Riviera Healthcare Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to revise two of three sampled residents' (Resident 6 and Resident 104) care plans after testing positive for influenza A (a contagious viral infection that affects the respiratory system).This deficient practice had the potential to negatively affect Residents 6 and 104's physical well-being and had the potential to delay the delivery of necessary care and services.Findings:a. During a review of Resident 6's admission Record, the admission Record indicated Resident 6 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 6's diagnoses included encephalopathy (damage or brain disease that alters the brain's function), dementia (a progressive state of decline in mental abilities), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest).During a review of Resident 6's Minimum Data Set (MDS- a resident assessment tool), dated 1/5/2026, the MDS indicated Resident 6'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 conduct 72-hour monitoring for two of two sampled residents (Resident 61 and Resident 7), after an allegation of sexual abuse.This deficient practice had the potential to result in a decline in Resident 61's psychosocial well being and potential for Resident 7's sexually inappropriate behavior being undetected.Cross Reference F609 and F842.Findings:1. During a review of Resident 61's admission Record, the admission Record indicated Resident 61 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 61's diagnoses included type 2 diabetes mellitus (a disorder characterized by difficulty in blood sugar control and poor wound healing), chronic kidney disease (kidney damage that occurs over time), hypertension (high blood pressure).During a review of Resident 61's Minimum Data Set (MDS- a resident assessment tool), dated 1/15/2026, the MDS indicated Resident 61's cognition (process of thinking) was intact. The MDS indicated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure intravenous (IV, administered directly into the blood stream) tubing (the tubing that allows medication to flow into the resident's blood stream) was labeled with the date and time for one of three sampled residents (Resident 87).This deficient practice had the potential to result in a bloodstream infection for Resident 87.Findings:During a review of Resident 87's admission Record, the admission Record indicated Resident 87 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 87's diagnoses included muscle weakness, dementia (a progressive state of decline in mental abilities), and hypertension (high blood pressure).During a review of Resident 87's Minimum Data Set ([MDS], a resident assessment tool), dated 1/28/2026, the MDS indicated Resident 87's cognitive skills (ability to think and reason) for daily decision making were moderately impaired. The MDS indicated Resident 87 required set-up…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 post an oxygen in use sign outside the room of one of three sampled residents (Resident 105). This deficient practice increased the risk for injury related to fire hazards.Findings:During a review of Resident 105's admission Record, the admission Record indicated Resident 105 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 105's diagnoses included pleural effusion (buildup of fluid between the thin layers of tissue lining the lungs and the chest cavity) and pneumonia (an infection/inflammation in the lungs). During a review of Resident 105's Minimum Data Set (MDS- a resident assessment tool), dated 2/3/2026, the MDS indicated Resident 105's cognition (process of thinking) was moderately impaired. The MDS indicated Resident 105 was dependent with toileting, bathing, and lower body dressing. The MDS indicated Resident 105 required oxygen therapy (a medical gas used to help with breathing).During a review…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 dialysis (treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) emergency kit (e-kit, a kit used for the management of emergency bleeding on venous access [catheter or device is inserted into a vein to deliver medications or fluids] was kept at the bedside for one of three sampled residents (Resident 142).This deficient practice placed Resident 142 at risk for uncontrolled bleeding and serious harm.Findings:During a review of Resident 142's admission Record, the admission Record indicated Resident 142 was initially admitted to the facility on [DATE]. Resident 142's diagnoses included dependence on dialysis, end stage renal disease (irreversible kidney failure), and muscle weakness.During a review of Resident 142's Minimum Data Set ([MDS], a resident assessment tool), dated, 2/15/2026, the MDS indicated Resident 142's cognitive skills (ability to think and reason)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 feeding assistance during breakfast for one of seven sampled residents (Resident 31).This deficient practice had the potential to negatively affect the residents' quality of life, and feeling of self-worth.Findings:During a review of Resident 31's admission Record, the admission Record indicated Resident 31 was admitted to the facility on [DATE]. Resident 31's diagnoses included diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control), blindness glaucoma ( an eye disease that damages the eye and can slowly cause blindness), low vision to the right eye, blindness to the left eye, hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (weakness on the side of the body, like one arm and one leg not working as well) affecting the left dominant side.During a review of Resident 31's History and Physical (H&P), dated 10/20/2025, the H&P indicated Resident 31 did…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure safe medication administration practices were observed when the following occurred for three of five sampled residents (Resident 1, Resident 66, and Resident 132):1. Failed to ensure Ferrous Sulfate (used to treat or prevent anemia [a lower-than-normal number of red blood cells]) Oral Solution 220 milligrams per five milliters (mg/ml, a unit of measurement) 7.4 ml was administered to Resident 1 one to two hours before or after tube feeding (method of delivering liquid nutrients, fluids, and medications directly into the stomach via a flexible tube) in accordance with physician's order for Resident 1.2. Failed to ensure Zinc Sulfate (a medication essential for wound healing) Oral Tablet 220 mg via g -tube was administered to Resident 1 in accordance with physician's order for Resident 1.3. Failed to ensure Metoprolol Tartrate (a medication used to treat high blood pressure) Oral Tablet 25 mg was administered to Resident 132 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 observation, interview, and record review, the facility failed to ensure