respond to signs and symptoms consistent with a possible cerebrovascular accident (CVA- stroke, loss of blood flow to a part of the brain), including left-sided weakness and facial drooping for one of one sampled residents (Resident 5). This deficient practice had the potential to result in delayed medical evaluation and interventions for time-sensitive conditions, which could lead to worsening neurological status, permanent deficits, or death.Findings: During a review of Resident 5's admission Record, the admission Record indicated Resident 5 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 5's diagnoses included hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (a condition characterized by weakness, reduced strength, or impaired movement on one side of the body) following cerebral infarction…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 annual evaluations were completed for two of five employees (Certified Nursing Assistant's [(CNA) CNA 3 and CNA 4]).This deficient practice had the potential to place residents at risk of not receiving quality care.Findings:During a review of five (5) employees' files, on 4/22/2026 at 11:07 a.m., a randomized annual evaluation audit was conducted for Certified Nursing Assistant (CNA) 3 and CNA 4. CNA 3's date of hire was 6/29/2015. CNA 4's date of hire was 3/15/2023. The audit did not indicate CNA 3 had an annual evaluation completed for the year of 2025-2026. The audit did not indicate CNA 4 had an annual evaluation completed for the year of 2025-2026.During an interview on 4/22/2026 at 12:51 a.m. with the Director of Staff Development (DSD), the DSD stated CNA 3 and CNA 4 did not have annual evaluations completed for the year of 2025-2026. The DSD stated annual evaluations should have been completed because its ensures staff are compliant with facility policies and expectations. The DSD stated failure to complete…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 pharmaceutical services were provided in accordance with accepted professional standards and facility policies to meet the needs of residents when the facility failed to ensure the following for two out of six sampled residents (Resident 16 and Resident 46):1. Ensure controlled medications (medications that the use and possession of are controlled by the federal government) were securely maintained and effectively destroyed.2. Ensure Resident 46's lisinopril (blood pressure medication) was available for timely administration.3. Ensure Resident 46's dose of lisinopril was accurately documented. 4. Ensure Resident 16's famotidine (a medication that treats conditions where the stomach produces too much acid) was administered at the correct time, per the physician's order. These deficient practices had the potential to result in diversion (the illegal, unauthorized, or improper transfer of prescription drugs) and unauthorized access 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 medications were administered in accordance with physician orders for one of six sampled residents (Resident 73).This deficient practice had the potential to result in hypotension (low blood pressure), decreased cardiac perfusion (blood oxygenation), and potential cardiac complications for Resident 73. Findings: During a review of Resident 73's admission Record, the admission Record indicated Resident 73 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 73's diagnoses included atrial fibrillation (ineffective pumping of the heart), hypertensive chronic kidney disease (progressive kidney damage caused by chronic, poorly controlled high blood pressure), chronic ischemic heart disease (tissue damage to the heart muscles due to a lack of oxygen), and bradycardia (slow heart rate). During a review of Resident 73's Minimum Data Set ([MDS], a resident assessment tool), dated 4/8/2026, the MDS indicated Resident 73's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure an unused and unopened NovoLog Flex Pen (a medication device that contains insulin aspart [a medication used to control blood sugar]) was stored in accordance with manufacturer's specifications and per facility policy for one of six sampled residents (Resident 37). This deficient practice had the potential to compromise the medication effectiveness, which could result in uncontrolled blood sugar levels and serious complications for Resident 37.Findings: During a review of Resident 37's admission Record, the admission Record indicated Resident 37 was initially admitted to the facility on [DATE]. Resident 37's diagnoses included diabetes (poor blood sugar control) and end stage renal disease (irreversible kidney failure). During a review of Resident 37's Minimum Data Set ([MDS], a resident assessment tool), dated 3/2/2026, the MDS indicated Resident 37's cognitive skills (ability to think and reason) for daily decision making were…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 medical record for one of six sampled residents (Resident 5) was complete and accurately reflected care provided after a change of condition. This deficient practice had the potential to result in incomplete communication among healthcare providers, delayed or inappropriate clinical decision-making, and inability to verify that appropriate assessment and interventions were performed for Resident 5. Cross Reference F580 and F726.Findings: During a review of Resident 5's admission Record, the admission Record indicated Resident 5 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 5's diagnoses included hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (a condition characterized by weakness, reduced strength, or impaired movement on one side of the body) following cerebral infarction (CVA- stroke, loss of blood flow to a part of the brain) affecting left…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 timely replacement and sanitation of water pitchers for two of six sampled residents (Resident 10 and Resident 53). This deficient practice had the potential to result in bacterial growth and contamination of the water pitchers, and subsequent infection for Resident 10 and Resident 53, who were both diagnosed with dysphagia (difficulty swallowing) and impaired cognition (ability to think and reason).Findings: a. During a review of Resident 10's admission Record, the admission Record indicated Resident 10 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 10's diagnoses included dementia (a progressive state of decline in mental abilities), dysphagia (difficulty swallowing), and urinary tract infection (UTI- an infection in the bladder/urinary tract). During a review of Resident 10's Minimum Data Set ([MDS], a resident assessment tool), dated 2/4/2026, the MDS indicated Resident 10's cognitive skills…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 sampled residents' (Resident 52) responsible party's (RP- decision maker when an individual does not have the mental capacity to do so) refusal of the coronavirus (COVID-19- a highly contagious respiratory illness) vaccine (a medical treatment to help the body's immune system to recognize and fight disease) was documented. This deficient practice had the potential to result in RP 3 being unaware of the risks involved in refusing the COVID-19 vaccine and potential for the facility to not track Resident 52's vaccination status and reoffer at another time. Findings: During a review of Resident 52's admission Record, the admission Record indicated Resident 52 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 52's diagnoses included type 2 diabetes mellitus (a disorder characterized by difficulty in blood sugar control and poor wound healing), dementia (a progressive state of decline in mental abilities),…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 an individualized care plan for one of three sampled residents (Residents 1) after Resident 1 had a change of condition, exhibited behavior of kneeling and placing self on floor, and was a high risk of falls. This failure had the potential to result in Residents 1's needs not being met, unidentified interventions and falls for Resident 1. Findings: During a review of Resident 1's admission Record, the admission Record indicated that Resident 1 was admitted to the facility on [DATE] with diagnoses including Metabolic Encephalopathy (a brain disorder caused by problems in the body's chemistry, leading to changes in brain function) fracture (broken bone) of the right ulna (long bone in the forearm) and unsteadiness on feet. During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool), dated 4/25/2025, the MDS indicated Resident 1 had severe (serious) cognitive impairment (problems with the ability to think, learn, use…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 practices in the kitchen that affected 67 residents out of 67 sampled residents when: 1. The 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 freezer had food that was not labeled with an in date and a use by date. 3. Food items in the refrigerator and freezer that were removed from original packaging were not labeled with what it was. 4. Refrigerator and freezer temperatures were not within acceptable range. 5. Dietary [NAME] (DC) 1 did not remove gloves when moving to another task. These failures had the potential to result in harmful bacteria growth and cross contamination that could lead to foodborne illness in residents that are medically compromised residents. Findings: 1. During the initial kitchen tour on 3/10/2025 at 8:40 a.m., the food in the refrigerator did not have a use by date. During the initial kitchen tour on 3/10/2025 at 8:49 a.m., the food in the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to inform one of three sampled residents' (Resident 34) Family Member (FM) 3, who was Resident 34's emergency contact, of an unwitnessed fall on 2/22/2025. This deficient practice resulted in FM 3 being unaware of Resident 34's fall which resulted in Resident 34's family being concerned of Resident 34's well-being. Findings: During a review of Resident 34's admission Record (Face Sheet), the Face Sheet indicated Resident 34 was admitted to the facility on [DATE] with diagnoses that included nontraumatic subdural hemorrhage (a collection of blood that accumulates between the brain the inner lining of the skull without any prior head trauma), dementia (a progressive state of decline in mental abilities), and urinary tract infection ([UTI], an infection in the bladder/urinary tract). During a review of Resident 34's Minimum Data Set ([MDS], dated 2/12/2025, the MDS indicated Resident 34'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 two sampled residents (Resident 34) had a safe discharge by failing to follow Resident 34's care and whereabouts after Resident 34 was transferred to general acute care hospital (GACH) 1 after an unwitnessed fall. This deficient practice resulted in the facility being misinformed of Resident 34's whereabouts and had the potential to result in Resident 34's discharge needs being unmet. Findings: During a review of Resident 34's admission Record (Face Sheet), the Face Sheet indicated Resident 