Claremont Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to accurately administer medication for two of six sampled residents (Resident 2 and Resident 4) according to the facility's policy and procedure (P&P) titled, Medication Administration, by failing to: 1. Ensure Licensed Vocational Nurses (LVN) 1, 3, 4, 5, 6, 7, and 8 assessed and documented Resident 4's blood pressure (BP- the pressure circulating blood against the walls of blood vessels where low BP was less than 120/80 millimeters of mercury [mmHg- unit of measurement] and BP above 140/90 mmHg considered high blood pressure) just prior to administering carvedilol (medication used to treat hypertension [HTN- condition where the force of blood against artery walls is consistently too high and BP is consistently high]) on 10/10/2025 to 10/25/2025, 10/27/2025 to 11/6/2025 at 2 pm. 2. Ensure LVNs 2, 6, 9, 10 and the Infection Prevention Nurse (IPN) assessed and documented Resident 4's BP just prior to administering nifedipine (medication used to treat HTN)…

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

Based on interview and record review, the facility failed to develop an individualized person-centered plan of care that included measurable objectives, timeframes, and interventions to meet the needs of one of three sampled residents (Resident 1). Specifically, the facility did not develop an individualized care plan (CP) for Resident 1 in a timely manner to address Resident 1's past trauma after Resident 1 reported the trauma to the administrator (ADM).This deficient practice had the potential to result in unmet individualized needs and adversely affect the delivery of necessary care and services to Resident 1.Findings:During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident 1 on 8/29/2024, with diagnoses including, heart failure (HF-a heart disorder which causes the heart to not pump blood efficiently, sometimes resulting in leg swelling), chronic (persistent or long-lasting) obstructive pulmonary disorder (COPD, , long standing group of diseases that cause airflow blockage and breathing-related problems, make it difficult to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) received care and treatment in accordance with the facility's policy and procedure (P&P) titled, Transportation to Doctors/Diagnostic Appointments, by failing to ensure staff was available to accompany Resident 1 to Resident 1's scheduled GI (gastrointestinal, refers collectively to the organs of the body that play a part in food digestion) consult (a process where a healthcare professional requests advice or expertise from another healthcare professional specialist or expert in a particular area regarding a patient's care) appointment on 6/25/2025.This failure resulted in Resident 1 missing Resident 1's scheduled GI consult appointment and had the potential to result in the delay in treatment for Resident 1 that could potentially lead to disease progression and complications to Resident 1.Findings:During a review of Resident 1's admission Record (AR), the AR indicated, Resident 1 was originally…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 assess and manage reported pain for one of three residents (Resident 1) as indicated in Resident 1's care plan and the facility's policies and procedures titled, Pain Recognition and Management, and Pain Management, by failing to: 1. Ensure Licensed Vocational Nurse (LVN) 1 assessed and documented Resident 1's pain location. 2. Ensure Resident 1 received pain medication when Resident 1 complained of persistent pain to Resident 1's right lower extremity (RLE- right leg, including hip, thigh, knee, calf, and foot) on 4/7/2025. These deficient practices had the potential for Resident 1 to experience unrelieved/uncontrolled pain that could result in physical, mental, and emotional distress. Cross Reference F842 Findings: During a review of Resident 1's admission Record (AR), the AR indicated Resident 1 was admitted to the facility on [DATE], with diagnoses of history of falling, right femur (thigh bone) fracture (break in the bone), and encounter for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to maintain complete and accurate medical records for one of three sampled residents (Resident 1) by failing to: 1. Ensure Physical Therapist (PT- a healthcare provider who helps improve how the body performs physical movements) 1 and PT 2 accurately documented Resident 1's pain location in Resident 1's Physical Therapy Encounter Notes (PT TEN) dated 4/7/2025 and 4/14/2025. 2. Ensure Licensed Vocational Nurse (LVN) 1 assessed and documented Resident 1's pain location in Resident 1's medical record. 3. Ensure staff documented the rationale for initiating a room transfer for Resident 1 on 4/7/2025 in Resident 1's medical record. These failures resulted in Resident 1's medical record to contain inaccurate and incomplete information and had the potential to affect Resident 1's care. Cross Reference F697 Findings: During a review of Resident 1's admission Record (AR), the AR indicated Resident 1 was admitted to the facility on [DATE], with diagnoses of history…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to revise the plan of care for one of three sampled residents (Resident 1), who was at high risk for falls, following episodes of getting up unassisted on 4/8/2025. This deficient practice had the potential to increase Resident 1's risk for falls and injury. Findings: During a review of Resident 1's admission Record (AR), the AR indicated Resident 1 was admitted to the facility on [DATE], with diagnoses of history of falling, right femur (thigh bone) fracture (break in the bone), and encounter for orthopedic (the branch of medicine dealing with the correction of deformities of bones or muscles) after care, dementia (progressive state of decline in mental abilities), osteoarthritis (OA- a progressive disorder of the joints caused by a gradual loss of cartilage [connective tissue that protects the joints/bones])abnormalities of gait (manner of walking) and mobility (ability to move freely), and generalized muscle weakness. During a review of Resident 1's…

