Inland Valley Care And Rehabilitation Center

Based on observation, interview, and record review, the facility failed to provide a comfortable, homelike environment by not fixing the window curtain from falling off the curtain rail for one (1) of 20 sampled residents (Resident 3).This deficient practice violated Resident 1's right to have a comfortable, homelike environment and had the potential to violate Resident 1's privacy and affect Resident 1's physical and psychosocial well-being.During a review of Resident 3's admission Record (AR), the AR indicated the facility admitted Resident 3 on 3/25/2026 with diagnoses which included type 2 diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), end stage renal disease (ESRD- irreversible kidney failure), dependence on renal dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney[s] have failed), and cellulitis (a skin infection that causes swelling and redness) of left lower limb.During a review of Resident 3's History and Physical (H&P, physician's clinical…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 (1) of 20 sampled residents (Resident 8) when Resident 8's MDS, dated [DATE], incorrectly indicated Resident 8 did not have any pressure ulcer/injuries (localized injury to the skin and/or underlying tissue) upon discharge from the facility on 2/23/2026.This failure had the potential to result in Resident 8 not receiving appropriate treatment and/or services.(Cross reference F627, F658, and F686)During a review of Resident 8's admission Record (AR), the AR indicated the facility admitted Resident 8 on 1/16/2026 with diagnoses including type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar), chronic pain, and chronic kidney disease (a condition in which the kidneys are damaged and cannot filter blood as well as they should). The AR indicated Resident 8's friend (RP 1) was Resident 8's Responsible Party…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 Wound Care Specialist (WCS) inaccurately diagnosed on e (1) of 20 sampled resident's (Resident 8) pressure injury (localized injury to the skin and/or underlying tissue) as a diabetic foot ulcer (ulcers [an open sore] caused by the neuropathic [a condition, disease, or pain caused by damage or malfunction in the nervous system] and small blood vessel complications of diabetes [a chronic condition that affects the way the body processes blood sugar]).This failure had the potential for Resident 8 to receive inappropriate care and treatment for Resident 8's pressure injury.(Cross reference F627, F641, and F686)During a review of Resident 8's admission Record (AR), the AR indicated the facility admitted Resident 8 on [DATE] with diagnoses including type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar), chronic pain, and chronic kidney disease (a condition in which the kidneys are damaged and cannot filter blood as well as they…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 create a care plan to ensure one (1) of 20 sampled residents (Resident 8), who was at high risk to develop pressure injury/ulcer (localized injury to the skin and/or underlying tissue), received interventions to prevent Resident 8 from developing a pressure injury/ulcer. This failure resulted in Resident 8 developing pressure injury to Resident 8's left heel while at the facility.(Cross reference F627, F641, and F658)During a review of Resident 8's admission Record (AR), the AR indicated the facility admitted Resident 8 on [DATE] with diagnoses including type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar), chronic pain, and chronic kidney disease (a condition in which the kidneys are damaged and cannot filter blood as well as they should).During a review of Resident 8's Minimum Data Set (MDS, a resident assessment tool), dated [DATE], the MDS indicated Resident 8 was moderately impaired in cognitive skills…

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

Based on interview and record review, the facility failed to arrange transportation to ensure one (1) of 20 sampled residents (Resident 3) received dialysis (hemodialysis, a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) on 4/13/2026 and on 4/20/2026 as scheduled.This deficient practice resulted in Resident 3 missing two (2) dialysis treatments, placing Resident 3 at risk for serious health complications.During a review of Resident 3's admission Record (AR), the AR indicated the facility admitted Resident 3 on 3/25/2026 with diagnoses which included type 2 diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), end stage renal disease (ESRD- irreversible kidney failure), dependence on renal dialysis, and cellulitis (a skin infection that causes swelling and redness) of left lower limb.During a review of Resident 3's History and Physical (H&P, physician's clinical evaluation and examination of the resident), dated 3/26/2026, the H&P indicated Resident 3 had…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 one of three sampled residents (Resident 1) received treatment and care in accordance with professional standards of practice by failing to perform reassessment, repeat blood pressure measurement or physician notification by the licensed nurse following the elevated blood pressure reading of Resident 1 on 2/27/2026. This deficient practice placed Resident 1 at risk of harm.Findings: During a review of Resident 1's admission Record (Face Sheet), the admission Record indicated the facility admitted Resident 1 on 2/23/2026 with diagnoses including hypertension (a long-term medical condition in which the blood pressure in the arteries is persistently elevated), and heart failure (a condition in which the heart can't pump enough blood to meet the body's needs). During a review of Resident 1's History and Physical (H&P) dated 2/25/2026, 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 federally mandated resident 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 to accommodate the needs for two (2) of 22 sampled residents (Resident 1 and Resident 2) when: 1. The facility did not ensure the call light (a device used by a resident to signal his or her need for assistance from staff) system was audible (able to be heard) for staff (in general) to hear. 2. The facility did not ensure the call light was answered in a timely manner for Resident 1 and Resident 2. These deficient practices resulted in Resident 1's and Resident 2's calls for assistance to be unanswered and for the residents to feel ignored. These deficient practices also placed Resident 1 and Resident 2 at risk for a delayed emergency response, accidents, or prolonged incontinence (lack of voluntary control over urination or defecation/bowel movement).Findings: 1. During a review of Resident 1's admission Record (AR), the AR indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included myasthenia gravis (a condition…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 fluids were provided to two (2) of 22 sampled residents (Resident 1 and 2) to maintain hydration (having enough water or fluids in the body) when Resident 1 and Resident 2 did not have a water pitcher in their room. This deficient practice had the potential to cause dehydration (absence of enough water or fluids in the body) which could lead to severe health complications for Resident 1 and Resident 2. Findings: 1. During a review of Resident 1's admission Record (AR), the AR indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included myasthenia gravis (a condition causing abnormal weakness of certain muscles) and other sequelae of cerebral infarction (long-term aftereffect and complications resulting from a stroke [loss of blood flow to a part of the brain]). During a review of Resident 1's History and Physical Examination (H&P, physician's clinical evaluation and examination of the resident), 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.

Based on observation, interview, and record review, the facility failed to ensure the light fixture above the resident's bed was operable (functional) for one (1) of 22 sampled residents (Resident 13). This deficient practice violated Resident 13's right to a safe, comfortable and homelike environment.Findings:During a review of Resident 13's admission Record (AR), the AR indicated the facility readmitted Resident 13 to the facility on 5/13/2024 with diagnoses that included cholecystitis (gallbladder inflammation), and dementia (a progressive state of decline in mental abilities).During a review of Resident 13's History and Physical (H&P, physician's clinical evaluation and examination of the resident), dated 5/14/2025, the H&P indicated Resident 13 had the capacity to make medical decisions.During a review of Resident 13's Minimum Data Set (MDS, a resident assessment tool), dated 1/8/2026, the MDS indicated Resident 13's cognitive skills (reasoning, learning, and problem-solving) to make daily decisions was moderately impaired. The MDS indicated Resident 13 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 provide medically related social services (services provided by the facility's staff to assist residents in attaining or maintaining their mental and psychosocial health) to one (1) of 22 sampled residents (Resident 15) when the Case Manager (CM- healthcare professional who supports, guides, and coordinates care for residents, families and caregivers) did not meet with Resident 15 upon Resident 15's request.This deficient practice resulted in Resident 15 not being seen by the CM from 2/10/2026 to 2/23/2026 which caused Resident 15 to be unaware of Resident 15's discharge plan and caused Resident 15's mental stress.Findings:During a review of Resident 15's admission Record (AR) the AR indicated Resident 15 was admitted to the facility on [DATE] with diagnoses which included unspecified fracture of lower end of right tibia (a broken right shinbone just above the ankle), diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 promote and protect the rights of two of three sampled residents (Residents 6 and 17) and/or their representatives to voice grievances (any formal or informal complaint about care or living conditions) and to have those grievances addressed promptly and thoroughly when:Facility staff failed to guide complainants (in general) on how to file written grievances and/or were unaware of grievance form locations or the identity of the facility's Grievance Officer.For Resident 6, the facility failed to investigate thoroughly and document the investigation regarding the grievances Resident 6's family member (RR 1) submitted to the facility on [DATE]. The facility also failed to inform (verbally and in writing) RR 1 of the findings of the investigation and the actions that will be taken to correct any identified problems.For Resident 17, the facility failed to investigate and document the investigation regarding the grievance Resident 17 submitted 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.

Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Residents 6), was provided with a clean, comfortable, and homelike environment when the sliding screen door in Resident 6's room would not latch and lock closed.This failure had the potential for Resident 6 not to feel safe and comfortable while in the care of the facility. During a review of Resident 6's admission Record (AR), the AR indicated the facility admitted Resident 6 on 6/18/2024 with diagnoses including type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar), dementia (a group of thinking and social symptoms that interferes with daily functioning), and anxiety disorder (mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities).During a review of Resident 6's Minimum Data Set (MDS, a resident assessment tool), dated 12/15/2025, the MDS indicated Resident 6 had no impairment in cognitive skills (ability to make daily decisions). The MDS…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement its policy and procedure (P&P) titled, Abuse Reporting and Investigation, for one of two sampled residents (Resident 2) by failing to ensure Social Services Assistant (SSA) 1 reported Resident 1's episode of yelling at Resident 2 and at Resident 2's family member (RR 2) and Resident 1's verbalization of harming Resident 2 on 1/28/2026.This deficient practice resulted in Resident 1's verbalization of harming Resident 2 to not be investigated and reported and placed Resident 2 at risk for abuse or harm by Resident 1.Findings: a. During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident 1 on 8/25/2025 with diagnoses that included essential hypertension (high blood pressure) and hyperlipidemia (high level of fats in the blood).During a review of Resident 1's History and Physical (H&P, physician's clinical evaluation and examination of the resident), dated 8/25/2025, the H&P indicated Resident 1 had the…

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

Based on interview and record review, the facility failed to provide foot care and treatment and failed to assist the resident in making appointments with a podiatrist (medical doctor focused on the treatment of disorders of the foot, ankle, and the lower leg) for one of three sampled residents (Resident 6).This failure had the potential in Resident 6 to experience compromised foot health and overall quality of life.Findings:During a review of Resident 6's admission Record (AR), the AR indicated the facility admitted Resident 6 on 6/18/2024 with diagnoses including type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar), dementia (a group of thinking and social symptoms that interferes with daily functioning), and anxiety disorder (mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities).During a review of Resident 6's Minimum Data Set (MDS, a resident assessment tool), dated 12/15/2025, the MDS indicated Resident 6 had no impairment in cognitive skills…

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

Based on record review and interview, the facility failed to ensure that the attending physician or designee wrote, signed, and dated original progress notes at each required visit for one of three sampled residents (Resident 6) when Resident 6's Nurse Practitioner (NP- a nurse who is qualified to treat certain medical conditions without the direct supervision of a doctor) photocopied the previous month's progress notes for visits on 8/4/2025, 9/5/2025, 10/6/2025, 11/7/2025, 12/7/2025, and 1/26/2026.This failure had the potential to result in overlooked changes in Resident 6's health status and had the potential for compromised physician oversight of Resident 6's total program of care.(Cross Reference F585, F790, and F804)Findings:During a review of Resident 6's admission Record (AR), the AR indicated the facility admitted Resident 6 on 6/18/2024 with diagnoses including type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar), dementia (a group of thinking and social symptoms that interferes with daily functioning), and anxiety disorder…

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

Based on observation, interview, and record review, the facility failed to assist one of three sampled residents (Resident 6) in obtaining routine dental services to meet the resident's oral health needs, when the facility did not ensure timely follow-up or coordination after the dentist visit on 12/8/2025.This failure resulted in Resident 6's ongoing untreated dental deterioration (missing most upper teeth, loose teeth), with the potential to result in further oral health decline, pain, difficulty eating/chewing, nutritional compromise, infection risk, or reduced quality of life related to untreated dental needs.(Cross Reference F585, F711, and F804)During a review of Resident 6's admission Record (AR), the AR indicated the facility admitted Resident 6 on 6/18/2024 with diagnoses including type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar), dementia (a group of thinking and social symptoms that interferes with daily functioning), and anxiety disorder (mental health disorder characterized by feelings of worry, anxiety, or fear that are…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 hot foods were served at a palatable, safe, and appetizing temperature for one of three sampled residents (Residents 6), when Resident 6's food was served cold.This failure had the potential for Resident 6 to experience weight loss and/or dehydration.(Cross Reference F585, F711, and F790)During a review of Resident 6's admission Record (AR), the AR indicated the facility admitted Resident 6 on 6/18/2024 with diagnoses including type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar), dementia (a group of thinking and social symptoms that interferes with daily functioning), and anxiety disorder (mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities).During a review of Resident 6's Minimum Data Set (MDS, a resident assessment tool), dated 12/15/2025, the MDS indicated Resident 6 had no impairment in cognitive skills (ability to make daily decisions). The MDS indicated Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility staff members failed to provide peri-care (the cleaning and maintenance of the perineum, the area between the anus and the genitals) for two of three sampled residents (Residents 2 and 3) who required physical assistance with toileting hygiene (the ability to maintain perineal hygiene, adjust clothes before and after urinating or having a bowel movement). This deficient practice had the potential to place Residents 2 and 3 at risk for increased risk for infection, skin breakdown and further potential health complications.Findings: a. During a review of Resident 2's admission Record (AR), the AR indicated Resident 2 was admitted to the facility on [DATE] with diagnoses including epilepsy (a brain disorder that can cause people to suddenly become unconscious and have violent, uncontrolled movements of the body), type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar), and a history of falling. 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 interview and record review, the facility failed to provide sufficient staffing, resulting in toileting and/or incontinent care not being provided for two of three sampled residents (Residents 2 and 3) in a timely manner. This failure had the potential to result in Residents 2 and 3 experiencing skin breakdown and/or placing the residents at risk for urinary tract infection (UTI, an infection in any part of the urinary system). Findings: a. During a review of Resident 2's admission Record (AR), the AR indicated Resident 2 was admitted to the facility on [DATE] with diagnoses including epilepsy (a brain disorder that can cause people to suddenly become unconscious and have violent, uncontrolled movements of the body), type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar), and a history of falling. During a review of Resident 2's History and Physical (H&P) dated 1/6/2025, the H&P indicated Resident 2 had the capacity to understand and make medical decisions.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide care and services to one of three sampled residents (Resident 3) by failing to ensure: 1. RNA 1 correctly applied Resident 3's right palm protector as indicated by rehabilitation staff. 2. RNA 1 and RNA 2 informed nursing staff when Resident 3's right palm and hand was known to get sweaty and develop moisture accumulation between the right thumb and index finger. These failures resulted in Resident 3 developing multiple open skin wounds on Resident 3's right thumb and index finger, and Resident 3 developed redness and an indentation on Resident 3's index finger knuckle. 3. Restorative Nursing Assistant (RNA) 1 and RNA 2 informed licensed nurses on 12/11/2025 at 11 am when RNA 1 removed Resident 3's right palm protector (a hand splint or supportive device, often foam and fabric, designed to prevent fingers from digging into the palm, which stops skin breakdown, ulcers, and pain, especially in conditions causing severe finger…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 that allow residents who wish to smoke, the opportunity to do so with optimal safety of themselves and others for two of eight sampled residents (Residents 4 and 5) according to the facility's policy and procedure (P&P) titled, Smoking by Residents, by failing to: Ensure Activities Assistant (AA) 1 provided adequate supervision (oversight, encouragement, or cueing) while Residents 4 and 5 were smoking on 11/13/2025 at 1 pm. As a result of this failure, AA 1 did not visualize Residents 4 and 5 smoking at the smoking patio. This failure placed Residents 4 and 5's safety at risk and had the potential for the residents to sustain cigarette burns (an injury to the skin's tissues caused by heat) and being harmful to themselves, each other, and being susceptible to abuse. Findings: a. During a Review of Resident 4's admission Record (AR), the AR indicated the facility admitted Resident 4 on 2/25/2025 and 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 arrange for a safe and orderly discharge for one of two sampled residents (Resident 7) when the facility failed to communicate Resident 7's medical conditions and needs to Intermediate Care Facility (ICF, provides long-term care for individuals who need more assistance than residential care but less than a skilled nursing facility) 1 prior to Resident 7's transfer to ICF 1. This failure had the potential for Resident 7 to experience an unsafe discharge due to receiving inappropriate and or inadequate care.Findings: During a review of Resident 7's admission Record (AR), the AR indicated the facility admitted Resident 7 on 8/8/2025 with diagnoses including acute kidney failure (a condition in which the kidneys suddenly can't filter waste from the blood), malignant melanoma of skin (skin cancer), and dysphagia (difficulty swallowing foods or liquids). During a review of Resident 7's Minimum Data Set (MDS, a resident assessment tool), dated 8/14/2025, the MDS indicated Resident 7 was severely impaired in cognitive skills…