34 was admitted to the facility on [DATE] with diagnoses that included nontraumatic subdural hemorrhage (a collection of blood that accumulates between the brain the inner lining of the skull without any prior head trauma), dementia (a progressive state of decline in mental abilities), and urinary tract infection ([UTI], an infection in the bladder/urinary tract). During a review of Resident 34's Minimum Data Set ([MDS], dated 2/12/2025, the MDS…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop a care plan addressing a resident's diagnosis of clostridioides difficile ([C. diff], a germ that causes diarrhea and inflammation of the colon [organ in the digestive system that stores and processes waste before it's eliminated from the body]) for one out of eight sampled residents (Resident 56). This deficient practice had the potential to delay and negatively affect the delivery of care for Resident 56. Findings: During a review of Resident 56's admission Record, the admission record indicated Resident 56 was originally admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses of respiratory failure (serious condition that makes it difficult to breathe, lungs cannot get enough oxygen into the blood) and atrial fibrillation (heart's upper chambers (atria) beat out of coordination with the lower chambers (ventricles), can lead to blood clots in the heart). During a review of Resident 56's History and Physical (H&P) dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents received treatment and care per the physician's orders for three residents (Residents 35, 55, and 124) out of 16 sampled residents by failing to ensure: 1. Resident 124's blood sugar level was monitored. 2. Resident 55's surgical dressing was changed. 3. Licensed Vocational Nurse (LVN) 3 administered regular insulin (a hormone that removed excess sugar from the blood, could be produced by the body or given artificially via medication) 30 minutes prior to Resident 35's meal. These deficient practices had the potential to not meet Resident's 35, 55, and 124's overall healthcare needs. Findings: 1. During a review of Resident 124's admission Record, the admission record indicated Resident 124 was admitted to the facility on [DATE] with diagnoses of diabetes mellitus ([DM], a disorder characterized by difficulty in blood sugar control and poor wound healing) with hyperglycemia (high sugar level) and multiple fractures (broken…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 interventions to prevent formation and/ or worsening of pressure ulcers/injuries (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence) were implemented for two of two residents (Resident 54 and 56) when the following occurred: 1. Resident 54's low air loss mattress (LALM, a mattress designed to distribute body weight over a broad surface area to help prevent skin breakdown) did not reflect the resident's correct weight on 3/10/2025. 2. Resident 56's LALM did not reflect the resident's correct weight. This deficient practice placed Resident 54 and 56 at risk for worsened condition of their exiting pressure injuries, and/ or the development of new pressure injuries. Findings: 1. During an observation on 3/10/2025 at 10:02 a.m., in Resident 54's room, Resident 54 was observed lying on a low air loss mattress (LALM, a mattress designed to distribute body weight over a broad surface…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to label one of one sampled resident's (Resident 69) peripheral intravenous line's ([IV], a soft, flexible tube placed inside a vein to administer medications or fluids) dressing with the date and time of insertion and the initial of the inserting nurse. This deficient practice had the potential to result in Resident 69's IV to be left in place longer than seven days, which could cause preventable infection. Findings: During a review of Resident 69's admission Record (Face Sheet), the Face Sheet indicated Resident 69 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included presence of an artificial right knee joint (surgical procedure where the damaged knee joint is replaced with metal and plastic), end stage renal disease ([ESRD], irreversible kidney damage), AND arthritis (joint inflammation). During a review of Resident 69's Minimum Data Set ([MDS], a resident assessment tool), dated 2/9/2025,…

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 display a No Smoking sign on the inside and outside of the resident's room for one of eight sampled resident's (Resident 14) use of an oxygen concentrator (a medical device that extracted oxygen from the air and delivered it to resident for breathing). This deficient practice had the potential to cause fire hazards to all residents, families, visitors, staff, and residents' properties, and result in serious harm and injury. Findings: During observations on 3/10/2025 at 9:33 a.m., on 3/10/2025 at 1:31 p.m., and on 3/12/2025 at 9:05 a.m., outside Resident 14's room, there was no No Smoking signage observed on the room entrance door. Resident 14 was observed lying in bed with an oxygen concentrator at the bedside. There was no No Smoking signage observed in the room. During a review of Resident 14's admission Record (face sheet), the face sheet indicated Resident 14 was admitted to the facility on [DATE]. Resident 14's diagnoses included…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the safe administration of medications for two of 20 sampled residents (Residents 125 and 29) by failing to: 1. Ensure Licensed Vocational Nurse (LVN) 1 did not leave