Playa Del Rey Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure care was provided in accordance with professional standards of practice and the resident's comprehensive person-centered care plan for one of three residents (Resident 1) who was admitted to the facility with a left hip surgical incision/wound received treatment. The facility failed to ensure:1). Resident 1's left hip surgical site/ wound was monitored for signs of infections like pustules (a small blister or pimple on the skin containing pus) and inflammation (a condition in which a part of the body becomes reddened, swollen, hot, and often painful, especially as a reaction to injury or infection) as indicated in Resident 1's care plan titled, Resident has skin breakdown related to surgical site.2). The Baseline Care Plan (a care plan developed within 48 hours of admission, which would address resident-specific health and safety concerns and instructions to prevent decline) was created timely, to ensure staff received the necessary…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 an interview and record review, the facility failed to implement the physician's order for pain management for one of four sampled residents (Resident 1).This failure had the potential to result in Resident 1 becoming dependent on pain medication.This failure had the potential for Resident 1 to reduce her capacity to manage and cope with her pain.Findings:During a review of Resident 1's Resident 1's Inter-Facility Transfer Report, dated 11/11/2025, the Inter-Facility Transfer Report indicated Resident 1 had left hip hemiarthroplasty (partial joint replacement surgery) on 11/9/2025.During a review of Resident 1's admission Record, Resident 1 was admitted on [DATE]. The admission Record indicated that Resident 1 had a history of fracture of left femur (leg bone), generalized anxiety (a mental condition characterized by excessive or a mental condition characterized by excessive worry) disorder, and polyneuropathy (disease or dysfunction of one or more nerves, typically causing numbness or weakness 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 observation, interview, and record review, the facility failed to provide pork sausage patty in the breakfast tray, for two of four sampled residents (Residents 2 and 3), as indicated on the menu and meal tickets (the diet order that matched the dietitian approved menu, honoring resident food preferences).This failure resulted in Resident 2 and Resident 3 not receiving the adequate protein and calories, potentially worsening their protein and calorie malnutrition (undernutrition).Findings:1.) During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was originally admitted on [DATE] and readmitted on [DATE]. Resident 2's diagnoses included generalized muscle weakness, anemia (a condition where the body does not have enough healthy red blood cells), and chronic kidney disease (long-term impaired kidney function).During a review of Resident 2's History and Physical (H&P), dated 10/28/2025, the H&P indicated Resident 2 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 ensure one of four sampled residents (Resident 2) was not served in her breakfast tray, orange juice and hot cereal as indicated in the resident's meal ticket.This failure resulted in a violation in Resident 2's rights, which caused her to feel angry and distressed.Findings:During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 2's diagnoses included generalized muscle weakness, anemia (a condition where the body does not have enough healthy red blood cells), and chronic kidney disease (long-term impaired kidney function).During a review of Resident 2's history and physical (H&P), dated 10/28/2025, the H&P indicated Resident 2 had the capacity to understand and make decisions.During a review of Resident 2's Minimum Data Set (MDS - a resident assessment tool), dated 12/4/2025, the MDS indicated Resident 2 was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure accurate documentation was maintained for one of four resident's (Resident 1).This failure had the potential for miscommunication and inaccurate clinical decision-making and could result in delayed identification of condition changes and providing care.Findings:During a record review of Resident 1's Inter-Facility Transfer Report (essential documentation accompanying a patient being transferred from one healthcare facility to another to receive a different level of care), dated 11/11/2025, the Inter-Facility Transfer Report indicated Resident 1 had left hip hemiarthroplasty (partial joint replacement surgery) on 11/9/2025.During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted on [DATE], with diagnoses including history of left femur (leg bone) fracture (broken bone) and for aftercare following joint replacement surgery.During a review of Resident 1's History and Physical (H&P), dated 11/12/2025,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure 1 of 3 sampled residents (Resident 1) did not have a diaper and bed linen soaked with urine.This failure placed Resident 1 at risk for skin breakdown.Findings:During a concurrent observation and interview on 9/29/2025 at 11 a.m. with the Certified Nurse Assistant (CNA 1), Resident 1 was observed lying in bed with diaper soaked with urine, the linen on bed was wet of urine from the low back to mid thighs. Resident 1 was observed scratching her buttocks area using her right hand with hand mitten (protective devices used to prevent self-harm, such as scratching, and to stop patients from pulling out essential medical equipment like intravenous lines or catheters). CNA1 stated he had not provided Resident 1 with morning care or a diaper change. During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 1'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.

Based on observation, interview and record review, the facility failed to ensure a current Direct Care Service Hours Per Patient Day (DHPPD- a staffing standard used in California's skilled nursing facilities, that measures the average number of actual hours of direct care provided to each patient in a 24-hour period) containing an updated census and number of staff on duty to ensure residents receive adequate level of direct care), was posted on 9/29/2025 at Nursing Station 1. This failure had the potential the facility did not meet the staffing requirements and placed the residents' care needs at risk of not being met.Findings: During a concurrent observation and interview on 9/29/2025 at 10:10 a.m., with the Director of Staff Development (DSD) at Nursing Station 1, The Census and Direct Care Service Hours Per Patient Day (DHPPD), dated 9/26/2025 was observed posted at the nursing station counter. The DSD acknowledged the DHPPD hours posted were not current and was 3 days old. The DSD stated the posted DHPPD hours should be updated daily. The DSD stated residents could feel…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 provision of pharmacy services for two of three sampled residents (Resident 94 and 17) when: 1. Resident 94 ' s supplements were not labeled with resident ' s name and date of birth . 2. Resident 17 ' s box of morphine medication was labeled with another resident ' s medication label This failure had the potential to result in medication errors. Findings: During a review of Resident 94 ' s admission Record (Face sheet), the admission Record indicated the facility admitted Resident 94 on 2/22/2025 and was readmitted on [DATE] with diagnosis including intraspinal abscess and granuloma (pus inside or around the spinal cord and collection of immune cells that form in response to infection), sepsis (a life-threatening blood infection), anemia (a condition where the body does not have enough healthy red blood cells), opioid dependence with withdrawal (body has become used to having pain killers and stopping them causes pain), 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: 1. Ensure one of five sampled residents (Resident 29) physician orders were updated when the Licensed staff received a telephone order. This deficient practice of not updating physician orders had the potential to cause the Licensed staff to administer the medication the incorrect route. 2. Complete an initial Body Check for one of three sampled residents (Resident 88), by not documenting the status of her skin upon admission. This deficient practice of failing to do an initial skin assessment, caused Resident 88's medical records to be incomplete. Findings: 1. During a review of Resident 29's admission Record, the admission Record indicated Resident 22 was admitted to the facility on [DATE] and was readmitted on [DATE]. Resident 29 diagnoses gastronomy ([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), gastro-esophageal reflux…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 staff disposed of a used protective personal equipment (PPE, clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments) inside the resident ' s room instead of the hallway. This failure had the potential to increase the chances of acquiring infections and for germs to be transmitted in between residents. Findings: During an observation on 6/10/2025 at 9:17 a.m. Licensed Vocational Nurse (LVN) 4 came out of Resident 4 and Resident 93 ' s room with a used PPE gown still on and proceeded to remove it and throw the gown away in a linen hamper located outside the resident ' s room and in the facility hallway. During an interview on 6/10/2025, at 1:50 p.m., LVN 4 stated, the gown should have been thrown away inside the resident ' s room. Doffing (putting on) outside the room can cause cross contamination and spread of infections. During an interview on 6/12/2025, at 2:07 p.m. with the Infectious Prevention Nurse (IPN) stated, if PPE was disposed outside…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 23 of 36 resident's rooms (rooms 2, 3, 4, 5, 7, 8, 9, 10, 11, 12, 13, 22, 23, 24, 28, 29, 30, 31, 32, 33, 34, 35, 36) met the requirement of 80 square feet (sq. ft.) per resident in a multiple resident room. This deficient practice had the potential for inadequate space for resident care and personal property and the inability to move around the room easily. Findings: During a facility tour and observation on 6/10/24 at 4:02 PM, residents in rooms 2, 3, 4, 5, 7, 8, 9, 10, 11, 12, 13, 22, 23, 24, 28, 29, 30, 31, 32, 33, 34, 35, 36 were able to move in and out of their rooms and had space for their personal property. During a review of the facility's Client Accommodations Analysis form, completed by the Maintenance Director (MS) indicated 23 resident rooms did not