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

Based on interview and record review, the facility failed to provide one of three sampled residents (Resident 14) or the Resident's Representative a copy of the Resident 14's medical record upon request and within two working days from notice per the facility's Policy and Procedure (P&P) titled, Residents Access to Records. This failure resulted in violation of Resident 14's rights and in Resident 14's Representatives not receiving the medical records in a timely manner. Findings: During a review of Resident 14's admission Record (AR), the AR indicated the facility admitted Resident 14 on 1/10/2025 with diagnoses that included lumbar region stenosis (narrowing of the spinal cannel which added pressure on the spinal cord and nerves) and hypertension (HTN, high blood pressure). During a review of Resident 14's Minimum Data Set (MDS, a resident assessment), dated 1/16/2025, the MDS indicated Resident 14's cognitive skills were intact. The MDS indicated Resident 14 required substantial assistance performing Activities of Daily Living (ADLs). The MDS indicated Resident 14 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 protect one of three sampled resident (Resident 8) from medication administration error in accordance with prescriber orders as indicated in the facility's policy and procedure (P&P) titled, Administering Medications. This failure resulted in Resident 8 administered melatonin (a hormone supplement that signals the body that it's time to sleep) pills without a physician order. Findings: During a review of Resident 8's admission Record (AR), the AR indicated Resident 8 was admitted to the facility on [DATE] with diagnoses which included end stage renal disease (the final stage of chronic kidney disease (CKD) where the kidneys have permanently failed and can no longer function at a level needed to sustain life), and dependence on renal dialysis (a patient's lifelong reliance on the dialysis machine to filter waste from their blood, as their kidneys can no longer perform this function.) During a review of Resident 8'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 protect the privacy and dignity of seven of seven sampled residents (Resident 11, Resident 27, Resident 33, Resident 45, Resident 116, Resident 136, and Resident 239), by failing to: A. Ensure the privacy curtain was closed while providing care and treatment to Resident 33.B. Ensure Resident 116 did not experience an extended waiting time for care for approximately one hour.C. Ensure Resident 45 and Resident 239 did not experience an extended wait time to receive care for approximately 30 minutes to 2.5 hours.D. Ensure Resident 136 did not experience an extended wait time for peri-care of more than four hours after requesting assistance.E. Ensure Resident 27's personal choices for showers instead of bed bath were respected.F. Ensure Resident 11 did not wait 20 minutes to be changed after soiling her diaper.Findings: a. During a review of Resident 33's admission Record (AR), the AR indicated Resident 33 was admitted to the facility on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to accommodate the residents' needs and preferences in accordance with the facility's policy and procedures (P&P) for five of five sampled residents (Residents 8, 41, 163,165, and 218) by failing to:a. Provide Resident 8 with an appropriate call light consistent with Resident 8's functional capability.b. Ensure Resident 41's call light was within reach.c. Ensure Resident 163's call light was within reach.d. Ensure Resident 165's bed was not too short causing Resident 165's feet to rest against the footboard. e. Ensure to accommodate Resident 218's request for room change due to noise from the roommate (Resident 209). These failures had the potential for Residents 8, 41, 163, 165, and 218 not to receive necessary care or receive delayed services and could affect the residents' quality of life.Findings: a. During the review of Resident 8’s admission Record (AR), the AR indicated Resident 8 was initially admitted to the facility on [DATE] 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 its policies and procedures (P&P) for Advance Directive (AD, a written preference regarding treatment options, a process of communication between individuals and their healthcare agents to understand, reflect on, discuss, and plan for future healthcare decisions for a time when individuals are not able to make their own healthcare decisions) was implemented for three of three sampled residents (Resident 7, 16 and 119) by failing to: a. Ensure Resident 7's AD was discussed and written information was provided to the residents and/or responsible parties.b. Ensure Resident 16's AD was discussed and written information was provided to the residents and/or responsible parties.c. Ensure Resident 119's Advance Directive Acknowledgement (ADA) Form was completed upon admission.These failures had the potential to result in facility staff to provide medical treatment and services against the residents' will. Findings: a. During a review of Resident 7’s…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure two of two sampled residents' (Resident 9's and Resident 13's), Minimum Data Set (MDS - a resident assessment tool) assessments were accurately documented to reflect:a. Resident 9's use of oxygen.b. Resident 13 was receiving hospice care.These failures had the potential to negatively affect Resident 9's and Resident 13's plan of care and delivery of necessary care and services.Findings: a. During a review of Resident 9’s admission Record (AR), the admission Record indicated Resident 9 was admitted on [DATE] with diagnoses that included respiratory failure (a condition caused by inadequate supply of oxygen and/or the inability to remove carbon dioxide from the lungs), chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), and heart failure (when the heart muscle can't pump enough blood to meet the body's needs for blood and oxygen). During a review of Resident 9’s History & Physical (H&P), dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to develop an individualized and person-centered care plan for two of five sampled residents (Resident 13 and Resident 33) in accordance with the facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, by failing to ensure:a. Resident 13, who had a diagnosis of dementia (a progressive stated of decline in mental abilities), had a plan of care for dementia.b. Resident 33's peripherally inserted central catheter (PICC - a long, thin catheter inserted into a vein in the arm, usually in the upper arm, and threaded to a large vein near the heart, used to administer fluids and or medications) was included in Resident 33's plan of care.These deficient practices had the potential for Resident 13 and Resident 33 to not receive appropriate care, treatment, and or services.Findings: a. During a review of Resident 13's admission Record (AR), the AR indicated Resident 13 was readmitted to the facility on [DATE] with diagnoses that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure three of three sampled residents (Residents 8, 11, and 58) received treatment and care in accordance with physician's orders/professional standards of practice when:a. The facility failed to provide a bolstered mattress to Resident 8, as ordered. b. The facility failed to provide treatment for Resident 11's complaint of burning pain when urinating. c. The facility failed to manage the pain & burning sensation upon urination for Resident 58. These failures resulted in Residents 11 and 58 continuing to experience burning pain when urinating and had the potential for Residents 8, 11, and 58 to experience a decline in health and wellbeing.(Cross Reference F580 and F697) Findings: a. During the review of Resident 8’s admission Record (AR), the AR indicated Resident 8 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including dementia (a progressive state of decline in mental abilities),…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, for five of five sampled residents, the facility failed to ensure:a. Resident 218's blisters under the ostomy bag were assessed.b. Resident 212's LAL mattress (tiny laser made air holes in the mattress top surface continually blowing out air causing the resident to float) was set up accurately according to manufacturer's instruction and not on static mode.c. Resident 213's LAL mattress was not set to static while the resident was in bed.d. The LAL mattress was set according to Residents 41 and 136's weight. These deficient practices placed the residents at risk for altered skin integrity and had the potential to result in the development/worsening of pressure ulcers (PU - localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence).Findings: a. A review of Resident 218’s admission Record (AR) dated 10/19/2024, the AR indicated that Resident 218 has hemiplegia (partial paralysis) and hemiparesis (weakness or inability 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 provide necessary care and services for residents on oxygen therapy (treatment that provides supplemental, or extra oxygen) in accordance with the facility's Policy and Procedure (P&P) on Oxygen Administration for three of four sampled residents (Residents 9, 25, and 122).These failures had the potential for Residents 9, 25, and 122 to result in respiratory complications and