that the medication error rate was less than five percent (%). Three medication errors out of a total of thirty-six opportunities contributed to an overall medication error rate of 8.33 %, for two of five sampled residents (Resident 1 and Resident 132) observed for medication administration (med pass). The medication errors noted were as follows:1. Failed to ensure Ferrous Sulfate (used to treat or prevent anemia [a lower-than-normal number of red blood cells]) Oral Solution 220 milligrams per five milliters (mg/ml, a unit of measurement) 7.4 ml was administered to Resident 1 one to two hours before or after tube feeding (method of delivering liquid nutrients, fluids, and medications directly into the stomach via a flexible tube) in accordance with physician's order.2. Failed to ensure Zinc Sulfate (a medication essential for wound healing) Oral Tablet 220 mg via gastrostomy tube (a tube that is surgically inserted to allow…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 food was palatable (tastes good and enjoyable to eat) and consistent with resident preferences for one of seven sampled residents (Resident 124).The deficient practice resulted in the residents not eating their food and had the potential to result in nutritional requirements not being met.Findings:During a review of Resident 124's admission Record, the admission Record indicated Resident 124 was admitted to the facility on [DATE]. Resident 124's diagnoses included chronic respiratory failure with hypoxia (the body or brain is not getting enough oxygen), diabetes mellitus (DM- disorder characterized by difficulty in blood sugar control and poor wound healing), and muscle weakness (loss of muscle strength).During a review of Resident 124's History and Physical (H&P), dated 11/10/2025, the H&P indicated Resident 124 had the capacity to understand and make decisions.During a review of Resident 124'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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure two of four sampled residents' (Residents 147 and 61) medical records were complete and accurate when:1. Resident 147's hospice (compassionate care for people who are near the end of life provided at the person's home or within a health care facility) record binder and medical record binder contained conflicting Physician Orders for Life-Sustaining Treatment (POLST - a form that contains written medical orders for healthcare professionals regarding specific medical treatments that can or cannot be done at the end-of life) forms.This deficient practice had the potential for licensed staff to rely on inaccurate or conflicting information and follow the incorrect POLST during a life-threatening emergency.2. Licensed Vocational Nurse (LVN) 3 did not document Resident 61's Change in Condition (COC) after his roommate tried to touch him inappropriately.These deficient practices resulted in the lack of care plan development and intervention…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 infection control measures for two of 11 sampled residents (Residents 33 and 5) when:1. Certified Nursing Assistant (CNA) 5 failed to implement droplet isolation precautions (infection control measures used to prevent the spread of pathogens transmitted through close respiratory contact) and failed to perform hand hygiene (hand washing with soap or using alcohol-based hand rubs) upon exiting Resident 33's room.2. Licensed Vocational Nurse (LVN) 3 disconnected a gastrostomy tube (g-tube- a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems) connector from Resident 5 and stored the connector inside a plastic bag while the g-tube feeding formula (specialized, nutrient-dense liquid diets delivered via g-tube) was left running.These deficient practices had the potential to place all residents at risk for infection and illness. Findings:1. During a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1) wore a cranial helmet (prescribed to residents to protect the head after undergoing a craniotomy [surgery that removes a portion of bone from the skull]) as ordered by the physician. This failure placed Resident 1 at risk for injuries, delayed healing and dehiscence (partial or complete separation of the edges of the resident's surgical incision). Findings: During an observation on 6/12/2025 at 7:40 a.m. in Resident 1's room, Resident 1 was observed without a cranial helmet on. During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted on [DATE] with diagnoses including intracerebral hemorrhage (bleeding into the brain tissue), person injured in motor vehicle accident (MVA), traumatic brain injury (TBI- a disruption in the normal function of the brain that can be caused by a bump, blow, or jolt to the head), epilepsy (a sudden, uncontrolled…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 five sampled residents (Resident 2), refused to receive wound care. This failure placed Resident 2 ' s wounds at risk for delayed healing and had the potential for complications such as severe infection, hospitalization, and death, because of the refusal. 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 was readmitted on [DATE]. Resident 2 ' s diagnoses included encounter for orthopedic (a branch of medicine that focuses on injuries and diseases of the musculoskeletal system) aftercare following surgical amputation (a surgical procedure to remove a limb or other body part). During a review of Resident 2 ' s Minimum Data Set ([MDS], a federally mandated resident assessment tool) dated, 12/12/2024, the MDS indicated Resident 2 was cognitively intact (having the ability to think, remember, and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to implement its policy and procedure (P&P) titled, Isolation – Categories of Transmission Based Precautions (additional infection control measures used for residents who may have a contagious disease), for two out of five residents (Residents 3 and 4) by failing to: a. Ensure staff wore personal protective equipment ([PPE] protection equipment that includes face shields, gloves, goggles and glasses, gowns, head covers, masks, respirators, and shoe cover to protect against the transmission of germs through contact and droplet routes) prior to entering a contact isolation (a type of infection control precaution used to prevent the spread of infectious diseases that are transmitted through direct or indirect contact with the patient or their environment) room and while inside a contact isolation room. b. Ensure staff discarded used PPE in designated receptacles prior to exiting a contact isolation room. These deficient practices had 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 safe and sanitary food preparation practices in the kitchen when: 1. Dietary Aide (DA 1) did not change gloves between touching food items and nonfood items. 