meet the space requirement in a multiple resident room. During an interview on 6/13/2025 at 9:32 AM, the Administrator (ADM) stated resident care was not affected due to the room sizes being out of compliance. The waiver request for bedroom to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure all residents had access to the weekly menu and list of alternative choices to the weekly menu, by posting them outside the kitchen, excluding access to residents who are bed or chair bound affecting two of three sampled residents (Resident 12 and Resident 36). The deficient practice of failing to provide menus to residents limited their choice of food due to their physical limitations. Findings: During a review of Resident 12's admission Record (front page of the chart that contains a summary of basic information about the resident), the admission record indicated Resident 12 was admitted to the facility on [DATE] with diagnoses including hypertension (high blood pressure), cardiac arrhythmia (a condition where the heart beats too fast, too slow, or irregularly), and hyperkalemia (a condition where there is too much potassium [an essential mineral vital for numerous bodily functions] in the blood). During a review of Resident 12'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 one out of five residents (Resident 22) call light was within reach. This failure had the potential for Resident 22 needs not being met. Findings: During a review of Resident 22's admission Record, the admission Record indicated Resident 22 was admitted to the facility on [DATE] and was readmitted on [DATE]. Resident 22 diagnoses included dementia (a progressive state of decline in mental abilities), schizoaffective disorder (a chronic mental illness that affects a person's thinking, behavior, and perception of reality), and gastro-esophageal reflux disease([GERD]- stomach acids flow back up into esophagus and causes heartburn). During a review of Resident 22's History and Physical (H&P), dated 7/8/2024, the H&P indicated Resident 22 did not have the capacity to understand and make decisions. During a review of Resident 22's Minimum Data Set ([MDS]- a resident assessment tool), dated 4/15/2025, the MDS indicated Resident 22'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 one out of three sampled residents (Resident 58): 1. Resident 58 was free from mental abuse. 2. To follow facility's policy and procedure (P&P) titled, Abuse Prohibition Policy and Procedure, dated 2/2021, the P&P indicated mental abuse were prohibited threats verbal or nonverbal conduct which can cause or had the potential for the patient to experience intimidation or fear. This deficient practice of not preventing mental abuse for Resident 58 had the potential for Resident 58 to feel unsafe and uncomfortable. Findings: a. During a review of Resident 18's admission Record, the admission Record indicated Resident 18 was admitted to the facility on [DATE] and readmitted to the facility on [DATE]. Resident 18 diagnoses included anxiety (a feeling of worry, nervousness, or unease), bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs),…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to report a femur (thigh bone) fracture of an unknown origin to the California Department of Public Health (CDPH) for one of one sampled residents (Resident 57). This failure resulted in a delay of an investigation by the CDPH. Findings: During a review of Resident 57's Face Sheet (front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated Resident 57 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage) of the hip, end stage renal disease (ESRD -irreversible kidney failure), and dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed). During a review of Resident 57's Minimum Data Set ([MDS]- a standardized assessment and care screening tool), dated 5/7/2025, the MDS indicated Resident 57 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 out of five sampled residents (Resident 29) had a revised care plan for medication administration to be taken by mouth. The deficient practice had the potential for repeat occurrences. Findings: During a review of Resident 29's admission Record, the admission Record indicated Resident 22 was admitted to the facility on [DATE] and was readmitted on [DATE]. Resident 29 diagnoses gastronomy ([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), gastro-esophageal reflux disease ([GERD]- stomach acids flow back up into esophagus and causes heartburn), and dysphagia (difficulty or discomfort in swallowing). During a review of Resident 29's History and Physical (H&P), dated 4/18/2025, the H&P indicated Resident 29 had the capacity to understand and make decisions. During a review of Resident 29's Minimum Data Set ([MDS]- a resident assessment tool),…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 the physician's orders to not give losartan (a medication used to control blood pressure) for one out of one resident (Resident 84) when the systolic blood pressure (SBP- the top number of a blood pressure reading) was less than 110 millimeters of mercury (mmHg- unit of measurement). This deficient practice had the potential for Resident 84 to experience adverse effects related to receiving losartan when her blood pressure was too low and could result in dizziness and falls. Findings: During a review of Resident 84's Face Sheet (front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated Resident 84 was originally admitted on [DATE] and readmitted on [DATE] with diagnoses that included syncope (fainting or passing out), and hypertension (high blood pressure). During a review of Resident 84's Minimum Data Set (MDS - a resident assessment tool) dated 4/7/2025, the MDS indicated Resident 84 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 observations, interview, and record review the facility failed to ensure one out of five sampled residents (Resident 77) was allowed to eat meals out of her bed. This deficient practice of not taking Resident 77 out of bed during mealtimes had the potential for the resident to decline in mobility (a patient's ability to move and change body positions, encompassing the physical capacity to perform functional movements and the independence to carry out daily activities) during activities of daily living ([ADL] -routine tasks/activities to perform daily care for themselves). Findings: During a review of Resident 77's admission Record, the admission Record indicated Resident 77 was admitted to the facility on [DATE]. Resident 77 diagnoses included epilepsy (a neurological disorder characterized by recurring, unprovoked seizures due to abnormal electrical activity in the brain), cerebral infraction (the death of brain tissue due to a lack of blood flow), dysarthria (motor speech disorder), and diabetes…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 certified nurse assistant (CNA) 5 placed the low air loss mattress ([LALM]- an air mattress used to prevent pressure sores) on static mode (mattress setting that provides a firm, even surface for the user by inflating all air cells) and provide two-person assistance when changing Resident 97 on a LALM. This deficient practiced resulted in Resident 97 rolling off the bed while being changed by CNA 5. Findings: During a review of Resident 97's Face Sheet (front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated Resident 97 was admitted on [DATE] with diagnoses that included muscle weakness, and encephalopathy (a broad range of conditions that cause brain dysfunction). During a review of Resident 97's Order Summary Report, the Order Summary Report indicated Resident 97 had an order placed on 5/2/2025 for the use of a LALM for skin management. During a review of Resident 97's Minimum Data…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review the facility failed to ensure the Medication Regimen Review (MRR- a review of medications to identify problems/errors) for one of two sampled residents (Resident 24) was reviewed by the doctor to approve or not approve the pharmacist's recommendation for the month of May. This failure had the potential to result in side effects that could go undetected by licensed staff and delay for the physician to act upon irregularities. Findings: During a review of Resident 24's Face Sheet (front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated Resident 24 was originally admitted on [DATE] and readmitted on [DATE] with diagnoses that included atrial fibrillation (a heart condition where the heart's upper chambers beat irregularly and rapidly, disrupting blood flow), and heart failure (heart disorder which causes the heart to not pump the blood efficiently). During a review of Resident 24's Order Summary Report, the Order…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure residents were free from significant medication error by failing to administer clonidine (a medicine used to treat high blood pressure) within the administration parameters (instructions in the medication order to give the medication if the blood pressure reading is high) a total of 33 times between 3/19/2025 and 6/11/2025 affecting one of three residents sampled for unnecessary medications (Resident 12.) The deficient practice of failing to administer clonidine as ordered had a potential to place Resident 12 at risk for adverse effects of uncontrolled high blood pressure such as heart attack, stroke, vision loss or other serious complications. Findings: During a review of Resident 12's admission Record (front page of the chart that contains a summary of basic information about the resident), the admission record indicated Resident 12 was admitted to the facility on [DATE] with diagnoses including hypertension (high blood pressure), cardiac…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 one of seven sampled residents (Resident 4) had timely documentation of his medications. This deficient practice had the potential to result in a duplicate dose of the medication being given due to no indication the resident received it. Findings: During a review of Resident 4 ' s admission Record, the admission Record indicated Resident 4 was admitted to the facility on [DATE], with a readmission on [DATE]. Resident 4 ' s diagnoses included cerebral infarction ([stroke]- a condition where brain tissue dies due to a lack of blood flow), hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body), and diabetes (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 4 ' s Minimum Data Set (MDS - a resident assessment tool), dated 4/24/2025, the MDS indicated Resident 4 ' s cognition (ability to think and reason) was moderately impaired. Resident 4 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: 1. Ensure one of seven sampled residents (Resident 4) received their scheduled dose of Lispro ([insulin]- a fast-acting medication that lowers the blood sugar) on time. This deficient practice had the potential to result in Resident 4 having a dangerously high blood sugar requiring medical attention. Findings: During a review of Resident 4 ' s admission Record, the admission Record indicated Resident 4 was admitted to the facility on [DATE], with a readmission on [DATE]. Resident 4 ' s diagnoses included cerebral infarction ([stroke]- a condition where brain tissue dies due to a lack of blood flow), hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body), and diabetes (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 4 ' s Minimum Data Set (MDS – a resident assessment tool), dated 4/24/2025, the MDS indicated Resident 4 ' s cognition (ability to think 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 provide the care and services necessary to relieve the pain for one of three sampled residents ' , Resident 1. This deficient practice resulted in the resident ' s discomforts, affecting his participation with physical therapy (PT) and his activities of daily living and had the potential to affect the resident ' s quality of life and recovery. 