infections. Findings: a. During a review of Resident 9’s admission Record (AR), the admission Record indicated Resident 9 was admitted on [DATE] with diagnoses that included respiratory failure (a condition caused by inadequate supply of oxygen and/or the inability to remove carbon dioxide from the lungs), chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), and heart failure (when the heart muscle can't pump enough blood to meet the body's needs for blood and oxygen). During a review of Resident 9’s Care Plan (CP),…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 residents on hemodialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) an emergency kit (E-kit, contains the main items needed in an emergency) at the bedside for two of six sampled residents (Residents 111 and 219) in accordance with the residents' comprehensive care plan.These failures had the potential for Residents 111 and 219 not to receive or receive delayed care and emergency treatment from complications caused by unexpected bleeding from the hemodialysis access site. Findings:a. During a review of Resident 111's admission Record (AR), the AR indicated Resident 111 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included end stage renal disease (ESRD, irreversible kidney failure), congestive heart failure (CHF, a heart disorder which causes the heart to not pump the blood efficiently), 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 provide sufficient staffing, resulting in toileting and/or incontinent care not being provided for two of three sampled residents (Residents 11 and 136) in a timely manner. This failure had the potential to result in Residents 11and 136 experiencing skin breakdown and/or placing the residents at risk of experiencing a urinary tract infection (UTI, an infection in any part of the urinary system, including the kidneys, bladder, or urethra). (Cross Reference F550) Findings: a. During a review of Resident 11's admission Record (AR), the AR indicated Resident 11 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD, a group of diseases that cause airflow blockage and breathing-related problems), type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar), and bipolar disorder (a mental illness that causes unusual shifts in a person's 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 observation, interview and record review the facility failed to:a. Administer medications in a timely manner for three of four sampled residents (Residents 218, 209 and 89). This failure had the potential to result in the effectiveness of the medication affecting the residents' wellbeing.b. Ensure during a medication pass observation on 8/21/2025 at 8:33 am, Licensed Vocational Nurse 8 (LVN 8) did not attempt to administer 2 tablets of Tylenol Oral Tablet 325 mg to Resident 34.c. Ensure an accurate account of the use of a controlled medication (medications that the use and possession of are controlled by the federal government), Pregabalin (a controlled medication used for pain and seizures) for Resident 47 when the licensed nurse did not document its usage on the controlled drug record.These deficient practices had the potential to result in adverse consequences for the residents. Findings: a. A review of Resident 218’s admission Record (AR), dated 10/19/2024, the AR indicated that Resident 218 has…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 safe storage of medications by failing to:a. Ensure Resident 15's eye drop bottle was labeled with the resident's name.b. Ensure Resident 71's eye drop bottle and box were labeled with the resident's name. c. Ensure the medication cart was not left open and unattended and outside of view of staff in nursing station 1.These deficient practices had the potential to result in unintentional medication administration to the wrong resident and could have also resulted in missing medications from the medication cart. Findings: a. During a review of Resident 15’s admission Record (AR), the admission Record indicated Resident 15 was admitted on [DATE] with diagnoses that included metabolic encephalopathy (brain dysfunction caused by diseases or toxins in the body) and sepsis (a life-threatening blood infection). During a review of Resident 15’s History & Physical (H&P), dated 6/26/2025, the H&P indicated the resident 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 observation, interview, and record review, the facility failed to ensure two of two sampled residents (Residents 70 and 244) received food that was palatable, attractive, and according to food preference according to the facility's Policy and Procedure (P&P) titled, Food and Nutrition Services, revised October 2017.These failures had the potential for Residents 70 and 244 to be at risk of unplanned weight loss, a consequence of poor food intake. Findings: a. During a review of Resident 244's admission Record (AR), the AR indicated the facility admitted Resident 244 on 6/8/2022 and readmitted on [DATE] with diagnoses including respiratory failure (when the lungs can't get enough oxygen into the blood), dependence on respiratory ventilator (a type of breathing apparatus that moves air into and out of the lungs), and dependence on renal dialysis (the process of removing excess water and toxins from the blood in people whose kidneys can no longer perform these functions naturally). During a review of…

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

Based on observation, interview, and record review, the facility failed to ensure each kitchen sanitization bucket (used to sanitize surfaces in the facility kitchen) and the sink sanitization compartment used to sanitize tray line preparation area, was maintained at the required concentration for effective sanitization by failing to:Ensure two red buckets and the sink sanitization compartment (third compartment of the sink) used in the kitchen for sanitation of kitchen surfaces and in food preparation areas, were maintained at the correct concentration to maintain effectiveness to prevent cross contamination.Findings:During a concurrent observation and interview, on 8/19/25, at 9:56 a.m., with the Dietary Supervisor (DS), two of four red sanitization buckets and the sanitization compartment of the kitchen sink were tested for efficacy (ability to produce a desired or intended result). Two of the red bucket sanitizations and third sink compartment concentrations were observed at 50 parts per million (ppm). The DS stated the red buckets are filled from the third sink compartment. The…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow its infection control policy for five of seven sampled residents (Residents 168, 175, 218, 1 and 105) by failing to ensure:a. The urine drainage bag was not touching the floor for Resident 168b. Resident 175 oxygen tubing was not touching the floor.c. Staff performed hand hygiene before and after taking care of Residents 218 and 1d. Resident 105's IV tubing was not looped at the end of the same administration set and the IV ports were not left uncovered.These deficient practices had the potential to result in infection for Residents 168, 175, 218, 1 and 105. a. During a review of Resident 168’s admission Record (AR), the AR indicated Resident 168 was admitted to the facility on [DATE] with diagnoses that included but not limited to fracture of neck, injury of head, quadriplegia (a form of paralysis that affects all four limbs, plus the torso), anxiety disorder (condition in which a person has excessive worry and feelings of fear,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to obtain written informed consent for one of five sampled residents (Resident 7) for the use of Buspirone (an antianxiety medication use to treat anxiety [emotion characterized by feelings of tension, worried thoughts and physical changes]. This deficient practice had the potential to result in Resident 7 not receiving adequate or sufficient information regarding Buspirone to make an informed health care decision.Findings:During a review of Resident 7's admission Record (AR), the AR indicated Resident 7 was admitted to the facility on [DATE] with diagnoses that included anxiety (emotion characterized by an unpleasant state of inner turmoil), depression (a feeling of severe sadness or hopelessness) and bipolar disorder (mental disorder with periods of depression and periods of elevated mood). During a review of Resident 7's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 7/5/2025 the MDS indicated Resident 7 had moderately…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to notify one of one sampled residents' (Resident 11) doctor of Resident 11's complaint of burning when urinating on 8/19/2025. This failure resulted in Resident 1 continuing to feel burning pain when urinating on 8/20/2025. (Cross Reference F550 and F684) Findings:During a review of Resident 11's admission Record (AR), the AR indicated Resident 11 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD, a group of diseases that cause airflow blockage and breathing-related problems), type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar), and bipolar disorder (a mental illness that causes unusual shifts in a person's mood).During a review of Resident 11's History and Physical (H&P), dated 6/7/2025, the H&P indicated, Resident 11 had the mental capacity to understand and make medical decisions.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.