2. Dietary staff did not provide a closed container for the ice scooper. These deficient practices had the potential to result in harmful bacteria 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). Findings: During an observation on 11/15/2024 at 7:21 a.m., in the kitchen, DA 1 checked the menu slip on the food trays and provided juice, water, or milk on the food trays. DA 1 touched the doorknob of the kitchen door. DA 1 opened the kitchen door and left the kitchen and returned to touching the resident food trays and drinks with the same gloves. Nursing staff came to the kitchen door. DA 1 opened the kitchen door took the menu slip from the nursing staff and continued 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 develop a person-centered care plan (document that helps nurses and other team care members organize aspects of resident care) and/or implement interventions (actions a nurse takes to implement a care plan, intend to improve the resident's comfort and health) for five of 27 sampled residents (Residents 39, 65, 72, 92, and 130) by failing to: 1. Implement care plan interventions for floor mats for Resident 72. 2. Failed to ensure Resident 39 was kept clean and dry and did not have to wait five and a half hours to be changed or cleaned, per the care plan. 3. Failed reposition Resident 92 every two hours, per the care plan. 4. Develop a care plan for Resident 92's use of Plavix (an antiplatelet medication used to prevent blood clots), lorazepam (also known as Ativan, a medication used to treat anxiety [a feeling of fear, dread, or uneasiness), and morphine sulphate (an pain medication used to treat moderate to severe pain). 5. Develop a care…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure interventions to prevent formation and/or worsening of pressure ulcers (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence) were implemented for nine of 27 sampled residents (Residents 39, 92, 24, 83, 72, 6, 19, 120, and 130) when the following occurred: 1. Resident 24's low-air-loss mattress (LALM, an air mattress that's designed to help prevent and treat pressure ulcers) settings did not reflect Resident 24's weight, and Treatment Nurse (TN) 1 failed to clarify Resident 24's LALM orders with Resident 24's physician. 2. Resident 72's LALM settings did not reflect Resident 72's weight. 3. Resident 83's LALM settings did not reflect Resident 83's weight. 4. Failed to ensure Resident 39 was kept clean and dry and did not have to wait five and a half hours to be changed or cleaned. 5. Failed to ensure Resident 92 was repositioned every two hours as indicated in his care plan. 6.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 enhanced barrier precautions (EBP, a resident-centered and activity-based approach for preventing infection spread) for four of 27 sampled residents (Residents 72, 24, 62, and 39). This deficient practice increased the potential for spread of multidrug-resistant organisms (MDROs, a type of bacteria that has become resistant to multiple antibiotics and other antimicrobial agents) among vulnerable facility residents. Findings: 1. During a review of Resident 72's admission Record, the admission Record indicated Resident 72 was admitted to the facility on [DATE]. Resident 72's admitting diagnoses included generalized muscle weakness, dementia (a progressive state of decline in mental abilities), and cancer to the colon (the longest part of the large intestine). During a review of Resident 72's History and Physical (H&P), dated 6/24/2024, the H&P indicated Resident 72 had fluctuating capacity to understand and make decisions. 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 interview and record review, the facility failed to obtain an 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 the administration of psychotropic medication (medications that affect the mind, emotions, and behavior) and the use of bed side rails (metal or plastic bars positioned along the side of a bed for three out of eight sampled residents (Resident 9, 68, and 121). This deficient practice violated Resident 9, 68, and 121's right to make an informed decision prior to the administration of psychotropics and bed siderails. Findings: a. During a review of Resident 9's admission Record, the admission record indicated Resident 9 was originally admitted to the facility on [DATE] and readmitted to the facility on [DATE]. Resident 9's diagnoses included depression (common mental health condition that involves a persistent low mood or loss of interest in activities) 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 remove the identifiable health information (any information that could be used to identify the individual, such as the full name, date of birth , etc.) on the gastrostomy tube (GT, a surgical opening fitted with a device to allow feedings to be administered directly to the stomach, for people with swallowing problems) feeding bottle before the disposition in the trash can for one of 11 sampled residents (Resident 100). This deficient practice had the potential to result in unauthorized disclosure of Resident 100's personal information to unauthorized users. Findings: During an observation on 11/12/2024 at 9:16 a.m., in Resident 100's room, Resident 100's GT feeding bottle with the resident's name was observed in the trash can. During a review of Resident 100's admission Record, the admission record indicated Resident 100 was admitted to the facility on [DATE]. Resident 100's diagnoses included diabetes mellitus (DM- a disorder…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to: 1. Revise the care plan when one of 27 sampled residents (Resident 75) did not meet the goals of maintaining her body weight, without additional weight loss. 2. Ensure the Registered Dietician (RD, a healthcare professional who specializes in nutrition and diet) was involved in the care planning for Resident 75's weight loss. These deficient practices increased the potential for Resident 75 to sustain continued and unplanned weight loss. Findings: During a review of Resident 75's admission Record, the admission record indicated Resident 75 was admitted to the facility on [DATE] and was most recently readmitted on [DATE]. Resident 75's diagnoses included heart failure (a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling) and stroke (loss of blood flow to a part of the brain). During a review of Resident 75's History and Physical (H&P), dated 2/164/2024, the H&P indicated Resident 75 had 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 Licensed Vocational Nurse (LVN) 2 signed the Medication Administration Record (MAR) and Pain Assessment Flowsheet immediately after administering Norco (medication used to treat moderate to severe pain) to one of one sampled resident (Resident 104). This deficient