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 obstructive and reflux uropathy, unspecified (urinary tract condition where urine flow is obstructed and refluxes [flows backward] into the urinary tract) and difficulty walking. During a review of Resident 1 ' s History and Physical (H&P) dated 3/26/2025, the H&P indicated Resident 1 had the capacity to understand and make decisions. During a review of Resident 1 ' s Minimum Data Set ([MDS] a standardized care screening and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure the care and services of one of three sampled residents (Resident 2) needed for the suprapubic catheter (a type of urinary catheter inserted into the bladder through a small incision in the lower abdomen, rather than through the urethra, to drain urine) was provided promptly. This deficient practice resulted in Resident 1 experiencing bladder spasm and discomfort. Findings: During a review of Resident 2 ' s admission Record, the admission Record indicated Resident 2 was admitted to the facility on [DATE]. Resident 2 ' s diagnoses included quadriplegia C5-C7 (paralysis of all four limbs and the torso, resulting from a spinal cord injury at the cervical [neck] region) and muscle weakness. During a review of Resident 2 ' s care plan titled, Indwelling catheter (suprapubic), dated 8/10/2017, the care plan indicated to lavage (wash out) suprapubic catheter per physician order. During a review of Resident 2 ' s History and Physical (H&P)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 thoroughly assess one of three sampled residents ' (Resident 1), who had an indwelling foley catheter ([FC] a thin, flexible tube inserted into the urethra and into the urinary bladder to drain urine) pain and provide interventions to alleviate the pain. This failure resulted in not identifying the cause of the resident ' s pain, resulting in delayed interventions to alleviate the pain. This failure had the potential to affect in maintaining the highest practicable, physical, mental and psychosocial well-being of the resident. 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 obstructive and reflux uropathy, unspecified (urinary tract condition where urine flow is obstructed and refluxes [flows backward] into the urinary tract) and difficulty walking. During a review of Resident 1 ' s Order Summary Report 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 staff was competent to apply a device to secure the foley catheter ([FC] a thin, flexible tube inserted into the bladder to drain urine) from moving or pulled. This failure resulted in the delay of securing Resident 1 ' s FC, causing more pain and discomfort to the affected resident. 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 obstructive and reflux uropathy, unspecified (urinary tract condition where urine flow is obstructed and refluxes [flows backward] into the urinary tract) and difficulty walking. During a review of Resident 1 ' s History and Physical (H&P) dated 3/26/2025, the H&P indicated Resident 1 had the capacity to understand and make decisions. During a review of Resident 1 ' s Minimum Data Set ([MDS] a standardized care screening and assessment tool) dated 3/25/2025, 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 report a change in behavior for one of three sampled residents (Resident 1). This failure had the potential for delay in identifying the underlying cause of change in behavior in Resident 1 and receiving treatment. Findings: During a concurrent observation and interview on 4/30/2025 at 9:33 a.m. in Resident 1 ' s room, Resident 1 was in the room sitting on a wheelchair with a sitter (a healthcare professional, often a trained patient sitter or companion, who provides continuous supervision and support to patients who may be at risk due to their medical condition or psychological state). Resident 1 stated at the time of the incident with Resident 2, she assumed the wheelchair was for anyone to use and did not know the wheelchair belonged to Resident 2. During a telephone interview on 4/30/2025 at 11:48 a.m., with Certified Nursing Assistant (CNA) 3, CNA 3 stated on 4/23/2025 witnessed the altercation between Resident 1 and Resident 2. CNA…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 nurses had the competencies and skill sets necessary to safely administer medications as ordered for one of three sample residents (Residents 5 and 2) when: 1. Licensed Vocational Nurse (LVN) 1 did not check Resident 5's blood pressure in a supine (lying flat on the person's back) position as indicated, prior to administering Droxidopa (medication to treat orthostatic hypotension [low blood pressure (BP) that happens when standing up from a sitting or lying position). 2. Resident 2 blood sugar was not checked on 4/21/2025 at 9:00 p.m. and 4/24/2025 at 6:30 a.m., who had an order to administer insulin (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication). These failures placed Resident 5 at risk for supine hypertension (high blood pressure when lying down which could lead to strokes, heart attacks and death) and Resident 2 at risk for hyperglycemia (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 implement its infection prevention and control measures for one of three sampled residents (Resident 5) by failing to perform hand hygiene washing hands or using an alcohol-based hand-sanitizer) after removing personal Protective Equipment (PPE- clothing and equipment worn or used to provide protection against hazardous substances and/or environments). This deficient practice had the potential for contamination (transfer of harmful bacteria or viruses from one place, object or person to another) and transmission of disease-causing organisms leading to illness to Resident 5. Findings: During a review of Resident 5's admission Record, the admission Record indicated Resident 5 was admitted to the facility on [DATE] and was readmitted on [DATE]. The admission Record indicated Resident 5's diagnoses included orthostatic hypotension (a significant drop in blood pressure that occurs when a person changes from a lying or sitting position to 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 three of the nine sampled residents (Resident 4, Resident 5 and Resident 6) call lightswere placed within reach. This deficient practice had the potential for the residents to not call for help in case of emergency and for any needs, and can negatively impact the physical, medical and psychosocial well-being of the resident when provision of services were delayed. Findings: a) During a concurrent observation and interview on 4/23/2025 at 11:20 a.m. with Certified Nurse Assistance (CNA) 1 in Resident 4 ' s room, Resident 4 ' s call light was hanging on the left side of the bed and was tangled on the siderail. Resident 4 was unable to reach the call light. Resident 4 stated the call light needs to be close to me, so I can ask for water. CNA 1 untangled the call light and handed it to Resident 4. CNA 1 stated the call light should be within Resident 4 ' s reach so he can call for assistance and we can attend to Resident ' s 4 needs.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to monitor one of one sampled resident (Resident 1) for signs and symptoms (s/s) of hypoglycemia (a condition where the level of sugar in the blood is too low) and hyperglycemia (a condition where the level of sugar in the blood is too high) who had a history of diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) and refusal of blood sugar level checks. This deficiency practice had the potential for a delay in care for Resident 1, leading to complications related to hypoglycemia and hyperglycemia such as seizures, loss of consciousness and death. Findings: During a review of Resident 1 ' s admission Record, the admission record indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 1 ' s diagnoses included DM with ketoacidosis (a life-threatening complication of DM in which acids build up in the blood) and hyperglycemia, Hypertension (HTN-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, for one of 9 sampled residents (Resident 1), the facility failed to: 1. Follow the physician ' s order for Resident 1 ' s wound care. 2. Document the treatment provided to Resident 1 in the Treatment administration record (TAR) on 4/19/2025, 4/20/2025, 4/21/2025, 4/22/2025, 4/23/2025 and 4/24/2025. These deficient practices placed Resident 1 at risk of poor wound healing process and wound infection. Findings: During a concurrent observation and interview on 4/23/2025 at 9:58 a.m., Resident 1 was observed on bed and had a very rough skin in both lower legs (BLE). Resident 1 stated the treatment nurse did not apply the lotion ordered by the doctor for my lower legs every day and did not wrap my legs. During a concurrent observation and interview on 4/24/2025 at 4:20 p.m. with Licensed Vocational Nurses (LVN) 1, LVN 1 was observed in Residents 1 ' s room providing wound care to the resident in bed A (roommate). LVN 1 was then asked to check Resident 1 ' s BLE. LVN…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 out of nine sampled Residents (Resident 1), who had a suprapubic foley catheter ([FC] a type of catheter inserted through the urethra, inserted through a hole in the