Based on observation, interview and record review, the facility failed to maintain a clean and stain-free floors of Resident 86's room and in Station 4 shower rooms.This failure resulted in an unsanitary appearance and did not maintain a homelike environment for the residents. Findings:During a review of Resident 86's admission Record (AR), the AR indicated the facility admitted Resident 86 on 5/27/23 with diagnoses that included Type 2 diabetes mellitus (elevated blood sugar level) and acute kidney failure (kidneys are not able to filter waste).During a review of Resident 86's History & Physical (H&P) dated 5/30/25, the H&P indicated Resident 86 had the capacity to make medical decisions.During a review of Resident 86's Minimum Data Set (MDS, a resident assessment tool) dated 8/16/25, the MDS indicated Resident 86 was independent for shower/bathing self.During a concurrent observation and interview on 8/22/25, at 3:30 p.m., with the Maintenance Supervisor (MS), Resident 86's floor had black stains. The MS stated the MS and the MS's staff check each resident's room weekly and there…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to revise a plan of care for one of one sampled resident (Resident 7), who sustained a fall on 8/15/2025, as indicated in the facility's policy Care Plans, Comprehensive Person Centered. This deficient practice had the potential to place Resident 7 at risk for recurrent falls.Findings: During a review of Resident 7's admission Record (AR), the AR indicated Resident 7 was admitted to the facility on [DATE] with diagnoses that included anxiety (emotion characterized by an unpleasant state of inner turmoil), depression (a feeling of severe sadness or hopelessness) and bipolar disorder (mental disorder with periods of depression and periods of elevated mood). During a review of Resident 7's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 7/5/2025, the MDS indicated Resident 7 had moderately impaired cognition (mental action or process of acquiring knowledge and understanding) for daily decision making. The MDS indicated Resident 7…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility staff members failed to provide peri-care (the cleaning and maintenance of the perineum, the area between the anus and the genitals) for two of two sampled residents, (Resident 136 and Resident 27), who required physical assistance with toileting hygiene (the ability to maintain perineal hygiene, adjust clothes before and after voiding or having a bowel movement). This deficient practice had the potential to place Resident 136 and Resident 27 at risk for increased risk for infection, skin breakdown and further potential health complications.Findings:a). During a review of Resident 136's admission Record (AR), the AR indicated Resident 136 was admitted to the facility on [DATE] with diagnoses that included but not limited to chronic obstructive pulmonary disease (COPD- is a common lung disease causing restricted airflow and breathing problems), type 2 diabetes (elevated sugar in the blood), pneumonia (is an infection that inflames the air sacs 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 ensure bilateral (both sides) hand rolls (a cylindrical device used to support and position the hand) were maintained in correct position for one of one sampled resident (Resident 125).This failure had the potential for a decline in range of motion (ROM, measure of joint flexibility and functionality), stiffness, and contractures (a stiffening/shortening at any joint, that reduces the joint's range of motion) for Resident 125. Findings:During a review of Resident 125's admission Record (AR), the AR indicated Resident 125 was admitted to the facility on [DATE] with diagnoses that included traumatic subarachnoid hemorrhage (a collection of blood that accumulates between the inner layer of the skull and the surface of the brain after a head injury), surgery on the nervous system (a complex network of organs, tissues, and cells that controls and coordinates all bodily functions), and benign prostatic hyperplasia (BPH, enlarged prostate…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 Foley catheter (FC, a thin, flexible, rubber or plastic tube used to drain urine from the bladder) was secured on the resident's thigh in accordance with the facility's Policy and Procedure (P&P) Catheter Care, Urinary) for one of four sampled residents (Resident 131).This failure had the potential for Resident 131 to result in catheter-related complications.Findings:During a review of Resident 131's admission Record (AR), the AR indicated Resident 131 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body), hemiparesis (weakness on one side of the body affecting the face, arm, or leg), acute kidney failure (a condition where the kidneys suddenly lose their ability to function properly) and urinary tract infection (UTI, an infection in the bladder/urinary tract).During a review of Resident 131's 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 observation, interview, and record review, the facility failed to provide necessary care and services for a resident with gastrostomy tube (GT, a tube inserted through the abdomen that delivers nutrition directly to the stomach) for one of two sampled residents (Resident 75) by failing to:a. Ensure Resident 75's GT site dressing was changed consistently with the physician's order.b. Ensure an individualized and comprehensive GT site plan of care was developed for Resident 75.These failures had the potential for complications related to tube feedings for Resident 75.Findings:a. During a review of Resident 75's admission Record (AR), the AR indicated Resident 75 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included respiratory failure (a medical condition where the lungs are unable to adequately exchange oxygen and carbon dioxide between the body and the environment), dysphagia (difficulty swallowing), and gastrostomy (a surgical opening fitted with a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to manage urinary tract infection (UTI- bacteria enter the urinary tract) symptoms and urinary pain for one of four sampled residents (Resident 58).This deficient practice resulted in Resident 58 experiencing unrelieved pain which caused physical and emotional distress and did not maintain the resident's highest practical physical and mental well-being. (Cross Reference F684) Findings:During a review of Resident 58's admission Record (AR), the AR indicated Resident 58 was admitted to the facility on [DATE] with diagnoses that included pericardial effusion (buildup of fluid in the membrane that surrounds the heart), Type 2 diabetes mellitus (elevated blood sugar levels) with chronic kidney disease (kidneys unable to filter waste), and chronic obstructive pulmonary disease (blocked airflow making it difficult to breathe). During a review of Resident 58's Physician's Order (PO) dated 9/7/24, the PO indicated for licensed staff to administer Acetaminophen…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure an informed consent (voluntary agreement to accept treatment and/or procedure after receiving education regarding the risks, benefits and alternatives offered) was obtained before the installation of bilateral (both sides) upper half siderails (adjustable metal or rigid plastic bars attached to the bed) for one of one sampled resident (Resident 8).This failure placed Resident 8 at risk for entrapment (an event in which a resident was caught, trapped, or entangled in the tight spaced around the bed) and injury from the use of siderails. Findings:During the review of Resident 8's admission Record (AR), the AR indicated Resident 8 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included dementia (a progressive state of decline in mental abilities), osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage), and osteoporosis (weak and brittle bones, due 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 ensure one of five sampled resident (Resident 34) was free from unnecessary drugs as indicated in the facility's policy and procedure titled, Administering Medication. This deficient practice had the potential to result in unnecessary use of Tylenol (Acetaminophen, medicine that relieves mild to moderate pain and reduces fever). Findings:During a review of Resident 34's admission Record (AR), the AR indicated Resident 34 was admitted to the facility on [DATE] with diagnoses that included acute kidney failure (condition characterized by a gradual loss of kidney function over time) and heart failure (condition when the heart is unable to pump sufficiently to maintain blood flow to meet the body's needs).During a review of Resident 34's Order Summary Report (OSR), dated 6/30/2025, indicated to administer Tylenol Oral Tablet 325 milligrams (mg, unit of measurement), give two (2) tablet by mouth in the morning for pain. Give 30 minutes prior…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 118), received and was provided food that accommodated Resident 118's food preferences.This deficient practice had the potential for Resident 118 to develop further weight loss. Findings:During a review of Resident 118's admission Record (AR), the AR indicated Resident 118 was admitted to the facility on [DATE] with diagnoses including type 2 diabetes mellitus (DM II - adult onset disorder characterized by difficulty in blood sugar control), anemia (a condition where the body does not have enough healthy red blood cells) and muscle wasting and atrophy (partial or complete wasting away of a part of the body).During a review of Resident 118's Order Summary Report (OSR) dated 3/31/2025, the OSR indicated CCHO (consistent controlled carbohydrate) regular texture, regular/thin consistency IDDSI (International Dysphagia Diet Standardization Initiative - an international collaboration of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to maintain a clean and stain-free privacy curtain and window curtain for two of seven sampled residents (Resident 2 and Resident 3).This failure resulted in an unsanitary and non-homelike environment for the residents.a). During a review of Resident 2's admission Record (AR), the AR indicated the facility readmitted Resident 2 to the facility on [DATE] with diagnoses that included amyotrophic lateral sclerosis (nervous system disease), respiratory failure (lungs cannot properly exchange gases), and adult failure to thrive (syndrome characterized by weight loss, decreased appetite, poor nutrition). During a review of Resident 2's History & Physical (H&P), dated 2/23/25, the H&P indicated Resident 2 had the capacity to make medical decisions.During a review of Resident 2's Minimum Data Set (MDS, a resident assessment tool), dated 6/4/25, the MDS indicated Resident 26 was cognitively intact (ability to understand and process thoughts), and 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 observation, interview, and record review, the facility failed to ensure three of three sampled residents (Residents 2, 3, and 8) were treated with dignity and respect by CNA 1 who slapped Resident 2 on the hand, spoke rudely to Resident 2, refused to change the television channel for Resident 3, and did not provide perineal care (washing the genital and anal area) for Resident 8. This failure resulted in Residents 2, 3, and 8 feeling upset and frustrated at not having their needs met and had the potential for Residents 2, 3, and 8 to experience feelings of decreased self-worth. Findings: a). During a review of Resident 2 ' s admission Record (AR), the AR indicated the facility admitted Resident 2 on 6/19/2023 with a readmission date of 3/1/2024 with diagnoses including respiratory failure (a medical condition that happens when your lungs cannot get enough oxygen), dependence on a ventilator (a machine used to support or replace the breathing of a person), and lack of coordination (the ability 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.