practice had the potential to result in the double administration of medication to Resident 104 that could lead to overdose (ingestion of a drug in quantities greater than recommended which could result in death). Findings: During a review of Resident 104's admission Record (Face Sheet), the admission record indicated Resident 104 was admitted to the facility on [DATE]. Resident 104's diagnosed included dementia (a progressive state of decline in mental abilities), chronic kidney disease (a long-term condition where the kidneys are damaged and can't filter blood properly), and contracture (a stiffening/shortening of any joint, that reduces the joint's range of motion) 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 nursing staff used a communication board for three of 11 sampled residents (Resident 15, 40, and 84) who did not speak the predominant language of the facility, English. This deficient practice had the potential to negatively affect Resident 15, 40, and 84's physical, mental, and psychosocial needs by preventing the residents from communicating with staff and potentially causing missed or delayed care and/or treatments. Findings: a. During a concurrent observation and interview on 11/13/2024 at 12:28 p.m., in Resident 15's room, there was no language board observed in the room. Resident 15 responded to English questions in Spanish. Resident 15's family member was at the bedside and stated Resident 15 only spoke Spanish. During a review of Resident 15's admission Record, dated 11/13/2024, the admission record indicated Resident 15 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 15's diagnoses…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 dependent residents were taken out of bed, for three out of eight sampled residents (Resident 5, 14, and 121). This deficient practice had the potential to negatively affect Resident 5, 14, 121's wellbeing, psychosocial status, and potentially cause an isolation of the residents. Findings: 1. During an observation on 11/12/2024 at 11:30 a.m., in Resident 121's room, Resident 121 was observed lying in bed watching television. During an observation on 11/13/2024 at 11:31 a.m., in Resident 121's room, Resident 121 was observed lying in bed watching television. During an observation on 11/14/2024 at 10:48 a.m. and at 3:12 p.m., in Resident 121's room, Resident 121 was observed lying in bed watching television. During an observation on 11/15/2024 at 11:14 a.m., in Resident 121's room, Resident 121 was observed lying in bed watching television. During a review of Resident 121's admission Record, the admission record indicated Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that floor mats (a cushioned floor pad designed to help prevent injury should a person fall) were placed on both sides of the bed for one of 27 sampled residents (Resident 72). This deficient practice increased the potential for Resident 72, who had a history of falls, to sustain injury from repeat subsequent falls. Findings: During a review of Resident 72's admission Record, the admission record indicated Resident 72 was admitted to the facility on [DATE]. Resident 72's admitting diagnoses included lack of coordination, generalized muscle weakness, age-related osteoporosis (weak and brittle bones due to lack of calcium and Vitamin D), and Alzheimer's disease (a disease characterized by a progressive decline in mental abilities). During a review of Resident 72's History and Physical (H&P), dated 6/24/2024, the H&P indicated Resident 72 had fluctuating capacity to understand and make decisions. During a review of Resident 72'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: 1. Ensure salt alternative seasoning (a product that can be used in place of salt [sodium chloride]) was available for and provided to one of 27 sampled residents (Resident 75), who was on a no added salt (NAS) diet. 2. Refer Resident 75 to the Registered Dietician (RD, a healthcare professional who specializes in nutrition and diet) as ordered by the physician on 9/8/2024. 3. Revise the care plan for Resident 75's weight loss between 8/2024 and 9/2024, when she continued to sustain weight loss. These deficient practices resulted in Resident 75's complaints of unappetizing and flavorless meals, and a self-reported decreased intake of facility-provided meals. These deficient practices also created the potential for Resident 75 to sustain continued unplanned and undesirable weight loss, possibly rising to the level of significant or severe weight loss, following her weight loss of 14 pounds (lbs., a unit of weight measurement) from 6/2024 to 11/2024.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 necessary respiratory care and services that were in accordance with facility policy for two of 11 sampled residents (Resident 32 and 15), when the facility did not display No Smoking/ Oxygen in Use signs on the outside of the doors of the resident room's or in the room where oxygen was in use for Resident 32 and 15. This deficient practice had the potential to cause fire hazards to all residents, families, visitors, staff, and residents' property, and result in serious harm and injury. Findings: a. During an observation on 11/12/2024 at 10:23 a.m., outside Resident 32's room, there was no No Smoking/ Oxygen in Use sign observed on the room entrance door. Resident 32 was observed using oxygen via a nasal cannula (NC, a device gave resident additional oxygen through nose) with an oxygen concentrator (a medical device that extracted oxygen from the air and delivered it to resident for breathing) at the bedside. There was no No…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 accurate and complete documentation of the administration of Norco (medication used to treat moderate to severe pain) on the Medication Count Sheet for one of one sampled resident (Resident 104). This deficient practice had the potential to result in Resident 104 accidentally being administered an additional dose of Norco before the next dose was due, drug diversion (the act of health care providers stealing prescription medicine for their own use), and/or the potential for medication error to occur. Findings: During a review of Resident 104's admission Record (Face Sheet), the admission record indicated Resident 104 was admitted to the facility on [DATE]. Resident 104's diagnosed included dementia (a progressive state of decline in mental abilities), chronic kidney disease (a long-term condition where the kidneys are damaged and can't filter blood properly), and contracture (a stiffening/shortening of any joint, that reduces…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 salt alternative seasoning (a product that can be used in place of salt [sodium chloride]) was available for and provided to one of 27 sampled residents (Resident 75), who was