medications at Resident 124's bedside and failing to ensure Resident 124 took all his medications. This deficient practice had the potential to result in Resident 124 self-administering his own medications unsafely or potentially leading to another resident self-administering medications not prescribed to them. 2. Ensure Resident 29's Ativan (an antianxiety medication used to treat anxiety [condition characterized by excessive and persistent worry or fear)] was accurately documented in the Medication Administration Record ([MAR], a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) on 3/10/2025. This deficient practice had the potential to result in Resident 29's anxiety being mismanaged and the Ativan…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure two of two sampled residents (Resident 46 and 65) were free from significant medication error (one which caused the resident discomfort or jeopardizes his or her health and safety) when: 1. Staff did not instruct Resident 65 to rinse his mouth thoroughly after administering Budesonide-Formoterol Fumarate inhaler (a medication to relax airway muscles, making breathing easier). This deficient practice had the potential to result in mouth discomfort and development of oral thrush (a fungal infection of the mouth, resulting in white, raised patches, that could be painful and cause discomfort) for Resident 65. 2. Resident 46 was administered Metoprolol (medication used to treat high blood pressure) outside of the ordered parameters (specific instructions that dictate whether the medication is safe to administer). This deficient practice had the potential to result in Resident 46 becoming hypotensive (low blood pressure) that could cause…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to remove three bags of expired intravenous (IV -given directly into the blood stream) fluid solution from inside the IV emergency kit (e-kit), in one of one inspected medication room (Medication Room Nursing Station 1). This deficient practice increased the risk that residents could have received medications that were expired and/or ineffective, possibly leading to health complications such as infection (the invasion and multiplication of microorganisms [like bacteria, viruses, etc.] in body tissues, potentially causing illness or harm) and electrolyte imbalance (an abnormal level of electrolytes in the body fluids, like blood and urine, which could disrupt vital functions like nerve and muscle activity, and fluid balance). Findings: During a concurrent observation and interview on [DATE] at 11:40 a.m. with Licensed Vocational Nurse (LVN) 4, in Medication Room Nursing Station 1, three bags of expired IV solution were observed stored in the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to notify the primary care physician (PCP), when one of three sampled residents (Resident 1), refused insulin (medicine for diabetes (DM], - abnormal blood sugar levels) administration, as ordered by the PCP. This failure placed the resident at risk for potential complications from diabetes such as diabetic ketoacidosis (a life-threatening complication that can occur if blood glucose levels are high) leading to hospitalization and death. Findings: 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 polyneuropathy (a condition where multiple nerves become damaged leading to problems with sensation, coordination, or other body functions) and Type 2 DM (when the body is resistant to insulin). During a review of Resident 1's Minimum Data Set ([MDS], a resident assessment tool) dated, 9/29/2024, the MDS indicated Resident 1 was cognitively intact…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 care plan to one of 3 residents (Resident 1), who refused to receive insulin (medicine for diabetes mellitus ([DM], abnormal blood sugar levels) injection on 9/24/2024, for the high blood sugar levels, as ordered by the physician. This failure had the potential that interventions Resident 1 would need will not be provided, resulting in poor quality care and complications. Findings: 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 polyneuropathy (a condition where multiple nerves become damaged leading to problems with sensation, coordination, or other body functions) and Type 2 DM (when the body becomes resistant to insulin). During a review of Resident 1's Minimum Data Set ([MDS], a resident assessment tool) dated, 9/29/2024, the MDS indicated that Resident 1 was cognitively intact (having the ability to think,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to meet professional standards of practice by failing to ensure one of three sampled residents (Resident 1), who was diabetic and who refused insulin (medicine for diabetes) injection, was monitored for any possible diabetic reactions which could be life-threatening. This failure had the potential for Resident 1 to suffer complications from uncontrolled blood sugar levels that could lead to hospitalization and/or death. Findings: 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 polyneuropathy (a condition where multiple nerves become damaged leading to problems with sensation, coordination, or other body functions) and Type 2 diabetes mellitus ([DM] a type of DM when the body becomes resistant to insulin). During a review of Resident 1's Minimum Data Set ([MDS], a resident assessment tool) dated, 9/29/2024, the MDS indicated Resident 1 was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the resident's responsible parties (RP) were informed of the utilization of bedrails and informed consent was given for two of 24 sampled residents (Resident 32 and Resident 66) by failing to: These deficient practices did not allow the Resident 32 and Resident 66's RP's the right to be fully informed in advance of the bedrails. Findings: a. During a review of Resident 32's admission Record, the admission record indicated Resident 32 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including heart failure (progressive heart disease that affects pumping action of the heart muscles) and hemiplegia (weakness, stiffness, and lack of control in one side of the body). During a review of Resident 32's History and Physical (H&P) dated 3/7/2024, the H&P indicated Resident 32 could make needs known but could not make medical decisions. During a review of Resident 32's Minimum Data Set (MDS, a standardized…