Based on interview and record review, the facility failed to provide occupational (a treatment focused on improving the performance of activities required in daily life) and physical therapy (a treatment focused on improving or restoring physical movement and function) to one of one sampled residents (Resident 9) who was discharged from physical therapy after receiving four days of physical therapy and occupational therapy after receiving five days of occupational therapy. This failure resulted in Resident 9 not receiving rehabilitative services and had the potential to result in further decline of physical, functional, and psychosocial well-being. Findings: During a review of Resident 9 ' s general acute care hospital (GACH) H&P record, dated 4/23/2025, the GACH record indicated, Will plan for transfer to rehab if remains clinically stable. Will do aggressive physical therapy/occupational therapy, discussed with Family Member (FM) 1 the need for long-term rehab given his weakness. During a review of Resident 9 ' s GACH Occupational Therapy Inpatient Weekly Progress Note, 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 facility's doors were closed and facility's screen doors and windows (an exterior door/window with a mesh screen, typically made of wire or plastic, that allows air to pass through while blocking insects and other small debris from entering a building) were intact to prevent flies and other insects from going inside the facility, in accordance with the facility's policy and procedure (P&P) titled, Pest Control. This failure resulted in flies and other insects entering the facility and had the potential for flies and other insects to spread diseases to all 220 residents in the facility. Findings: During an interview on 6/24/25 at 11:41 am with Licensed Vocational Nurse (LVN) 3, LVN 3 stated LVN 3 sees gnats (insects) in residents' rooms especially in the rooms with juices, drinks, and foods. LVN 3 stated staff (in general) would inform the Maintenance Department (MD), whenever staff (in general) saw insects inside 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.

Based on interview and record review, the facility failed to obtain informed consent (the voluntary agreement of a resident or a resident ' s representative to accept a treatment or procedure after receiving information regarding risks and benefits of the treatment) from one of one sampled resident (Resident 9) prior to administering the covid vaccine (a substance that helps the body ' s immune system learn to recognize and fight off the coronavirus [an infectious disease caused by the SARS-Cov-2 virus]) when Infection Prevention Nurse (IPN) 2 requested consent for the covid vaccine from Resident 9 ' s Family Member (FM) 1 instead of Resident 9. This failure resulted in Resident 9 receiving the covid vaccine without giving consent. Findings: During a review of Resident 9 ' s admission Record (AR), the AR indicated the facility admitted Resident 1 on 4/24/2025 with diagnoses including encephalopathy (a disturbance of brain function) and hemiplegia and hemiparesis (paralysis or weakness on one side of the body) following cerebral infarction (a medical condition where blood flow 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 interview and record review, the facility failed to provide three (3) of three sampled residents (Residents 4, 5, and 6) or the Residents' Representative a copy of the residents' medical records upon request and within two working days from notice per the facility's policy and procedure titled, Release of Information. This failure resulted violated Residents 4, 5, 6's rights and resulted in Resident 5 and Resident 4's and Resident 6's Representatives not receiving the medical records in timely manner. Findings: 1. During a review of Resident 5's admission Record (AR), the facility admitted Resident 5 on 2/7/2025 with diagnoses that included unspecified injury at C5 level of the cervical spinal cord (spinal cord injury), fracture of the body of sternum (breastbone), and Type 2 Diabetes Mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 5's History and Physical (H&P), dated 2/10/2025, the H&P indicated Resident 5 did have the…