on a no added salt (NAS) diet. This deficient practice resulted in Resident 75's complaints of unappetizing and flavorless meals, a self-reported decreased intake of facility-provided meals, and placed Resident 75 at risk for unplanned and undesirable weight loss. This also placed Resident 75 at risk complications of her existing medical conditions, due to seeking out food that was not compliant with her prescribed diet. Findings: During a review of Resident 75's admission record, the admission record indicated Resident 75 was admitted to the facility on [DATE] and was most recently readmitted on [DATE]. Resident 75's admitting diagnoses included heart failure (a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the physician was notified and orders were received prior to providing Tapatio brand hot sauce packets to one of 27 sampled residents (Resident 75), who was on a no added salt (NAS) diet. This deficient practice placed Resident 75 at risk complications of her existing medical conditions due to the high sodium content of the hot sauce packets. Findings: During a review of Resident 75's admission Record, the admission record indicated Resident 75 was admitted to the facility on [DATE] and was most recently readmitted on [DATE]. Resident 75's admitting diagnoses included heart failure (a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling) and stroke (loss of blood flow to a part of the brain), and hypertension (high blood pressure). During a review of Resident 75's History and Physical (H&P), dated 2/16/2024, the H&P indicated Resident 75 had the capacity to understand and make decisions.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to readmit one of three sampled residents (Resident 1), who was transferred to a General Acute Care Hospital (GACH) for refusal of care at the facility and was deemed appropriate to return to the facility. This deficient practice placed the resident at risk for confusion and psychosocial harm related to the inability to return to the facility and unnecessary, extended stay at the GACH. Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including cellulitis (a skin infection that causes swelling and redness) of the buttock and left lower limb, type two diabetes mellitus ([DM[ a disorder characterized by difficulty in blood sugar control), and pressure ulcer (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence) of the right. The admission record indicated Resident 1 was self-responsible. During a review…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 pain was assessed every shift, as ordered, for one of three sampled residents (Resident 1). This deficient practice had the potential to cause avoidable discomfort and distress due to unidentified and untreated pain for Resident 1. Findings: During a review of Resident 1's admission Record, the admisssion record indicated the facility originally admitted Resident 1 on 1/14/2016, and most recently re-admitted Resident 1 on 10/6/2024. Resident 1's diagnoses included broken left hip bone, abnormalities of gait and mobility, generalized muscle weakness, age-related osteoporosis (weak and brittle bones due to lack of calcium and Vitamin D), contracture (a stiffening/shortening at any joint, that reduces the joint's range of motion) of the right hip, and unspecified dementia (a progressive state of decline in mental abilities). During a review of Resident 1's Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 9/7/2024, the MDS indicated Resident 1 had severely impaired cognitive skills for 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 interview and record review, the facility failed to ensure, one of 3 residents, (Resident 1) was free from injury as indicated in the resident care plan titled, At risk for injuries related to impaired bed mobility, which indicated to provide resident a safe environment. As a result, Resident 1 sled near the edge of the bed during care, resulting to a fracture (broken bone) on the left lower leg that required admission to a general acute care hospital (GACH) for evaluation and treatment. Findings: A review of Resident 1's admission record dated 4/2/2024 indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 1's diagnoses included nondisplaced transverse fracture of the shaft of left tibia and fibula (a break in the lower leg bones across the bone that did not move out of alignment), osteoporosis (a condition in which bones become weak and brittle), and functional quadriplegia (the inability to move the body from the neck down). A review of Resident 1's…

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

Based on observation, interview, and record review, the facility failed to store food in a sanitary manner to prevent growth of microorganisms that could cause food borne illness (food poisoning: any illness resulting from the food spoilage of contaminated food, pathogenic bacteria, viruses, or parasites that contaminate food, as well as toxins) for 107 out of the 117 residents in the facility by not: 1. Storing food with received dates, open dates, and use by dates. 2. Discarding expired foods. 3. Properly covering, containing, or wrapping foods exposing them to air and contamination. These deficient practices had the potential to cause food borne illnesses to 107 vulnerable residents. Findings: During an observation on 11/27/2023, at 8:25 a.m., on the initial tour of the facility kitchen refrigerator, the following was observed: 1. A large clear container of jelly expired on 6/25/2023, per the labeled use by date. 2. A box of bacon inside of a plastic bag was open and was expired (11/21/2023) per the facility's policy for frozen cured meats. 3. Opened Dijon mustard in its original…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 two of four sampled residents (Resident 22 and Resident 1) by failing to: 1. Wash or sanitize after the removal of gloves and before putting on a new pair of gloves during the administration of medication for Resident 22. 2. Clean and disinfect a blood pressure (BP) monitor and cuff that was used for more than one resident after each use and prior to storing away in the medication cart (MedCart). 3. Perform hand hygiene upon entering and exiting a room with enhanced standard precautions (an infection control intervention designed to reduce the spread of multidrug resistant organisms in nursing homes) for Resident 1. 4. Remove and dispose of face shields after exiting a COVID (a disease caused by a virus, that can be contagious and spread quickly) positive isolation room, which had the potential to affect all 121 residents within the facility. 