abdomen and then directly into the bladder) was free of signs of urinary tract infection (UTI) like sediments (happens when crystals, bacteria, or blood exit through the urine as a result of dehydration, urinary tract infections, or other conditions) and cloudiness (looks milky or hazy) in the urinary drainage bag. This deficient practice had the potential for Resident 1 to have UTI. Findings: During a concurrent observation and interview on 4/24/2025 at 10:00 a.m., with Licensed Vocational Nurses (LVN) 3, LVN 3 stated Resident 1 ' s FC drainage bag had sediments, the urine was cloudy and amber in color. LVN 3 stated FC needed to be irrigated. During a review of Resident 1 ' s admission Record, the admission Record indicated Resident 1 was admitted to the facility…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 in observation, interview and record review, the facility failed to ensure the Licensed Vocational Nurses (LVN) working in the facility were able to administer all the medications for two of five sampled residents (Residents 1 and 2), timely, as ordered by the physician and as per standards of practice. This deficient practice had the potential to cause these residents not to maintain the therapeutic level of the medication and to not receive the full benefit of the ordered medications. Findings: 1). During a review of Resident 1 admission Record, the admission record indicated that Resident 1 was admitted to the facility on [DATE] with diagnoses including metabolic encephalopathy, chronic obstructive pulmonary disease and acute respiratory failure. During a review of Resident 1 ' s Minimum data Set ([MDS] a federally mandated resident assessment tool) dated 2/21/2025, the MDS indicated Resident 1 had the ability to make her needs known. During an interview on 2/28/2025 at 9 30 a.m., with Resident 1,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based in observation, interview and records review, facility failed to: 1. Provide medications, to four of five sampled residents (Residents 2,3,4, and 5), in a timely manner and as ordered by the physician. 2. Ensure Licensed staff did not crush Resident 2 ' s three medications and mixed with apple source before administering it to Resident 2. This deficient practice had the potential to cause drug interaction when two medications could not be mixed together and could lead to staff not being able to identify each medicine in the case resident refused to take any of the medications. This deficient practice placed Resident 2 at risk for high level of the medication in her system, crushing extended-release (medications designed to release an active ingredient over a specific duration gradually) medication converts it to immediate release (developed to dissolve without delaying or prolonging dissolution or absorption of the drug). 3. Ensure facility staff did not crush Resident 2 ' s extended-release medication…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and records review, the facility failed to ensure, 1 of 5 sampled residents ' (Resident 2) medications were administered, as ordered by the physician. The facility failed to ensure: 1. The facility staff did not crush Resident 2 ' s three medications together without physicians ' order. 2. The facility staff did not crush Resident 2 ' s extended-release medication (medications designed to release an active ingredient over a specific duration gradually) prior to its administration. These deficient practices placed Resident 2 at risk for high level of the medication in her system, as crushing extended-release medication, converts it to immediate release (developed to dissolve without delaying or prolonging dissolution or absorption of the drug). Findings: During a review of Resident 2 ' s admission Record, the admission record indicated Resident 2 was admitted to the facility on [DATE] with diagnoses including hypertension (high blood pressure), atrial fibrillation ([A Fib]…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to create a baseline care plan (a care plan developed within 48 hours of admission that included minimum healthcare information necessary to properly care for each resident immediately upon their admission) for diabetes (DM-a disease that result in too much sugar in the blood) for one of three sampled residents, (Resident 1). This failure had a potential to cause Resident 1 to not have the appropriate interventions for diabetes. Findings During a review of Resident 1's admission Record, dated 2/14/2025, the admission Record indicated Resident 1 was admitted to the facility on [DATE] and discharged on 3/11/2024 with diagnoses including endocarditis (an infection that causes the swelling of the lining of the heart valves and chambers), type 2 DM and chronic kidney disease, stage 3A (a disease with progressive loss of kidney function, with mild to moderate loss of kidney function). During a review of Resident 1's History and Physical (H&P), dated 3/5/2024,…

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 interviews and record review, the facility failed to follow professional standards of practice for one of three sampled residents (Resident 1), who was receiving insulin (a medication to lower blood sugar) injections, by not ensuring a physician order for blood sugar monitoring was obtained and monitored, as indicated in the resident's care plan. This deficient practice had the potential for Resident 1's blood sugar not being adequately monitored and managed. 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 endocarditis (an infection that causes the swelling of the lining of the heart valves and chambers), type 2 diabetes mellitus (DM-a long term condition in which the body has trouble controlling blood sugar and using it for energy), and chronic kidney disease, stage 3A (kidney failure). During a review of Resident 1's History and Physical (H&P), dated 3/5/2024, the H&P indicated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to record the respiratory rate, temperature, and oxygen saturation (O2 sat- a measurement of how much oxygen the blood is carrying as a percentage) for one of two residents (Resident 2). This deficient practice had the potential for Resident 2 to experience a delay in interventions if the resident had fluctuating respiratory rate, temperature, and O2 sat. Findings: During a review of Resident 2's Face Sheet, it indicated Resident 2 was admitted on [DATE], with diagnoses that included Influenza A (flu), and asthma (a lung disease that causes narrowing of the airways making it difficult to breathe). During a review of Resident 2's Minimum Data Set (MDS – a resident assessment tool), dated 10/29/2024, it indicated Resident 2 was cognitively intact (ability to reason, understand, remember, judge, and learn). During a review of Resident 2's Care Plan, dated 1/24/2025, it indicated Resident 2 was at risk for respiratory complications due to a positive Influenza…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide pharmaceutical services to one of one sampled resident (Resident 1) by failing to: 1. Ensure the licensed nurses followed the facility's policy and procedure (P&P) titled, Administering Medications to administer medications within one hour of their prescribed time. This deficient practice placed Resident 1 at risk for mismanagement of medication regimen. Findings: During a review of Resident 1's admission Record (front page of the chart that contains a summary of basic information about the resident), the admission Record indicated, Resident 1 was admitted to the facility on [DATE]. The admission Record indicated Resident 1's diagnoses included rupture of other tendons (injuries to the soft tissues that connect muscles and joints), encounter for other orthopedic after care (the care that you need to take after having orthopedic surgery), and unspecified knee patellar tendinitis (an injury to the tendon connecting your kneecap to your shinbone.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to: 1. Ensure a request for access to medical records and provide copies to resident representative was fulfilled in a timely manner for one of one sampled resident (Resident 1). This deficient practice had the potential to result in Resident 1 feeling frustrated and violated resident rights to obtain medical records. Findings: During a review of Resident 1's admission Record (front page of the chart that contains a summary of basic information about the resident), the admission Record indicated, Resident 1 was admitted to the facility on [DATE]. The admission Record indicated Resident 1's diagnoses included rupture of other tendons (injuries to the soft tissues that connect muscles and joints), encounter for other orthopedic after care (the care that you need to take after having orthopedic surgery), and unspecified knee patellar tendinitis (an injury to the tendon connecting your kneecap to your shinbone. During a review of Resident 1's History and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice, by failing to: 1. Follow-up with orthopedic (a medical specialty that focuses on the diagnosis, treatment, and prevention of injuries and diseases affecting the musculoskeletal system) surgeon in a timely manner for resident with bilateral (having or involving two sides) knee immobilizer (a medical device that restricts movement of the knee joint) for one of one sampled resident (Resident 1). This deficient practice had the potential for Resident 1 to have decline in mobility and range of motion. Findings: During a review of Resident 1's admission Record (front page of the chart that contains a summary of basic information about the resident), the admission Record indicated, Resident 1 was admitted to the facility on [DATE]. The admission Record indicated Resident 1's diagnoses included rupture of other tendons (injuries to the soft tissues that connect…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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. Administer influenza vaccine (a vaccine that protects against the influenza virus) to one of one sampled resident (Resident 1). This deficient practice placed Resident 1 at risk for acquiring influenza virus. Findings: During a review of Resident 1's admission Record (front page of the chart that contains a summary of basic information about the resident), the admission Record indicated, Resident 1 was admitted to the facility on [DATE]. The admission Record indicated Resident 1's diagnoses included rupture of other tendons (injuries to the soft tissues that connect muscles and joints), encounter for other orthopedic after care (the care that you need to take after having orthopedic surgery), and unspecified knee patellar tendinitis (an injury to the tendon connecting your kneecap to your shinbone. During a review of Resident 1's History and Physical (H&P), dated 11/11/2024, the H&P indicated, Resident 1 was alert, oriented x 3 (person, place, and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to complete a care plan for one of three sampled residents (Resident 1) to address the resident's losing belongings at the facility. This deficient practice had the potential to result in recurring loss, theft, and psychosocial harm for Resident 1. Finding: 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 fracture (broken bone) of the right femur (thigh bone), muscle weakness and hypertension ([HTN] high blood pressure) The admission Record indicated Resident 1 was self-responsible. During a review of Resident 1's History and Physical (H&P), dated 10/15/2024, the H&P indicated Resident 1 had the capacity to make medical decisions. During a review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool) dated 10/18/2024, the MDS indicated Resident 1 was able to understand and be understood by others. The MDS indicated Resident 1 required…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 for one out of four sampled residents (Resident 1) who was admitted with a wound to the sacrum [bone located at the base of the spine). This deficient practice had the potential to result in Resident 1 ' s needs not being met and unidentified interventions to address the resident ' s wound. 