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

Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 7) was provided with the necessary treatment and services to prevent formation of and promote healing of an existing pressure injury (PI, injury to skin and underlying tissue resulting from prolonged pressure on the skin) by: 1. failing to ensure Resident 7 received physician-ordered wound care treatment for a stage 3 PI on Resident 7's right knee. 2. failing to follow the physician's order that indicated cleansing with normal saline (NS-sterile salt solution) and application of zinc oxide (barrier ointment) for Resident 7's sacrococcyx (sacral [a triangular shaped bone at the bottom of the spine] coccyx [tailbone]) stage 4 (full thickness tissue loss with exposed bone, tendon, or muscle) PI. This failure resulted in an increased risk for an infection, pain, and further skin breakdown to Resident 7. Additionally, the failure had the potential to result in delayed wound healing to Resident 7. Findings: During a review of Resident 7's admission Record (AR), the AR…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 2) had a clutter-free room environment and did not have multiple plugs in the electrical outlet. These deficient practices placed Resident 2 at risk for accident hazards from a possible overloaded electrical circuit and heightened risk of fire with a cluttered area of flammable materials (ability to ignite easily and burn rapidly) surrounding Resident 2's bed. Findings: During a review of Resident 2's admission Record (AR), the AR indicated Resident 2 was admitted to the facility on [DATE], with diagnoses that included type 2 diabetes (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing), acute kidney failure (kidneys suddenly lose their ability to filter waste and balance fluids and electrolytes), anxiety disorder (excessive and persistent fear or worry), depression (persistent sadness, loss of interest, and difficulty functioning) , and nicotine…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 safe and functional shower for one (1) out of four (4) shower rooms in the facility with two holes in the wall located where the wall meets the base of the tile floor. This deficient practice had the potential for residents to be placed at risk for injury. Findings: During an observation on 5/22/25 at 1:40 p.m., two (2) holes in the shower wall at the base of the tile where it meets the wall were observed. During a concurrent interview and record review on 5/22/25, at 1:46 p.m. with the Maintenance Worker (MW), the maintenance logs dated 1/2024 to 5/2025 were reviewed. The MW stated there was no documentation that staff requested shower or wall repairs in the maintenance logs. The MW stated the MW would have the wall repaired right away because it was a safety hazard to the residents who showered in that room. During a review of the facility's policy and procedure (P&P) titled, Maintenance Service, revised 12/2009, the P&P indicated, The maintenance department is responsible for maintaining 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 examine and assess one of 16 sampled residents (Resident 1) according to the facility's policy and procedure (P&P) titled, and Resident Assessment and Examination, by failing to: 1. Ensure when Resident 1 experienced a change of condition (COC- a change in the resident's health or functioning that requires further assessment and intervention) on [DATE] at 8 am, Registered Nurse 2 (RN 2) and RN 3 assessed Resident 1's abdominal distension (bloating or swelling ), abdominal firmness (abdomen feeling hard or tight to the touch) rebound or guarding (physical signs that can indicate inflammation of the abdominal lining or other acute abdominal issues), bowel sounds (sound produced by the movement of fluid and air in the intestines) for hyperactivity (increased bowel sounds), hypoactivity (reduced bowel sounds) and pain. 2. Ensure RN 5 and Licensed Vocational Nurse (LVN) 3 assessed Resident 1's abdomen and pain on [DATE] between 3 pm and 11 pm when Resident…

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

Based on interview and record review, the facility failed to ensure accurate and complete documentation for one of one sampled resident (Resident 1), in accordance with the facility's policies and procedures (P&P) titled, Charting and Documentation and Change in a Resident's Condition or Status. This deficient practice resulted in no documentation of Resident 1's full assessments during a Change of Condition (COC, a sudden clinically important deviation in the resident's health or functioning that requires further assessments and interventions) on 5/6/2025 and had the potential to result in complications leading to a physical decline to Resident 1. Cross Reference: F580 and F641 Findings: During a review of Resident 1's admission Record (AR), the AR indicated the facility initially admitted Resident 1 on 10/24/2022 and readmitted the resident on 1/25/2023 with diagnoses that included psychosis (refers to symptoms that happen when a person is disconnected from reality), muscle wasting, and atrophy (wasting away). During a review of Resident 1's Minimum Data Set (MDS - a resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide care in a manner that maintained or enhanced a resident's dignity and respect in full recognition of her individuality for four of 67 sampled residents (Residents 2, 5, 11 and 14) as indicated in the facility's policies and procedures (P&P) by failing to: a. Ensure Resident 2 was not awakened inappropriately early in the morning by a loud noise from the licensed nurse and the light was turned on in Resident 2's room. b. Ensure Resident 5's urinal receptacle (a container used to hold bodily waste) was kept clean and labeled with Resident 5's name. c1. Ensure staff (general) were not rude whenever they answered Resident 11's call light and disrespectful whenever they spoke to Resident 11. c2. Ensure staff (general) did not joked around loudly outside Resident 11's room while Resident 11 was taking a nap. d. Ensure Resident 14 was not sitting in the hallway in a wheeled recliner chair with only a short-sleeved shirt and 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.

Based on interview and record review, the facility failed to ensure that 59 of 67 sampled residents (Resident 2, Resident 4, Resident 5, Resident 6, Resident 7, Resident 8, Resident 9, Resident 15, Resident 16, Resident 17, Resident 18, Resident 19, Resident 20, Resident 21, Resident 22, Resident 23, Resident 24, Resident 25, Resident 26, Resident 27, Resident 28, Resident 29, Resident 30, Resident 31, Resident 32, Resident 33, Resident 34, Resident 35, Resident 36, Resident 37, Resident 38, Resident 39, Resident 40, Resident 41, Resident 42, Resident 43, Resident 44, Resident 45, Resident 46, Resident 47, Resident 48, Resident 49, Resident 50, Resident 51, Resident 52, Resident 53, Resident 54, Resident 55, Resident 56, Resident 57, Resident 58, Resident 59, Resident 60, Resident 61, Resident 62, Resident 63, Resident 64, Resident 66, and Resident 67) who required assistance with activities of daily living (ADLs-tasks of everyday life such as bathing dressing, and toileting) were provided care and received assistance with showering/bathing in accordance with the residents' care…

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

Based on interview and record review, the facility failed to provide sufficient nurse staffing for 16 of 45 shifts staffing reviewed in the subacute unit (specific unit in the facility where residents with a tracheostomy tube [a tube inserted in a surgically created hole in the windpipe to provide an alternative airway for breathing] and residents on a ventilator [a medical device to help support or replace breathing] stayed) to provide care and assistance to 59 of 67 sampled residents in accordance with the facility's policy and procedure (P&P) titled, Staffing, and Facility Assessment, and the facility's Facility Assessment, (FA- a guide used by the facility to evaluate what resources are necessary to care for the facility's residents) and staffing goal for the subacute unit when: 1. Showers were not provided for 59 residents (Resident 2, Resident 4, Resident 5, Resident 6, Resident 7, Resident 8, Resident 9, Resident 15, Resident 16, Resident 17, Resident 18, Resident 19, Resident 20, Resident 21, Resident 22, Resident 23, Resident 24, Resident 25, Resident 26, Resident 27,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 proper medication administration for six of six sampled residents (Resident 5, Resident 6, Resident 26, Resident 55, Resident 56, and Resident 68) by failing to: 1. Ensure the facility followed best practices for medication preparation and administration for Resident 6 when multiple medications were crushed and mixed in one medication cup and administered via gastrostomy tube (G-tube, a feeding tube inserted directly into the stomach through the abdominal wall). 2. Ensure medications were administered at their respective scheduled times as prescribed by the ordering physicians for Resident 6, 26, 55, 56, and 68 on 4/21/2025. 3. Ensure Resident 5's medication was omitted due to lack of supply for Resident 5, without timely notification to the pharmacy or physician, potentially compromising Resident 5's treatment plan. These deficient practices had the potential to affect Resident 6, 26, 55, 56, and 68's health, safety, 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 keep the facility clean for four of four rooms (Rooms 421, 416, 222 and 223). 1. There were dried reddish-brown stains on the privacy curtain next to the bed by the window in room [ROOM NUMBER]. The privacy curtain separated the two beds in room [ROOM NUMBER]. 2. The baseboards in room [ROOM NUMBER] were dirty. 3. There were unpainted white patches on the walls in room [ROOM NUMBER]. 4. There was a brownish gray stain on the ceiling and on the top of the wall by the air vent in room [ROOM NUMBER]. 5. There were holes in the wall with chipped paint behind the headboard of the bed by the window in room [ROOM NUMBER]. 6. The baseboards in room [ROOM NUMBER] were dirty. 7. The linoleum flooring in the restroom in room [ROOM NUMBER] was cracked and peeling off the wall. 8. The sink in the restroom in room [ROOM NUMBER] was chipped and the faucet was corroded. 9. The window tint on the sliding door in room [ROOM NUMBER] was peeling off. 10.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow the facility ' s policy and procedure (P&P) titled, Maintenance Service, by failing to ensure floor tiles in two of six stations (Station 4 and Station 6) of the facility were free of holes and cracks. This deficient practice had the potential to place the safety of residents, staff, and visitors at risk. Findings: During an observation on 4/3/2025 at 1:50 pm, with the Maintenance Staff (MS), the following were observed: a. The floor at the doorway of room [ROOM NUMBER] in Station 4 had a hole which measured two by 24 inches. b. There was a hole around the drain in a hallway of Station 4 with a measurement of four inches. c. There were cracks on the floor tiles in the hallway in front of the facility ' s beauty salon on Station 6. d. The floor at the doorway of room [ROOM NUMBER] in Station 6 had a hole with a measurement of three by eight inches. During an interview on 4/3/2025 at 4:06 pm, with the Administrator (ADM), the ADM…