5. Complete and update the facility's water…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 dignity and feeding assistance during meals to three residents out of 29 sampled residents (Resident 59, 61, and 108) by: 1. Failing to ensure nursing staff fed Resident 59 and Resident 61 at eye level and were not standing over Resident 59 and Resident 61 when assisting the residents with their meal. 2. Failing to provide feeding assistance to Resident 61 and Resident 108 during meals. These deficient practices had the potential to negatively impact Resident 59, 61, and 108's physical needs, nutritional needs, and their psychosocial wellbeing. Findings: 1a. During a review of Resident 59's admission Record, the admission record indicated Resident 59 was originally admitted to the facility on [DATE] and readmitted to facility on 7/5/2023 with diagnoses of dysphagia (difficulty or discomfort in swallowing) and hemiplegia (a condition caused by a brain injury, that results in a varying degree of weakness, stiffness, and lack 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 that three of 26 sampled residents' (Resident 57, 85, and 97) personal property were protected from loss or theft when: a. Resident 57's clothing was misplaced on three separate occasions. b. Resident 85's cell phone was misplaced. c. Resident 97's yellow necklace and yellow ring were misplaced. This failure had the potential to result in avoidable theft and loss of the residents' personal property, and to negatively affect the residents' psychosocial well-being. Findings: a. During a review of Resident 57's admission Record, dated 11/29/2023, the admission record indicated Resident 57 was originally admitted to the facility on [DATE] and was readmitted on [DATE]. Resident 57's diagnoses included palliative care (specialized medical care that focuses on providing relief from pain and other symptoms of a serious illness), Parkinson's disease (a problem of the brain and spinal cord which causes a person to have trouble controlling their body'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 develop a resident-centered care plan (document helps nurses and other team care members organize aspects of resident care) with measurable objectives, timeframe, and interventions for seven out of 29 sampled resident (Resident 4, 6, 45, 59, 61, 78, 89, and 108). The facility failed to: 1. Develop a care plan for the prevention of moisture-associated skin damage (MASD, caused by prolonged exposure to various sources of moisture, including urine or stool, sweat, or wound drainage) for Resident 6, due to the resident's immobility and due to a soiled washcloth being left in the resident's incontinent (inability to control) brief (diaper) for an unknown length of time. 2. Develop a care plan indicating the need for feeding assistance for Resident 59, Resident 61, and Resident 108. 3. Develop a care plan for the need for oxygen (O2) administration for Resident 4, Resident 45, and Resident 78. 4. Develop a care addressing Resident 89's need for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to take preventative measures to prevent skin break down for two out of three sampled residents (Resident 84 and 6) by failing to: 1. Remove a moist, soiled washcloth inside of Resident 6's diaper (incontinence [the inability to control bowel and bladder functions] wear). 2. Reposition Resident 84 every 2 hours. These deficient practices caused Resident 6 to sustain moisture-associated skin damage (MASD, inflammation or skin erosion caused by prolonged exposure to a source of moisture such as urine, stool, and/or sweat) and had the potential to cause skin breakdown for Resident 84. Findings: a. During a review of Resident 6's admission Record, the admission Record indicated Resident 6 was initially admitted to the facility on [DATE]. The admission Record indicated Resident 6 was admitted with diagnoses that included but not limited to autistic disorder (a diverse group of conditions related to development of the brain), schizophrenia…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the resident's nasal cannula (device used to deliver supplemental oxygen or increased airflow through the nose) was dated and ensure the oxygen concentrator humidifier bottle (medical device that increases the humidity in the nostrils when using supplemental oxygen) was not empty for 3 out of 3 sampled residents (Resident 4, 45, 78). These deficient practices had the potential to cause a negative respiratory outcome and increase the risk for residents to acquire a respiratory infection. Findings: a. During a review of Resident 4's admission Record, the admission record indicated Resident 4 was originally admitted to the facility on [DATE]. Resident 4's diagnoses included congestive heart failure (a chronic condition in which the heart doesn't pump blood as well as it should) and respiratory failure (serious condition that makes it difficult to breathe on your own, lungs can't get enough oxygen into the blood) with hypoxia (a 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 medications and biologicals were properly stored and labeled for three of three residents (Resident 45, Resident 13, and Resident 70). The facility failed to: 1. Ensure Resident 45's expired emergency injectable medication, Glucagon (used to help raise blood glucose [blood sugar] level quickly during an emergency) was removed from the medication cart (MedCart 5) on Nursing Station 3 and replaced. 2. Ensure Resident 13's controlled [high abuse potential] medications, Lorazepam Oral Solution (a psychotropic medication which act on the brain and nerves to produce a calming effect) requiring refrigeration were stored according to the manufacturer's requirements. 3. Ensure a topical shampoo, labeled for Resident 70, was securely stored, and not left available inside of a shared bathroom accessible by other residents (Resident 89, 105, 58, and 29) and staff. These deficient practices of failing to store or label medications per 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 light device was within reach for one of 26 sampled residents (Resident 37). This failure had the potential to result in a delay or in the inability for Resident 37 to obtain necessary care and services from the facility staff. Findings: During a review of Resident 37's admission Record (Face Sheet), the admission Record indicated Resident 37 was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses that included but not limited to type 2 diabetes mellitus (condition that results in too much sugar circulating in the blood), cerebral infarction (also known as a stroke; refers to damage to the tissues in the brain due to a loss of oxygen to the area), and dementia (a condition characterized by progressive or persistent loss of intellectual functioning). During a review of Resident 37's Minimum Data Set (MDS, a standardized assessment and screening tool, dated 8/25/2023, 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 observation, interview, and