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 hydrocephalus (a condition in which fluid builds up in the brain and can cause brain damage), dementia (a chronic condition that causes a loss of memory, language, problem solving, and other thinking abilities that are severe enough to interfere with daily life), and cognitive communication deficit (a difficulty with communication caused by an impairment with memory, attention, or problem solving). The admission Record indicated Resident 1 was discharged from the facility to 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 three (3) of 3 emergency crash carts ([crash cart] cart containing medical emergency equipment and medications) contained emergency oxygen tanks (e-tank). This failure had the potential to affect the quality of care and emergency medical interventions residents may need, in cases of emergency medical crisis (a point in a disease where a significant change [like cardiac and respiratory arrest-unexpected loss of heart function, breathing, and consciousness] occurs which can lead to either recovery or death) affecting the recovery and survival chance of the affected resident. Findings: During a concurrent observation, interview and record review on [DATE] at 2:30 p.m. with Registered Nurse (RN 1), crash carts 1 and 3 were observed and the crash carts 1 and 3 logs (checklist) were reviewed. The crash cart log indicated emergency (e-tank) tank oxygen was on the left side of the carts, however, crash carts 1 and 3 did not have an e-tank…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 implement its policy and procedure (P&P) titled, Protected Health Information (PHI), Management and Protection, which indicated all personnel who have access to residents information are responsible to ensure information are managed and protected to prevent unauthorized release or disclosure of personal informations. This failure had the potential to result in unauthorized exposure of resident ' s confidential information to other personnel not involved in the residents' care and had the potential to violate residents' rights to privacy and confidentiality. Findings: During an observation on 6/25/2024 at 8:45 a.m., in Nurse Sation 1&4, random resident ' s physician orders sheets, random residents ' medication orders, and lists of resident admissions with residents ' personal information visible to everyone in the facility, were observed uncovered and spread at the nurse ' s station. During an observation on 6/25/2024 at 9:00 a.m., in Nurse Sation 2&3, a box that was open, labeled medical record containing…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 a safe environment for one of six residents (Resident 5), who was at risk for elopement (when a resident leaves the premises without authorization), by failing to ensure 3 of 4 emergency door alarms (a sound alerting staff when emergency door is opened) were turned on. This failure had the potential for residents at risk for elopement leave the facility successfully, resulting in accidents, injuries, hospitalization and death. Findings: A review of Resident 5 ' s admission Record, indicated Resident 1 was admitted to the facility on [DATE], and re-admitted on [DATE]. Resident 1 ' s diagnoses included vascular dementia (memory loss), muscle weakness and difficulty walking. A review of Resident 5 ' s Minimum Data Set ([MDS] a standardized care assessment and care screening tool), dated 4/23/2024, indicated Resident 5 had severe cognitive (thought process) impairment. The MDS indicated Resident 5 was dependent (helper complete all the…

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

Based on interview, and record review, the facility failed to ensure a system was in place for the accurate reconciliation and turnover of controlled drugs (drugs controlled by the government with the potential for abuse and addiction) by licensed staff at each change of shifts (when current nurse goes off, and an incoming nurse start work). This failure had the potential to result in drug diversion (illegal distribution or abuse of prescription drugs or their use for purposes not intended by the prescriber) within the facility. Findings: On 7/5/2024, at 10:20 a.m. a review of the Controlled Drugs' logbook (record) in Medication Cart 1 was conducted. The Narcotic Count Release (a document signed by incoming and outgoing nurse after counting narcotic drugs) form for the month of June 2024 indicated blank spaces and did not indicate licensed nurses' signatures at 7am-3pm, 3pm-11pm, or 11pm-7am shift change. On 7/5/2024, at 11:00 a.m., a review of the Controlled Drugs' logbook in Medication Cart 3 for the month of June 2024 indicated blank spaces and did not indicate licensed nurses'…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 did not maintain resident equipment in good working condition, by failing to: 1. Ensure 4 of 12 screens doors were maintained in good working condition. 2. Ensure toilet and sink in one of 3 resident (Resident 3) rooms were not leaking. This failure had the potential to cause resident injuries. Findings: a). During an observation on 6/28/2024 at 10:20 a.m., the facility had a total of 12 screen doors connecting to Residents rooms. The screen doors in residents' room [ROOM NUMBER] and 11 were out of rail (needs repair). The screen doors in residents' room [ROOM NUMBER] and 13 were broken and could not be opened. During an interview on 7/5/2024 at 11:57 p.m., with Maintenance Supervisor (MS), the MS stated, I do rounds around the facility every day. The MS stated, he (MS) was aware of some screen doors that needed to be fixed. The MS stated, it was important to check all the screens as it could fall on residents and cause injuries. The MS stated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to: 1. Ensure two of six sampled residents (Resident 41 and 138) the Physician Orders for Life-Sustaining Treatment ([POLST] patients treatment wishes so that emergency personnel know what treatments the patient wants in the event of a medical emergency) form was completed. This deficient practice had the potential for not following the residents desired health care decisions when they become unable to make decisions for themselves. Findings: a. A review of Resident 41's admission record, indicated Resident 41 was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE]. Resident 41's diagnoses included schizophrenia (a group of severe disabling psychiatric disorders marked by withdrawal from reality, illogical thinking, delusions, hallucinations, emotional, and behavioral disturbance), diabetes mellitus (a disease of inadequate control of blood levels of glucose), and depression (a mood disorder that causes a persistent…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 two of six Residents (Resident 41 and 138) had a comprehensive care plan for a Physician Orders for Life-Sustaining Treatment ([POLST] patients treatment wishes so that emergency personnel know what treatments the patient wants in the event of a medical emergency) form was completed. This deficient practice of not having a comprehensive care plan for the POLST had the potential of Resident 41 and 138 wishes not being carried out. Findings: a. A review of Resident 41's admission Record (Face Sheet), the Face Sheet indicated Resident 41 was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE]. Resident 41's diagnoses included schizophrenia (a group of severe disabling psychiatric disorders marked by withdrawal from reality, illogical thinking, delusions, hallucinations, emotional, and behavioral disturbance), diabetes mellitus (a disease of inadequate control of blood levels of glucose), and depression (a mood…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to: 1. Ensure one of five sampled residents (Resident 61) had weekly documented summaries. 2. Ensure one of one sampled residents (Resident 25) weekly weights were completed as ordered by the physician. This failure had the potential for the staff to not be aware if Resident 61's health status is improving or deteriorating. Findings: a. A review of Resident 61's Face Sheet indicated Resident 61 was admitted to the facility on [DATE] with diagnoses that included hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side of the body) following nontraumatic intracerebral hemorrhage (brain bleed). A review of Resident 61's Minimum Data Set ([MDS]- a standardized assessment and screening tool), indicated Resident 61 was cognitively intact (ability to reason, understand, remember, judge, and learn). During a concurrent interview and record review on 6/13/2024 at 10:34 AM with Licensed Vocational Nurse (LVN) 5, Resident 61's Weekly…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 two of five sampled residents ( Residents 2 and 61) had restorative nursing aide (RNA) services provided five times per week, as ordered. This deficient practice had the potential for Resident 2 and Resident 61 to experience a decline in functional mobility (ability to move independently and safely to accomplish tasks). Findings: A review of Resident 2's admission record indicated Resident 2 was admitted to the facility on [DATE] with diagnoses that included difficulty in walking, and muscle weakness. A review of Resident 2's Minimum Data Set ([MDS]- a standardized assessment and screening tool), indicated Resident 61 was moderately cognitively impaired (unable to fully reason, understand, remember, judge, and learn) A review of Resident 2's Order Summary Report indicated Resident 2 was in the RNA program that included ambulating with a front wheel walker ([FWW]- walker with 2 wheels at the front) with moderate assistance up to tolerance 5…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to: 1. Remove two boxes of expired influenza vaccinations from the medication refrigerator in the medication storage room. This deficient practice had the potential to result in the use of ineffective vaccines for the residents. 