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

Based on observation, interview, and record review, the facility failed to maintain a clean, sanitary, and homelike environment for ten of ten sampled residents (Residents 13, 23, 30, 32, 44, 56, 61, 75, 298, and 299's) rooms. These deficient practices had the potential for Resident 13, 23, 30, 32, 44, 56, 61, 75, 298, and 299 to be exposed to dirt, mold, and drywall dust, which can lead to adverse health effects such as irritating eyes, skin, nose, throat, and lungs. Prolonged exposure can cause more serious problems such as acute respiratory illness, persistent coughing, and asthma. Findings: During an observation on 12/11/24 at 9:10 a.m. in Resident 61, 298, and299's bathroom, the bathroom sink was observed with peeling paint, cracked drywall, a loosely fitting pipe escutcheon (a type of plumbing supply typically made of metal that hides the unsightly hole in the wall that pipes come through) exposing the pipe and hole in the wall under the sink, and there were brown spots underneath the sink. During an observation on 12/11/24 at 9:21 a.m. in Residents 23 and 75's bathroom, 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 administer insulin as ordered for one of one sampled resident (Resident 19) in a timely manner. This deficient practice had the potential to make Resident 19 become lethargic, experience an altered level of consciousness or unresponsive to external stimuli. Findings: During a review of Resident 19's admission Record, (AR), the AR indicated Resident 19 was admitted on [DATE] with multiple diagnoses including type 2 diabetes (a disorder characterized by difficulty in blood sugar control and poor wound healing), dementia (a progressive state of decline in mental abilities) and adult failure to thrive ( a state of decline that is manifested by weight loss, decreased appetite, poor nutrition and inactivity). During a review of Resident 19's Minimum Data Set (MDS - a resident assessment tool) dated 10/2/2024, indicated Resident 19 did not have intact cognition (ability to think and process information). The MDS indicated Resident 20 was dependent (helper…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 foods are handled, prepared, and stored in a manner that prevents foodborne illness (food poisoning) in the facility for one of one kitchen when: 1. Eleven milk cartons were observed in the reach-in refrigerator with an expiration date of 12/7/24. 2. Seven milk cartons with an expiration date of 12/7/24 were observed on a tray of drinks to be serve to residents. 3. One half empty milk carton with an expiration date of 12/7/24 on a resident's tray was observed being brought back to the kitchen by Certified Nursing Assistant (CNA) 4. These deficient practices had the potential to result in pathogen (germ) exposure to residents and placed the residents at risk for developing foodborne illness (food poisoning) with symptoms including upset stomach, stomach cramps, nausea, vomiting, diarrhea, and fever, and can lead to other serious medical complications and hospitalization. Findings: 1. On 12/9/24 at 7:45 a.m., during an initial Kitchen tour, eleven cartons of 2% fat milk were observed in the reach-in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow its infection prevention and control program for two of six sampled residents (Residents 20 and 78) by failing to: a. [NAME] (put on) a gown before entering Resident 78's room which it was under contact precautions. b. Wear personal protective equipment (PPE, prefers to protective clothing, helmets, gloves, face shields, goggles, facemasks and/or respirators or other equipment designed to protect the wearer from injury or the spread of infection or illness) when cleaning Resident 20's room which it was under enhanced barrier precautions. These deficient practices had the potential to transmit infectious microorganisms and increase the risk of infection for all the residents and staff in the facility. Findings a. During a review of Resident 78's admission Record (AR), the AR indicated the facility admitted Resident 78 on 9/3/2024, and re-admitted on [DATE], with diagnoses including pneumonia (an infection/inflammation in the lungs),…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a Minimum Data Set (MDS, a standardized assessment and care-screening tool) was accurate for one of one sampled resident (Residents 90). Resident 90's MDS did not accurately reflect the resident's discharge status. This deficient practice resulted in inaccurate assessment on Resident 90's discharge status with wrong medical information on Resident 90's MDS. Findings: During a review of Resident 90's admission Record (AR), the AR indicated Resident 90's was admitted on [DATE]. During a review of Resident 90's Physician's Discharge Summary (PDS), signed by the resident's physician on 9/23/2024, the PDS indicated Resident 90 diagnoses included Dementia (a decline in mental abilities, such as thinking, remembering, and reasoning), emphysema (damages air sacs in the lungs, making it difficult to breathe), and history of falling. The PDS indicated Resident 90's Transfer/Discharge was necessary due to: Against Medical Advice (AMA, when a patient…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 have a communication board easily accessible for one of two sampled residents (Resident 79) as indicated in Resident 79's care plan. This deficient practice prevented Resident 79 from communicating with facility staff and had a potential to delay appropriate nursing care/treatment and services for Resident 79. Findings: During a review of Resident 79's admission Record (AR), the AR indicated the facility admitted Resident 79 on 9/5/2024, with diagnoses including metabolic encephalopathy (a change in how your brain works due to an underlying condition), reduced mobility and need for assistance with personal care. During a review of Resident 79's History and Physical (H&P), dated 9/5/2024, the H&P indicated Resident 79 did not have decision making capacity. During a review of Resident 79's Care Plan, dated 9/5/2024, the Care Plan indicated Resident 79 had a communication problem related to language barrier (Mandarin speaking only). The goal was for Resident 79 to be able to make basic needs know on a daily…