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

Based on observation, interview, and record review, the facility failed to report a change in condition of a resident's refusal of monthly weights to the physician for one out of three residents (Resident 6). This deficient practice had the potential for Resident 6 to have continued weight loss without facility awareness and intervention. Findings: During a review of Resident 6's admission Record, the record indicated the facility originally admitted Resident 6 on 3/6/2023, and readmitted Resident 6 on 8/14/2023. Resident 6's admitting diagnoses included adult failure to thrive (a syndrome of weight loss, decreased appetite, and poor nutrition), signs and symptoms concerning food and fluid intake, dysphagia (difficulty swallowing), dementia (the loss of cognitive functioning such as thinking, remembering, and reasoning interfering with daily life and activities), abnormality of albumin (a protein necessary in the blood that keeps fluid from leaking into tissues), and depression. During a review of Resident 6's Minimum Data Set ([MDS] a standardized assessment and care screening…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 person-centered care plan's (document that helps nurses and other team care members organize aspect of resident care) interventions for one of six sampled residents (Resident 39) when Certified Nursing Assistant (CNA) 1 only wore a gown when providing feeding assistance to Resident 39, who was on Enhanced Standard Precautions (ESP, infection control intervention using gown and gloves during high contact resident care activities designed to reduce the transmission of multi-drug resistant organisms [MDRO]). This deficient practice had the potential to result in Resident 39 contracting an MDRO and potentially spreading the MDRO to other residents in the facility. Findings: During a review of Resident 39's admission Record (Face Sheet), the admission Record indicated Resident 39 was admitted to the facility on [DATE] with diagnoses that included but not limited to heart failure (a chronic condition in which the heart does 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 revise the person-centered care plan (document that helps nurses and other team care members organize aspect of resident care) for one of six sampled residents (Resident 59) who had nonstop bleeding of their arteriovenous shunt (AVS, a connection between an artery and vein that is a commonly used access site in patients receiving regular hemodialysis [a process of filtering the blood of a person whose kidneys are not working normally]) and was sent to the general acute care hospital (GACH). This deficient practice had the potential to result in Resident 59's needs not being met due to staff being unaware on how to care for Resident 59's bleeding AVS. Findings: During a review of Resident 59's admission Record (Face Sheet), the admission Record indicated Resident 59 was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses that included but not limited to transient cerebral ischemic attack (neurological…

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

Based on observation, interview, and record review, the facility failed to follow physician's orders for one out of three residents (Resident 19) by not getting Resident 19 out of bed. This deficient practice had the potential to negatively affect Resident 19's psychosocial well-being due to lack of socialization and stimulation. Findings: During a review of Resident 19's admission Record, the record indicated the facility originally admitted Resident 19 on 12/17/2019, and readmitted Resident 19 on 1/11/2024. Resident 19's admitting diagnoses included chronic obstructive pulmonary disease ([COPD] a condition involving constriction of the airways and difficulty or discomfort in breathing), congested heart failure ([CHF] a condition where the heart does not adequately pump blood into the body), acute and chronic respiratory failure with hypoxia (a short-term higher in severity and long-term lesser in severity condition making it difficult to breath, accompanied with low oxygen in the blood), acute pulmonary edema (a short-term higher in severity fluid congestion of the lungs),…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility staff failed to assist residents who were unable to carry out their activities of daily living (ADLs, self care activities performed daily such as grooming, personal hygiene, and dressing) for two out of 24 sampled residents (Resident 32 and Resident 43) by failing to: 1. Ensure Resident 32's and Resident 43's teeth were routinely brushed. 2. Ensure Resident 32's and Resident 43's clothes were changed daily. 