record review, the facility failed to notify the physician of a change of condition for one out of six sampled residents (Resident 6) when Resident 6 was exhibiting forceful, rhythmic, sudden, and involuntary (uncontrolled) muscle movements of the torso (shoulders, chest, lower abdomen, back, and buttocks), mouth, arms, legs, and feet. This failure had the potential to cause a decline in Resident 6's health and negatively impact Resident 6's quality of life. Findings: During a review of Resident 6's admission Record, the admission Record indicated Resident 6 was initially admitted to the facility on [DATE]. The admission Record indicated Resident 6 was admitted with diagnoses that included but not limited to autistic disorder (a diverse group of conditions related to development of the brain), schizophrenia (serious mental illness that affects how a person thinks, feels, and behaves), encephalopathy (group of conditions that cause brain dysfunction), and respiratory failure…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 responsible party (RP) for one of three residents (Resident 37) was notified and understood the changes to Resident 37's Medicare coverage through provision of the Notice of Medicare Non-Coverage (NOMNC) form and the Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNFABN) form. This failure had the potential to result in Resident 37, or Resident 37's RP, not being able to exercise their right to file an appeal and to choose whether or not to continue with the nursing skilled services. Findings: During a review of Resident 37's admission Record (Face Sheet), the admission Record indicated Resident 37 was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses that included but not limited to type 2 diabetes mellitus (condition that results in too much sugar circulating in the blood), cerebral infarction (also known as a stroke; refers to damage to the tissues in the brain due…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 comprehensive standardized assessment and screening tool) within the regulatory time frame for one of seven sampled residents (Resident 13). This deficient practice had the potential to negatively affect the provision of necessary care and services. Findings: During a review of Resident 13's admission Record, the admission record indicated Resident 13 was originally admitted to the facility on [DATE] and re-admitted on [DATE]. Resident 13's diagnoses included functional quadriplegia (complete inability to move due to severe physical disability or medical condition without physical injury or damage to the spinal cord), right sided hemiplegia (weakness to one side of the body) and hemiparesis (inability to move one side of the body) following a cerebral infarction (stroke, blockage of the flow of blood brain, causing or resulting in brain tissue death), and malignant neoplasm of the right breast (breast cancer).…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow the physician's orders for one out of six sampled residents (Resident 6) when the facility did not ensure the following: a. Resident 6's upper bilateral (both sides) bed side rails were padded. b. Resident 6's oxygen concentrator (a machine that delivers oxygen) was set to three liters (l, unit of measurement) per (/) minute (l/min) as ordered. These failures had the potential to cause physical injury and respiratory distress (breathing issues) for Resident 6. Cross Reference F689. Findings: During a review of Resident 6's admission Record, the admission Record indicated Resident 6 was initially admitted to the facility on [DATE]. The admission Record indicated Resident 6 was admitted with diagnoses that included but not limited to autistic disorder (a diverse group of conditions related to development of the brain), schizophrenia (serious mental illness that affects how a person thinks, feels, and behaves), encephalopathy (group…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 up on the doctor's referral for an ophthalmology (branch of medicine that deals with the diagnosis and treatment of disorders of the eye) appointment for one out of 29 sampled residents (Resident 108). This deficient practiced caused a delay in treatment for Resident 108 and caused the resident to experience depression (mood disorder that causes persistent feelings of sadness and loss of lowering of a person's mood) due to impaired vision and negatively impacted Resident 108's needs and psychosocial wellbeing. Findings: During a review of Resident 108's admission Record, the admission record indicated Resident 108 was originally admitted to the facility on [DATE] and readmitted to facility on 10/15/2023 with diagnoses of bilateral eye blindness (no vision) and myocardial infarction (heart attack, a blockage of blood flow to the heart muscle). During a review of Resident 108's History and Physical (H&P) dated 10/16/2023, the H&P indicated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement measures to ensure the safety for one out of six sampled residents (Resident 6) when the facility did not pad the left upper rail of Resident 6's bed. This failure had the potential to cause Resident 6 to hit any part of his body against the metal side rail of the bed due to Resident 6's forceful, rhythmic (recurring), sudden, and involuntary (uncontrolled) muscle movements of the torso (shoulders, chest, lower abdomen, back, and buttocks), mouth, arms, legs, and feet. Findings: During a review of Resident 6's admission Record, the admission Record indicated Resident 6 was initially admitted to the facility on [DATE]. The admission Record indicated Resident 6 was admitted with diagnoses that included but not limited to autistic disorder (a diverse group of conditions related to development of the brain), schizophrenia (serious mental illness that affects how a person thinks, feels, and behaves), encephalopathy (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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to effectively assess and manage a resident's pain for one of three sampled residents (Resident 69). This deficient practice caused Resident 69 to experience pain while the resident's head of bed was being raised, when repositioned in bed, and when moving her left leg. Findings: During a review of Resident 69's admission Record, dated 11/29/2023, the admission record indicated Resident 69 was initially admitted to the facility on [DATE] with the following diagnoses which included palliative care (care that optimizes quality of life by anticipating, preventing and treating suffering), malignant neoplasm (cancerous tumor) of the pharynx (throat), osteoarthritis (joint disease where tissues in the joint break down over time) and osteoporosis (disease where bones become fragile and are more likely to break), dementia (a loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life),…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 resident who received dialysis treatment (the process of removing waste products and excess fluid from the body using a machine when the kidneys are not able to do so) was thoroughly and accurately assessed pre and post dialysis treatment in the Dialysis Communication Records for one of one sampled resident (Resident 108) receiving dialysis treatment. This deficient practice had the potential for unidentified complications after dialysis treatment such as swelling, pain, bleeding, and bruising for Resident 108. Findings: During a review of Resident 108's admission Record, the admission record indicated Resident 108 was originally admitted to the facility on [DATE] and readmitted to facility on 10/15/2023 with diagnoses that included end stage of renal disease (ESRD, a medical condition in which a person's kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis treatment or a kidney…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 accurate and safe pharmaceutical services for one of one residents (Residents 13) when: 1. Resident 13 received one dose of Lorazepam Oral Concentrate medication (a psychotropic medication which act on the brain and nerves to produce a calming effect) stored unrefrigerated inside of a Medication Carts (MedCart) 5 and not in accordance with manufacturer's storage requirement. 2. Resident 13 was administered a PRN (as needed) psychotropic medication (Lorazepam Oral Concentrate) without monitoring documentation to indicated need for use, interventions tried, or effectiveness of therapy. This deficient practice increased the risk for Residents 13 to be exposed to deteriorated and expired PRN medication. This failure created the potential for Resident 13 to be administered less potent medication to treat or relieve the resident's agitation (a feeling of irritability or severe restlessness) and restlessness without monitoring for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of three residents (Resident 106) understood the arbitration (a way of resolving a dispute without filing a lawsuit and going to court) agreement when Resident 106 entered a binding contract (an agreement between two or more parties that creates certain obligations that must be adhered to by law) with the facility. This failure resulted in Resident 106 being unaware that his right to resolve a dispute in court was waived due to entering the binding arbitration agreement. Findings: During a review of Resident 106's admission Record (Face Sheet), the admission Record indicated Resident 106 was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses included but not limited to type 2 diabetes mellitus (condition that results in too much sugar circulating in the blood), dementia (a condition characterized by progressive or persistent loss of intellectual functioning), and hypertension (high 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 observation, interview, and record review, the facility failed to prevent a flying insect from entering one of 26 sampled residents' (Resident 97) room through an open sliding glass door. This failure had the potential to result in the spread of infection to the residents. Findings: During a review of Resident 97's admission Record (Face Sheet), the admission Record indicated Resident 97 was admitted to the facility on [DATE] with diagnoses that included but not limited to urinary tract infection (UTI, infection in any part of the urinary system that includes the kidneys and bladder), major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), and rhabdomyolysis (a breakdown of muscle tissue that releases a damaging protein into the blood). During a review of Resident 97's History and Physical (H&P), dated 10/30/2023, the H&P indicated Resident 97 had the capacity to understand and make…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow their infection control policy and procedure (P&P) by failing to ensure staff donned (put on and use personal protective equipment [PPE, specialized clothing or equipment such as gown and gloves] properly to achieve intended protection) for one of six sampled residents (Resident 1) who was on Enhanced Standard Precautions (an infection control intervention designed to reduce the spread of multidrug resistant organisms [(MDRO) bacteria that are resistant to certain antibiotics). This deficient practice had the potential to cause Resident 1 to get an infection or spread germs to staff and other residents. Findings: During a review of Resident 1's Face Sheet, the Face Sheet indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including end stage renal disease (a condition in which the kidneys lose the ability to remove waste and balance fluids), type 2 diabetes mellitus with…

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

Based on observation, interview and record review the facility failed to ensure two of eight staff (RCTN and HK 2) wore their face mask properly while inside the facility. This deficient practice had the potential to result in the spread of infection (when viruses, bacteria, or other microbes enter your body and begin to multiply). Findings: During a concurrent observation and interview on 9/15/23 at 9:45 a.m. withRCTN (Receptionist), RCTN (Receptionist) wore a facemask under her nose. RCTN stated The face mask should be covering the nose to prevent getting or spreading infection. During a concurrent observation and interview on 9/15/23 at 10:50 a.m. with HK2 (Housekeeper), HK2 wore a face mask under her nose. HK 2 stated Theface mask should be covering the nose. HK2 further stated if the face mask is not worn properly, you can get sick and spread infection. During an interview and record review on 9/15/23 at 11:10 a.m. with the Infection Preventionist (IP), the facility's policy and procedure(P&P) titled Covid 19 Mitigation Plan indicated all health care providers are to wear…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 meet professional standards of care for one of three sampled residents (Resident 1) when nursing staff failed to assess the skin discoloration on the dorsal (top) side of Resident 1's hand. This failure had the potential to result in the a wound forming from the skin discoloration. 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 to the facility on [DATE], with diagnoses including but not limited to schizophrenia (a severe mental illness that causes disturbed or unusual thinking, loss of interest in life, and strong or inappropriate emotions), bipolar disorder (a mental illness that causes unusual shifts in mood, energy, and concentration), and major depressive disorder (MDD, a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment…

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