2. Label a bottle of Latanoprost (medication to treat glaucoma [eye disease that damages the nerve]) and Dorzolamide (medication to treat high eye pressure) eye drops with the open date for Resident 20. This deficient practice had the potential to result in using outdated medication for the resident. Findings: During a concurrent observation and interview on [DATE] at 3:01 PM, the medication refrigerator in the medication storage room in nurse's station 2 and 3 was inspected. There were two boxes of unopened influenza vaccines with an expiration date of [DATE]. Licensed Vocational Nurse (LVN) 2 stated the two boxes of influenza vaccines are expired and should be discarded because you do not want to unintentionally…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 three of six sampled residents (Resident 138, 81, and 141) had a consent for influenza, pneumococcal vaccine, and education about the vaccines. This deficient practice of not having a consent for influenza, pneumococcal vaccine, and education placed Residents 138, 81, and 141 at risk for being misinformed the risk and benefits of having vaccinations. Findings: a. A review of Resident 138's admission Record (Face Sheet), the Face Sheet indicated Resident 138 was admitted to the facility on [DATE]. Resident 138's diagnoses included amyloidosis (a buildup of protein in the heart, kidneys, liver, and other organs), diabetes mellitus (a disease of inadequate control of blood levels of glucose), and spondylosis (a condition in which there is abnormal wear on the cartilage and bones of the neck). A review of Resident 138's History and Physical (H&P), dated 6/1/2024, the H&P indicated Resident 138 had the capacity to make decisions. A review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to: 1. Ensure interdisciplinary team meetings ([IDT]- group of healthcare individuals with expertise in different areas who work together to achieve goals for the residents) were held for one of five sampled residents, (Resident 61) to participate in IDT meetings to discuss his care and discharge goals. This deficient practice had the potential to violate Resident 61's right to be an active participant in his care. Findings: A review of Resident 61's face sheet indicated Resident 61 was admitted to the facility on [DATE] with diagnoses that included hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side of the body) following nontraumatic intracerebral hemorrhage (brain bleed). A review of Resident 61's Minimum Data Set ([MDS]- a standardized assessment and screening tool), indicated Resident 61 was cognitively intact (ability to reason, understand, remember, judge, and learn). During an interview on 6/11/2024 at 12:13 PM…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to: 1. Ensure the bedrails were free of debris for one of one sampled resident (Resident 34). This deficient practice had the potential to result in cross contamination (the movement of germs from one place to another) while providing care to Resident 34. Findings: During an observation on 6/11/24 at 1:26 p.m. at the bedside of Resident 34, the right bedrail was noted to have an unknown brown liquid spilled on it. During a concurrent observation and interview on 6/12/24 at 1:54 p.m. with the IP Nurse at the bedside of Resident 34, she stated the bedrails should not be dirty or had any brown unknown substance on it. The IP nurse further stated housekeeping are supposed to clean all surfaces in the rooms. During an interview on 6/12/24 at 2:06 p.m. with HK1, HK1 stated he was assigned to clean Resident 34's room yesterday and today. Stated he is responsible for cleaning all surfaces in resident rooms. Stated he did not see the brown liquid on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to: 1. Ensure one of six sampled resident (Resident 41) had an PASARR ([Preadmission Screening and Resident Review] to determine if facility practices are in place to identify residents with mental disorders) screening for a new diagnosis for mental disorder. This deficient practice of not initiating a PASARR screening for a new diagnosis placed Resident 41 at risk for receiving proper care. Findings: A review of Resident 41's admission Record (Face Sheet), the Face Sheet indicated Resident 41 was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE]. Resident 41's diagnoses included schizophrenia (a group of severe disabling psychiatric disorders marked by withdrawal from reality, illogical thinking, delusions, hallucinations, emotional, and behavioral disturbance), diabetes mellitus (a disease of inadequate control of blood levels of glucose), and depression (a mood disorder that causes a persistent feeling of sadness and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to: 1. Ensure one of six sampled Residents (Resident 41) had eyeglasses. This deficient practice had the potential in Resident 41 being unable to see necessary objects. Findings: A review of Resident 41's admission Record (Face Sheet), the Face Sheet indicated Resident 41 was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE]. Resident 41's diagnoses included schizophrenia (a group of severe disabling psychiatric disorders marked by withdrawal from reality, illogical thinking, delusions, hallucinations, emotional, and behavioral disturbance), diabetes mellitus (a disease of inadequate control of blood levels of glucose), and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). A review of Resident 41's History and Physical (H&P), dated 1/18/2024, the H&P indicated Resident 41 does not have the capacity to understand and make decisions. A review of Resident 41's Minimum Data Set…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to: 1. Follow the doctor's order to document the oxygen saturation (measurement of how much oxygen is circulating in the blood) level for one of one sampled resident (Resident 73), every shift. 2. Clarify the doctor's order for one of one sampled resident (Resident 73's) continuous supplemental oxygen when Resident 73 was only using oxygen as needed. These deficient practices had the potential to cause complications associated with oxygen therapy. Findings: a. A review of Resident 73's admission Record (Face Sheet) indicated Resident 73 was admitted to the facility on [DATE] with diagnoses that included congestive heart failure (condition where the heart can not pump blood effectively), acute and chronic respiratory failure (difficulty breathing), and chronic obstructive pulmonary disorder ([COPD]- a chronic disease of the lungs where airflow from the lungs is blocked). A review of Resident 73'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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility failed to: 1. Ensure Medication Regimen Review (review of medications to identify problems/errors) recommendations were reported to the physician for one of one sampled resident (Resident 77). This failure had the potential to result in a dangerously low blood sugar for Resident 77. Findings: A review of Resident 77's Medication Regimen Review (MMR) dated March 2024 and May 2024, the MRR indicated there was an order for Lispro (medication that lowers the blood sugar) three units as needed for hyperglycemia (high blood sugar). The MRR indicated was not clear as to what blood sugar is considered high. The MRR also indicated Resident 77 had an additional order for Lispro (medication given to lower the blood sugar based on blood sugar reading). During an interview on 6/14/24 at 2:13 p.m. with RN1, RN1 stated when the Medication Regimen Review (MRR) is received it is the responsibility of the Charge RN or DON to follow up with the physician with the recommendation. You need to inform the doctor right…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to: 1. Offer a replacement meal for one of one sampled residents (Resident 34) on subsequent days. This failure had the potential to result in low blood sugar or weight loss. Findings: During a concurrent observation and interview on 6/11/24 at 1:26 p.m. in Resident 34's room, Resident 34 was observed drinking hot tea. Resident 34 stated he did not want the soft food served for lunch. Stated staff took the lunch tray away and did not bring a replacement. During an interview on 6/11/24 at 1:30 p.m. with CNA4, CNA4 stated Resident 34 was given a regular soft lunch tray as ordered. Resident 34 declined the lunch tray. CNA4 stated she took the tray away. CNA4 stated she did not bring Resident 34 another tray. CNA4 states the kitchen has substitutes available. During a concurrent observation and interview on 6/12/24 at 12:28 p.m. in Resident 34's room, Resident 34 was observed eating cake and hot tea. Resident 34 stated he didn't like his lunch…

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