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

Based on observation, interview and record review, the facility failed to ensure residents who were at risk for skin breakdown and pressure injuries (localized damage to the skin and underlying soft tissue, usually occurring over a bony prominence or related to medical devices) received treatment and services to prevent skin breakdown for one of three sampled residents (Resident 2) by failing to ensure the low air loss mattress (LAL mattress - air filled mattress used to relieve pressure) was set according to the resident's weight. Resident 2's LAL mattress was set at 180 pounds (lbs) and Resident 2's body weight was 117 (lbs). This deficient practice put Resident 2 at risk for developing pressure injury and/or worsening of the pressure injury. Findings: During a review of Resident 2's admission Record (AR), the AR indicated the facility admitted Resident 2 on 11/13/2024, with diagnoses including urinary tract infection (UTI- an infection in the bladder/urinary tract), metabolic encephalopathy (a change in how your brain works due to an underlying condition) and reduced mobility.…

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

Based on observation, interview, and record review, the facility failed to provide care and services to prevent a fall (move downward, typically rapidly and freely without control, from a higher to a lower level) for one of two sampled residents (Resident 1) as indicated in the facility's policy and procedure (P&P) titled, Fall Management System, and Resident 1's care plan when facility staff failed to turn on Resident 1's pressure pad alarm (a device that alerts a caregiver when a patient or family member is getting out of bed) and return Resident 1's bed to the lowest position. These failures had the potential to increase Resident 1's risk of fall and result in Resident 1 to sustain injury and/or harm in an event of a fall. Findings: During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident 1 on 11/19/2023, and readmitted Resident 1 on 2/19/2024, with diagnoses including type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar), heart failure (condition in which the heart cannot pump enough blood…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide two of two sampled residents (Resident 28 and 32) or Resident 28's family member/representative with information regarding the right to formulate an advance directive (AD, a legal document that provides instructions for medical care and only goes into effect if the person cannot communicate their wishes) and failed to have ADs on file prior to, upon, or immediately after admission as stated in the facilities policy and procedure (P&P). This deficient practice had the potential to result with Resident 28 and Resident 32 to receive inaccurate or unnecessary care and/or treatment services regarding life-sustaining treatment and the resident's wishes not met. Findings: 1. During a review of Resident 28's admission Record (AR), the AR indicated the facility initially admitted Resident 28 on 6/26/2016 and readmitted on [DATE], with multiple diagnoses including hemiplegia (paralysis of one side of the body) and hemiparesis (muscle weakness or 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 seven of seven Resident Council members (Resident 7, 15, 17, 34, 39, 48, and 61) and one alert and oriented resident (Resident 47) knew how to file a grievance (official statement of a complaint) and the identity of the facility's designated Grievance Official. The facility also failed to include the contact information of the facility's Grievance Official in the facility's policy and procedure (P&P) for grievances. These failures violated the rights of Residents 7, 15, 17, 34, 39, 48, 61 and 47, and had the potential for the residents to feel the facility did not hear or address the residents' concerns. Findings: During a review of the Resident Council Minutes (official record of a meeting), dated 8/29/2023, the Resident Council Minutes indicated the residents reviewed the topic of grievances including the right to voice grievances without discrimination (unjust treatment) and reprisal (act of returning an attack). During a review 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 implement the care plan for two of two sampled residents (Resident 21and 5). 