3. Ensure Resident 32 and Resident 43 got out of bed daily. These deficient practices had the potential to result in a negative impact on Residents 32's and Resident 43's quality of life and self- esteem. Findings: a. During a review of Resident 32's admission Record, the admission record indicated Resident 32 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including heart failure (progressive heart disease that affects pumping action of the heart muscles) and hemiplegia (weakness, stiffness, and lack…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 prevent pressure ulcer (injury to the skin and underlying tissue resulting from prolonged pressure on the skin) development for one out of three residents (Resident 19) by not turning Resident 19 as needed. This deficient practice resulted in Resident 19 developing a Stage II (partial thickness loss of the top layer of the skin presenting a shallow open ulcer with a red, pink wound bed) pressure ulcer, and had the potential to negatively affect Resident 19's skin by potentially becoming infected and spreading to the bone or blood stream. Findings: During a review of Resident 19's admission Record, the record indicated the facility originally admitted Resident 19 on 12/17/2019, and readmitted Resident 19 on 1/11/2024. Resident 19's admitting diagnoses included chronic obstructive pulmonary disease ([COPD] a condition involving constriction of the airways and difficulty or discomfort in breathing, which could cause a delay in wound healing due to lack of oxygen), congestive heart failure (a condition where 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 follow their oxygen administration policy for one resident out of 24 sampled residents (Resident 7) by not ensuring Resident 7's nasal cannula (a plastic medical device to provide supplemental oxygen therapy to people who have lower oxygen levels, device goes directly into the nostrils) was labeled. This deficient practice increased the risk for Resident 7 to acquire a respiratory infection. Findings: During a review of Resident 7's admission Record, the admission record indicated Resident 7 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including heart failure (a chronic condition in which the heart doesn't pump blood as well as it should). During a review of Resident 7's History and Physical (H&P) dated 12/18/2023, the H&P indicated Resident 7 had the capacity to understand and make decisions. During a review of Resident 7's Minimum Data Set (MDS, a standardized assessment and care planning…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure informed consents were signed by the physician prior to the use of administering two antipsychotic (used to treat various mental disorders) medications, and for the utilization of bedside rails for one out of 24 sampled residents (Resident 32). This deficient practice had the potential of delay of necessary services, poor continuity of care and poor follow-up on the resident's status. Findings: During a review of Resident 32's admission Record, the admission record indicated Resident 32 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including heart failure (progressive heart disease that affects pumping action of the heart muscles) and hemiplegia (weakness, stiffness, and lack of control in one side of the body). During a review of Resident 32's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 11/30/2023, the MDS indicated that Resident 32's cognitive skills (mental action…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 document medication administration of a Schedule II-controlled substance (drugs with accepted medical use but with a high abuse potential), Norco (medication used to treat moderate to severe pain), when administering medication to one out of three residents (Resident 9). This deficient practice had the potential for harm due to an inaccurate record of narcotic medication use, and the loss of accountability, which affected the controls against drug loss, diversion (transfer of a legally prescribed controlled substance from the individual for whom it was prescribed to another person for any illicit use), or theft. Findings: During a review of Resident 9's admission Record, the admission record indicated the facility admitted Resident 9 on 5/2/2023. Resident 9's admitting diagnoses included second degree burns (burns that only affect up to the second layer of the skin) of the right arm, and both legs. During a review of Resident 9's Minimum Data Set ([MDS] a standardized assessment and care screening tool), dated 12/13/2023,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 effective infection prevention measures for one of six sampled residents (Resident 39) when Certified Nursing Assistant (CNA) 1 only wore a gown when providing feeding assistance to Resident 39, who was on Enhanced Standard Precautions (ESP, infection control intervention using gown and gloves during high contact resident care activities designed to reduce the transmission of multi-drug resistant organisms [MDRO]). This deficient practice had the potential to result in Resident 39 contracting an MDRO and potentially spreading infection to other residents and staff. Findings: During a review of Resident 39's admission Record (Face Sheet), the admission Record indicated Resident 39 was admitted to the facility on [DATE] with diagnoses that included but not limited to heart failure (a chronic condition in which the heart does not provide adequate blood flow to meet the body's needs), benign prostatic hyperplasia (BPH, 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.