Based on observation, interview, and record review the facility failed to: 1. Ensure one of three sampled residents (Resident 1's) call light was working. This deficient practice increased the risk for Resident 1 to be unable to call for staff for assistance. Findings: A review of Resident 1's admission Record indicated the facility admitted Resident 1 on 6/29/2023. Resident 1's admitting diagnoses included a healed traumatic fracture (broken bone) and anxiety disorder (intense, excessive, and persistent worry and fear about everyday situations). A review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care screening/planning tool), dated 4/3/2024, indicated Resident 1 did not have any cognitive impairment (problems with a person's ability to think, learn, remember, use judgement, and make decisions). The MDS indicated Resident 1 had impairment to the lower extremity on one side of his body and required a walker or wheelchair for mobility. Resident 1 required substantial to maximal assistance from staff with toileting, and showering/bathing. Resident 1 also…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 implement infection control measures by failing to clean and sanitize two vending machines during a Coronavirus Disease ([Covid-19], a highly contagious respiratory infection caused by a virus that could easily spread from person to person) outbreak. This deficient practice had the potential to spread Covid-19 to residents, staff, and the community. Findings: During a concurrent observation and interview on 12/4/2023 at 12:50 p.m. with the Infection Preventionist (IP), on the smoking patio, a soda vending machine and a food vending machine were observed. During a concurrent telephone interview and record review on 12/8/2023 at 9 a.m. with the housekeeping manager in training (HMT), the Healthcare Services Group, Inc.-High Touch Area Disinfecting logs dated 11/2023 and 12/2023 were reviewed. HMT stated the vending machines were considered high touch surfaces (areas frequently touched by residents) and should be disinfected routinely. HMT also stated, there was no supporting documentation to indicate the vending…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 assistance with activities of daily living (ADLS, activities related to personal care, that includes bathing or showering, dressing, getting in and out of bed or a chair, walking, using the toilet, and eating) was provided to 1 of 4 sampled residents, Resident 1. This failure resulted in Resident 1 sitting on a soiled undergarments for several hours and had the potential to cause skin irritation and damage. Findings: During a review of Resident 1's admission record dated 11/8/2023, the admission record indicated Resident 1 was admitted to the facility on [DATE] with diagnosis of hypertension (high blood pressure), dementia (general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life) and psychosis (a severe mental condition in which thought and emotions are so affected that contact is lost with external reality). During a review of Resident 1's Minimum…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 report an abuse allegation for two of four sampled residents (Resident 1 and Resident 2) within two hours after being made aware of the allegation. This deficient practice had the potential to result in unidentified abuse in the facility and a failure to protect residents from further abuse. Findings: A review of Resident 1's admission Record indicated Resident 1 was admitted on [DATE] with admitting diagnoses that included dementia (a general term to describe a group of symptoms related to loss of memory, judgment, language, complex motor skills, and other intellectual function) and encephalopathy (any brain disease that alters brain function or structure, with potential for symptoms such as declining ability to reason and concentrate, and/or memory loss). A review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 7/26/2023, indicated Resident 1 had severe impairments to his cognition (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 two-person assistance was provided during provision of care for one of four sampled residents (Resident 3). This deficiency had the potential for avoidable harm to Resident 3, who was placed at an increased risk for falls and subsequent injuries related to falls. Findings: A review of Resident 3's admission Record indicated Resident 3 was originally admitted on [DATE] and re-admitted on [DATE]. Resident 3's admitting diagnoses included quadriplegia (a condition where you can't deliberately control or move your muscles from the neck down), cauda equina syndrome (compression of a collection of nerve roots called the cauda equina nerves , causing pain, weakness, incontinence and other symptoms), and personal history of other diseases of the musculoskeletal system and connective tissue (group of tissues in the body that maintain the form of the body and its organs, providing cohesion and internal support). A review of Resident 3'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 provide monitoring and supervision for three of three sampled residents (Resident 1, 2 and 3) per facility policies and care plans. These deficient practices resulted in Resident 1 and Resident 3 to experience emotional distress due to the lack of staff supervision and monitoring Resident 2. Findings: a. During a review of Resident 2's admission Record (Face Sheet), the Face Sheet indicated Resident 2 was admitted to the facility on [DATE]. Resident 2's diagnoses included dementia (the loss of thinking, remembering, and reasoning), anxiety (persistent worry and fear about everyday situations), metabolic encephalopathy (an alteration in consciousness caused due to brain dysfunction). During a review of Resident 2's History and Physical (H&P), dated 8/14/2023, the H&P indicated Resident 2 cannot make decisions but can make needs known. During a review of Resident 2's Minimum Data Set ([MDS] a comprehensive 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 interview and record review, the facility failed to ensure Resident 1 did not physically and emotionally abuse two of three sample residents (Resident 2 and Resident 3). On 7/31/2023 at 3:35 p.m., Resident 1 tried to pushed Resident 2's out of their (Resident 1 and Resident 2) room by aggressively pushing Resident 2 while in the wheelchair and blocking Resident 2 between the bed and the exit door of the room preventing Resident 2 from leaving the room. On 8/2/2023 at 3:23 p.m., Resident 1 hit (using his hand) Resident 3 on her left arm while passing by in the hallway. This failure resulted in Resident 2 felt uncomfortable and upset with Resident 1. Resident 3 felt fearful for her safety. Findings: a. A review of Resident 1's admission Record (face sheet), dated 8/4/2023 indicated Resident 1 was admitted to the facility on [DATE], with a diagnoses that included dementia (the loss of cognitive (the ability to think and process information) functioning - thinking, remembering, and reasoning - to such an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to develop and/or implement an individualized person-centered plan of care with measurable objectives, timeframes, and interventions to meet residents' needs for four out of 18 sampled residents (Resident 5, 54, 59, and 228) by failing to: 1. Develop a baseline care plan addressing the diagnosis of major depressive disorder (a mental health disorder characterized by a persistent sad mood or loss of interest in activities, causing significant impairment in daily life) for Resident 5 and 59. 2. Develop an individualized/person- centered care plan to address Resident 54's oxygen use. 3. Implement Resident 228's plan of care, interventions, and how to monitor for signs and symptoms of a urinary tract infection. These deficient practices had the potential for residents not to receive individualized care and treatment to meet their medical and psychosocial needs. Findings: 1. During a review of the admission record (face sheet) for Resident 5, the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure residents were included in the comprehensive care plan for 3 of 18 sampled residents (Residents 54, 77, and 228). These deficient practices had the potential for the residents to not receive appropriate care treatment and/or services. Findings: During A review of Residents 54's admission record, the admission record indicated Resident 54 was admitted to the facility on [DATE], with diagnosis including Chronic obstructive pulmonary disease [(COPD) lung disease that makes it hard to breath] and hyperlipidemia (high cholesterol). During a review of Resident 54's MDS dated [DATE], the MDS indicated Resident 54 had the ability to understand and be understood by others. During a review of Resident 54's History and Physical (H/P) dated 2/14/2022, the H/P indicated Resident 54 had the capacity to understand and make decisions. During a review of Resident 54's Physicians Orders dated 2/10/2022 through 2/28/2022, the orders indicated Oxygen 2 liters per…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to: 1. Follow the manufactures requirements to remove from use one expired insulin pen for Resident 43 in one of two inspected medications carts (Medication Cart 2). 2. Follow the manufactures requirements to remove from use one expired insulin vial for Resident 12 in one of two inspected medication carts (Medication Carts 3). 3. Refrigerate and label with a date an unopened vial of Novolog insulin (a medication used to regulate blood sugar levels) for Resident 27 in accordance with the manufacturer's requirements in one of two inspected medication carts (Medication Cart 2). 4. Refrigerate and label with a date one unopened container of Latanoprost (medication used to treat [glaucoma] condition where the nerve connecting the eye to the brain is damaged, usually due to high eye pressure) eyedrops for Resident 67. The Latanoprost was not stored in the refrigerator in one of two inspected medication carts (Medication Cart 3). These deficient…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 interventions to prevent and control the spread of the coronavirus ([COVID-19] a severe respiratory illness caused by a virus and spread from person to person) disease and infection in accordance with its infection prevention and control program by failing to ensure: 1. Certified Nurse Assistant (CNA) 1 performed hand hygiene before and after providing care to one of one sampled resident (Resident 31). 