1. For Resident 21, the facility failed to implement the care plan related to Resident 21's fluid restrictions to address the fluid imbalances related to the resident's kidney failure and hemodialysis (mechanical filtering of the blood when the kidneys are not working properly). 2. For Resident 5, the facility failed to implement the care plan related to Resident 5's oxygen therapy. These failure had the potential to result in the decline of Resident 5 and 21's physical and psychosocial well-being. Findings: 1. During a review of Resident 21's admission Record (AR), the AR indicated the facility admitted Resident 21 on 5/27/2023, with multiple diagnoses including acute kidney failure with dependence on hemodialysis (procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly) and multiple sclerosis (long-lasting…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 revise the care plans for bowel/bladder incontinence (inability to hold urine or stool) and skin problems for one of one sampled resident (Resident 21). This failure resulted in Resident 21's confusion and frustration of Resident 21's plan of care related to fluid intake (fluid consumed, daily) vs. fluid restriction (restriction of fluid intake consumed, daily), causing Resident 21 to become teary-eyed from the misinformation the facility was providing Resident 21. Findings: During a review of Resident 21's admission Record (AR), the AR indicated the facility readmitted Resident 21 on 5/27/2023 with multiple diagnoses including acute kidney failure with dependence on hemodialysis (mechanical filtering of the blood when the kidneys are not working properly) and multiple sclerosis (long-lasting disease of the central nervous system). During a review of Resident 21's History and Physical Examination (H&P), dated 5/30/2023, the H&P indicated Resident 21 had the capacity to understand and make decisions. During a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure respiratory services were provided for two of two sampled residents (Residents 19 and 5). The facility did not follow the physician's orders to provide continuous oxygen therapy (administration of oxygen with the intent of treating or preventing the symptoms and manifestations of decreased level oxygen in tissues) for Residents 19 and 5. This failure resulted in incomplete respiratory care and had the potential to result in respiratory distress to Residents 19 and 5. Findings: a.During a review of Resident 19's admission Record (AR), dated, the AR indicated the facility initially admitted Resident 19 on 10/8/2023 with multiple diagnoses including epilepsy (seizure disorder due to abnormal nerve cell activity in the brain), dementia (impaired ability to remember, think, or make decisions that interferes with daily activities), sepsis (body's extreme response to infection), and acute upper respiratory infection (URI, short-term…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow infection control practices and implement interventions to prevent and control the spread of infections in the facility in accordance with the facility policy and procedures (P&P) and national health guidelines for five of five sampled residents (Residents 22, 3, 32, 238, and 76) when, 1. For Resident 22, the facility failed to follow the Centers for Disease Control and Prevention (CDC, national public health agency of the United States) recommendations when the indwelling urinary catheter (IUC, flexible tube used to empty the bladder and collect urine in a drainage bag) was not maintained sterile (free from bacteria or other living microorganisms) or as a closed system (free of disconnections or dislodgements to prevent entry of contaminants) when frequent IUC irrigations (flushing fluid to maintain patency) must be done. 2 & 3. For Residents 32 and 3, the facility failed to ensure the Nasal cannula ([NC], a device consisting of…