2. Staff was fit tested (a test performed to ensure a respirator (mask) forms a tight seal around the wearer's face to prevent the spread of infection) to determine the correct respirator to wear in a timely manner for five of five staff (Housekeeping [HK] 3, CNA 10, CNA 13, CNA 14, CNA 15) and failed to fit test two of two staff (CNAs 11 and 12). These deficient practices had the potential to result in the spread of infection to residents and staff. Findings: 1. During a review of the admission record for Resident 31, 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 maintain the confidentiality of the electronic medical record for one of 18 sampled residents (Resident 27). This deficient practice violated Resident 27's right to privacy and confidentiality of her personal information. Findings: During a review of Resident 27's admission Record, dated 3/24/2022, the admission Record indicated Resident 27 was admitted to the facility on [DATE] with a diagnosis including encephalopathy (a brain disease that alters brain function or structure) and type 2 diabetes mellitus (abnormal blood sugar). During a review of Resident 27's History and Physical (H/P), dated 8/30/2021, the H/P indicated Resident 27 had the capacity to understand and make decisions. During a review of Resident 27's Minimum Data Set ([MDS], a standardized resident assessment and care screening tool), dated 1/19/2022, the MDS indicated Resident 27 had the ability to understand and be understood. The MDS indicated Resident 27 required 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 accurately complete the Preadmission Screening and Resident Review (PASRR) for one of eighteen sampled residents (Resident 77) who was diagnosed with a mental illness. This deficient practice resulted in not triggering recommendations to obtain PASRR level II evaluation and had the potential for inappropriate placement and unidentified specialized services for Resident 77. Findings: During A review of Residents 77's admission record, the admission record indicated the resident was admitted to the facility on [DATE], with diagnosis including anxiety disorder (feelings of fear and restlessness) and hypertension (high blood pressure). During a review of Resident 77's History and Physical (H/P) dated 2/24/2022, the H/P indicated Resident 77 had major depressive disorder with psychotic features (feelings of sadness and loss of interest with loss of contact with reality). During a review of Resident 77's Minimum Data Set ([MDS] an assessment…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure Licensed Vocational Nurse (LVN) 1 administered medications in accordance with professional standards of quality to one of 18 sampled residents by ensuring LVN 1 did not leave Resident 29's room until she was sure the resident had taken his medications. LVN 1 left five medications (amiodarone, Nephro-Vite multivitamin, sevelamer, simethicone and Vitamin D3 5000) unattended on the bedside table of one of 18 sampled residents (Resident 29) and told the resident to take the medications later one hour before he leaves for dialysis. This deficient practice had the potential to cause harm to Resident 29 if he did not take the medication in a timely manner and had the potential to cause harm to other residents who may consume the unattended medications. Findings: During a review of the admission record, the admission record indicated Resident 29 was admitted to the facility on [DATE] with a diagnosis of Type 2 diabetes mellitus (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 provide necessary care and services by not placing a call light within reach for two of 18 sampled residents (Resident 5 and 17). This deficient practice has the potential to cause a negative impact on the resident 5's psychosocial well-being. Findings: 1.During a review of the admission record (face sheet) for Resident 5, the facesheet indicated Resident 5 was originally admitted to the facility on [DATE] and readmitted on [DATE], with a diagnosis of major depressive disorder (a common and serious medical illness that negatively affects how you feel, the way you think and how you act. Depression causes feelings of sadness and/or a loss of interest in activities you once enjoyed), and quadriplegia (paralysis from the neck down, including the trunk, legs, and arms. This condition is typically caused by an injury to the spinal cord that contains the nerves that transmit messages of movement and sensation from the brain to parts of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide translation services to one of eighteen (18) sampled residents (Resident 129), who's primary language was Spanish. This deficient practice resulted in Resident 129 feeling frustrated, and anxious with the care and therapy he was receiving. Findings: During a review of Resident 129's admission record (Face Sheet) the face sheet indicated Resident 129 was admitted to the facility on [DATE], with a diagnosis including hypertension (high blood pressure), diabetes mellitus (high blood sugar), and falls. During a review of Resident 129's social services assessment dated [DATE], the assessment indicated Resident 129's mental health and wellness was stable and the resident was capable of making his own decisions. During a review of Resident 129's care plan meeting notes dated 3/9/2022, the care planning meeting notes indicated Resident 129 was admitted to the facility due to a slip and fall. The care planning meeting notes 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 residents received treatment and care in accordance with professional standards of practice for two of 18 sampled residents (Resident 5, 39) by not providing proper positioning care (turn every two hours) to Resident 5 and 39, who are dependent on staff for positioning. These deficient practices had the potential to negatively affect Resident 5 and 39's physical comfort, skin integrity, and psychosocial wellbeing. Findings: 1. During a review of the admission record (face sheet) for Resident 5, the facesheet indicated resident 5 was originally admitted to the facility on [DATE] and readmitted on [DATE], with a diagnosis of major depressive disorder (a common and serious medical illness that negatively affects how you feel, the way you think and how you act. Depression causes feelings of sadness and/or a loss of interest in activities you once enjoyed), and quadriplegia (refers to paralysis from the neck down, including the trunk,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 license nurses failed to adequately manage pain level for 1 of eighteen (18) sampled Residents. For Resident 42, license nurses did not administer pain medication when resident stated she had pain level of 8 on her right thigh. This deficient practice resulted in Resident 42 being left through the night with a pain level of 8 causing anxiety and distress. Findings: During a review of Resident 42's admission record (face sheet) on 3/22/2022 indicates Resident 42 was initially admitted to the facility on [DATE] with a diagnosis of fracture (break) of the right femur (right thigh bone), hemiplegia (paralysis) of the right side of the body, cerebral infarction (damage to the brain from interruption of blood supply), (high blood sugar), aphasia (inability to communicate), hypertension (high blood pressure), and end stage renal disease (kidney failure). During a review of Resident 42's Minimum Data Set (MDS- a standardize care screening and assessment tool) 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: 1. To provide pharmaceutical services that meet the needs for one of 18 sampled residents (Resident 29). Licensed Vocational Nurse (LVN) 1 did not wait for Resident 29 to take five medications and medications were left unattended on Resident 29's bedside table. This deficient practice had the potential to cause harm to Resident 29 and other residents as medications were left unsupervised at the bedside of the resident. 2. To ensure licensed nurses followed policies and procedures to count controlled medications every (prescription medication that is controlled and monitored by the government) shift with two licensed nurses for one of two inspected medication carts (Medication Cart 3). This deficient practice had the potential to result in an inaccurate account and monitoring of controlled medications which increased the potential risk of drug diversion (the transfer of a controlled substance or other medication from a lawful to an unlawful…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 nurses did not administer doses of expired insulin (a medication used to control high blood sugar) to residents (Resident 43 and 12). This deficient practice increased the risk for Resident 43 and Resident 12 to potentially experience harmful side effects related to the administration of expired insulin, which could have resulted in medical complications possibly leading to hyperglycemia, coma, hospitalization, or death. Findings: 1. During a review of Resident 43's admission record, dated [DATE], the admission record indicated Resident 43 was admitted to the facility on [DATE] with a diagnosis of Type 2 diabetes mellitus (a condition that affects the way the body processes blood sugar) with diabetic neuropathy (a type of nerve damage that can occur with diabetes; condition affects the legs and feet; symptoms can be painful, debilitating, and even fatal). During a review of Resident 43's history and physical examination…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 assure a menu was developed and prepared to meet resident choices including their religious, cultural, and ethnic needs for one of 18 sampled residents (Resident 50). This deficient practice prevented Resident 50 from practicing his religious beliefs by not honoring his food preferences. Findings: During a review of the admission record (face sheet) for Resident 50, indicated Resident 50 was originally admitted to the facility on [DATE], with a diagnosis of severe protein calorie malnutrition (not enough protein and calorie intake. This can lead to muscle loss, fat loss, and loss of body function) and muscle weakness (lack of muscle strength, when a full effort doesn't produce a normal muscle contraction or movement). During a review of the Minimum Data Sheet (MDS, a standardized assessment and care planning tool) for Resident 50 dated 1/26/2022, indicated Resident 50's cognitive skills (mental action or process of acquiring knowledge and…

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

Based on observation and interview, the facility failed to ensure one of four dietary staff wore an N95 mask (a respirator mask used to prevent the spread of an airborne illness) and one of one cook (Cook 1) wore gloves during tray line food preparation. These deficient practices had the potential to cause food-borne illnesses. Findings: During an observation on 3/22/22, at 11:45 a.m., in the kitchen, [NAME] 1 was not wearing gloves. During an observation on 3/23/22, at 10:30 a.m., in the kitchen [NAME] 1 was again not wearing gloves. During an observation on 3/23/22, at 10:45 a.m., in the kitchen, DA1 was observed not wearing an N95 mask during tray line (assembly line of food) preparation. During an interview on 3/23/22, at 10:50 a.m., [NAME] 1 stated N95, gloves, hairnet, aprons are all required personal protective equipment [PPE, equipment worn to minimize exposure to hazards that cause serious workplace injuries and illnesses] were to be used in the kitchen for food handling to prevent the spread of germs and for infection control. [NAME] 1 stated gloves should be used 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.