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

Based on interview and record review, the facility failed to ensure any abnormal vital signs for one of one sampled resident (Resident 83) was reported to the physician timely. This failure had the potential to result in a decline in Resident 83's condition due to a delay in the delivery of treatment and services. Findings: During a review of Resident 83's admission Record (AR), the AR indicated the facility originally admitted Resident 83 on 10/1/2023 with multiple diagnoses including sepsis (body's extreme response to infection), hypovolemic shock (life-threatening condition wherein severe blood or fluid loss causes the heart's inability to pump enough blood to the body), urinary tract infection, and acute kidney failure (condition when the kidneys do not filter waste products from the blood). During a review of Resident 83's History and Physical Examination (H&P), dated 10/12/2023, the H&P indicated Resident 83 had the capacity to understand and make decisions. During a review of Resident 83's Minimum Data Set (MDS, a standardized resident screening and care-planning 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, Licensed Vocational Nurse (LVN) 1 failed to monitor Resident 238's heart rate prior to administering blood pressure medication per the parameters indicated in the physician orders. This deficient practice had the potential to result in Resident 238 having an increased risk for complications related to the management of blood pressure, dizziness and falls. Findings: During a review of Resident 238's Admissions Record dated 11/27/23, Admissions Record, indicated Resident 238 was admitted to the facility on [DATE] with a diagnosis of hypertensive heart disease (heart problems that occur because of high blood pressure that is present over a long time), hyperlipidemia (abnormally high concentration of fats in the blood), anemia (condition where your blood produces a lower than normal amount of healthy red blood cells), atherosclerotic heart disease (a condition characterized by the buildup of fats, cholesterol and other substances in and on the artery walls) 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 one of two sampled residents (Resident 10), was provided the preferred choice of activities. This deficient practice resulted in Resident 10 being bored and had the potential to result in a decline in Resident 10's physical, mental, and psychosocial well-being. Findings: During a review of Resident 10's admission Record (AR), the AR indicated, Resident 10 was admitted on [DATE] with multiple diagnoses including multiple pressure ulcers (also known as bedsores, are wounds that occur because of prolonged pressure on a specific area of the skin) stage 3 (involves full-thickness tissue loss), stage 4 (most severe with injuries extending to muscle, tendon, or bone) and unstageable (when stage is not clear due to base of the wound is covered by a layer of dead tissue), quadriplegia (paralysis of all four limbs), major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide treatment and correctly apply a splint (material used to restrict, protect, or immobilize a part of the body to support function, assist and/or increase range of motion) to one of six sampled residents (Resident 26) with limited range of motion [ROM, full movement potential of a joint (where two bones meet)] by failing to: 1. Ensure Resident 26 received passive range of motion (PROM, movement of joint through the ROM with no effort from the person) to the left arm from 11/13/2023 to 11/27/2023. 2. Provide PROM to Resident 26's left elbow prior to application of a left elbow extension splint (material used to extend or straighten the elbow as much as possible) on 11/28/23, and correctly apply a left elbow extension splint to the left elbow. These failures had the potential to further limit Resident 26's left arm ROM and promote the development of contractures (chronic joint stiffness). Findings: During a review of Resident 26's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide the necessary care and services for one of one sampled resident (Resident 236) in accordance with Resident 236's physician's order to follow up with a urologist (a medical doctor that treat bladder issues) for Resident 236's urinary retention (unable to empty the bladder) This failure had the potential to result in Resident 236 to experience a delay in treatment and had the potential to result in a physical decline to Resident 236 and affect the resident's overall well-being. Findings: During a review of the admission Record (AR), the AR indicated Resident 236 was admitted to the facility on [DATE] with diagnosis that included overactive bladder (sudden need to urinate) and major laceration (cut) of the spleen (an organ part of the immune system). During a review of a Minimum Data Set (MDS, a resident assessment and care-screening tool), dated 11/15/2023, indicated Resident 236's cognition (ability to understand and process information) 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.

Based on interview and record review, the facility failed to ensure the signed binding arbitration agreement (BAA, contract between the facility and resident requiring disputes to be resolved by an arbitrator [third party decision-maker] instead of a judge or jury in court) for one of one sampled residents (Resident 136) provided a selection of a convenient venue (location to carry out arbitration proceedings agreed upon and suitable to both parties). This failure had a potential to result in a decline in Resident 136's physical and psychosocial wellbeing due to possible hardships related to arbitration proceedings. Findings: During a review of Resident 136's admission Record (AR), the AR indicated the facility initially admitted Resident 136 on 11/19/2023 with multiple diagnoses including heart failure, chronic (long standing) kidney disease, generalized osteoarthritis (joint tissues break down over time), and difficulty in walking. During a review of Resident 136's History and Physical Examination (H&P), dated 11/21/2023, the H&P indicated Resident 136 had the capacity to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to designate a staff representative to coordinate and ensure hospice services (a type of care and philosophy of care that focuses on the relief and comfort of a terminally ill patient's pain and symptoms and attends to their emotional and spiritual needs) and visits were given as ordered for one of one sampled resident (Resident 3). This failure had the potential to result in Resident 3 not receiving well-coordinated and comprehensive hospice services. Findings: A review of Resident 3's admission Record (AR), the AR indicated Resident 3 was admitted to the facility on [DATE]. Resident's 3 current diagnoses include, but are not limited to, a primary diagnosis as an encounter for palliative care (treatment that relieves the symptoms of a disorder without curing it) as of 7/18/2023, hypertensive heart disease (heart problems that occur because of high blood pressure that is present over a long time) without heart failure (the inability of the heart to pump…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to notify the physician that one of three sampled residents (Resident 486) did not qualify for antibiotic use based on the facility's guide (McGreer's Criteria) used to review true infections. This deficient practice had the potential for the resident to develop adverse effects related to antibiotic use and antibiotic resistance. Findings: During a review of Resident 486's Admissions Record, dated 11/15/23, the Admissions Record indicated Resident 486 was admitted to the facility on [DATE] with a diagnosis of acute osteomyelitis (bone infection) of left ankle and foot, sepsis (a serious condition that happens when the body's immune system has an extreme response to an infection), methicillin resistant staphylococcus aureus infection (MRSA - an infection caused by a type of staph bacteria that has become resistant to many antibiotics), and Type 2 diabetes (a disease that occurs when your blood sugar is too high). During a review of Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to establish and maintain infection prevention and control practices (a set of practices that prevent or stop the spread the of infection and/or diseases in the healthcare setting) in accordance with the facility ' s policy and procedure and Centers for Disease Control and Prevention (CDC) guidelines by failing to: a. Ensure one of 13 sampled staff (Licensed Vocational Nurse 1 [LVN 1] performed hand hygiene (procedures that included the use of alcohol-based hand rub (ABHR- containing 60%-90% alcohol) and hand washing with soap and water before entering and after providing care to one of six sampled residents (Resident 5), who was positive for COVID-19 (infectious disease caused by SARS-CoV-2 virus). b. Ensure one of 13 sampled staff (LVN 1) wore, donned (to put on) and doffed (to take off) personal protective equipment (PPE- equipment worn to minimize exposure to a variety of hazards) according to the facility ' s policy and procedure while…

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