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

Based on observation, interview, and record review, the facility failed to follow the facility ' s policy and procedure (P&P) titled, Smoking by Residents, for one of three sampled residents (Resident 1) by failing to: 1. Ensure Resident 1 was supervised while smoking in the smoking patio. 2. Ensure Resident 1 ' s smoking materials were stored in a locked box or drawer. These deficient practices had the potential to place Resident 1 and other residents ' safety at risk. Findings: During an observation on 4/3/2025 at 2:56 pm of the smoking patio, there were three residents sitting up in a wheelchair in the smoking patio. Resident 1 was observed smoking a cigarette. There was no staff observed supervising Resident 1 while smoking. During an observation on 4/3/2025 at 5:09 pm of Resident 1 ' s room, there was a lighter observed on Resident 1 ' s bed. During a review of Resident 1 ' s admission Record (AR), the AR indicated the facility originally admitted Resident 1 on 9/5/2024 and recently admitted Resident 1 on 2/23/2025 with diagnoses that included encephalopathy (damage or disease…

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

Based on observation, interview, and record review, the facility failed to ensure the ordered tab alarm (device used to notify staff when residents attempted to transfer unassisted by staff) was attached to one of three sampled residents (Resident 8) who was at risk of falls. This failure resulted in Resident 8 falling to the floor on 3/12/2025 while in the care of the facility. The failure had the potential for Resident 8 to be injured due to the fall. Findings: During a review of Resident 8's admission Record (AR), the AR indicated the facility admitted Resident 8 on 3/11/2025 with diagnoses including hemiplegia (Muscle weakness or partial paralysis on one side of the body that can affect the arms, legs, and facial muscles) and hemiparesis (muscle weakness or partial paralysis on one side of the body) following cerebral infarction (also called ischemic stroke, occurs as a result of disrupted blood flow to the brain), type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar), and chronic obstructive pulmonary disease (COPD, a group of…

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

Based on observation, interview, and record review, the facility failed to dispose of garbage and refuse properly when eight of eight facility dumpsters' lids were open, leaving the top of the dumpsters uncovered. This failure had the potential to negatively impact the health of residents by attracting rodents and pests to the facility, which could carry infectious diseases. Findings: During a concurrent observation and interview on 2/20/2025 at 2:40 p.m. with the Director of Food Services and Environmental (DOF), eight dumpsters were observed behind the facility. All the dumpsters had their lids opened. Three of the dumpsters had trash inside. The DOF stated the dumpster lids should be closed because rodents could get inside the dumpsters if left opened. During a review of the facility's policy and procedure (P&P) titled, Food-Related Garbage and Refuse Disposal, revised October 2017, the P&P indicated, Outside dumpsters provided by garbage pickup services will be kept closed and free of surrounding littler.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow the facility ' s Policy and Procedure (P&P) titled, Answering the Call Light, and Maintenance Service, for 12 of 29 resident rooms (Rooms 112, 114a, 202, 208, 209, 211, 212, 216, 221, 222, 223 and 225) by failing to: a. Ensure the call lights in the resident rooms were functioning. b. Ensure the call light was accessible for one resident in room [ROOM NUMBER]a. These deficient practices had the potential to result in the delay of care for the residents affecting their safety and quality of life. Findings: During a concurrent observation and interview on 2/20/2025 at 11:31 am, with Resident 9, Resident 9 stated the call light did not work the night before (2/19/2025). Resident 9 pressed the call light, and the light did not turn on outside of Resident 9 ' s room above the door. During an observation on 2/20/2025 at 11:35 am, with the Director of Staff Development (DSD) and Maintenance Staff (MS), the facility call lights were…

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

Based on interview and record review, the facility failed to protect a resident's right to remain free from verbal (the use of oral, written or gestured communication or sounds that willfully includes disparaging and derogatory terms to residents) and physical abuse (willful infliction of injury, deliberate aggressive or violent behavior with the intention to cause harm) for one of two sampled residents (Resident 2), when Resident 3 physically and verbally abused Resident 2 on 2/10/2025. This failure had the potential to result in bodily injury to Resident 2 and/or Resident 2 to feel afraid and not safe while under the care of the facility. Findings: A1. During a review of Resident 2's admission Record (AR), the AR indicated the facility admitted Resident 2 on 9/5/2024 with diagnoses including encephalopathy (brain disease that alters brain function or structure), respiratory failure (when the lungs can't get enough oxygen into the blood), and pneumonia (infection that inflames air sacs in one or both lungs). During a review of Resident 2's Minimum Data Set (MDS - a resident…

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

Based on interview and record review, the facility failed to ensure one of one sampled resident (Resident 4) received Physical Therapy (PT, specialized rehabilitative service that helps you improve how your body performs physical movements) and Occupational Therapy (OT, specialized rehabilitative service that helps you improve your ability to perform daily tasks) as indicated in Resident 4's untitled care plan, dated 2/25/2025. This failure had the potential for Resident 4 to not attain, maintain or restore his highest practicable level of physical, mental, functional and psycho-social well-being. (Cross Reference F693 and F825) Findings: During a review of Resident 4's admission Record (AR), the AR indicated the facility admitted Resident 4 on 8/31/2024 diagnoses including traumatic subarachnoid hemorrhage (SAH, a type of bleeding in the brain), acute respiratory failure (when the lungs can't get enough oxygen into the blood), and dysphagia (difficulty swallowing foods or liquids). During a review of Resident 4's Minimum Data Set (MDS, a resident assessment tool), dated 12/20/2024,…

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.

Based on observation, interview, and record review, the facility failed to ensure proper care and treatment for gastrostomy tube (G-tube, a tube inserted through the abdomen that delivers nutrition directly to the stomach) was provided for two of three sampled residents (Resident 4 and Resident 8) when: a. Resident 4's head of bed (HOB) was not elevated to an angle of 30-45 degrees while on G-tube feeding. b. Licensed Vocational Nurse (LVN) 2, who was administering five medications to Resident 8 via Resident 8's G-tube, failed to flush the G-tube with water between administering the second, third, and fourth medications. These failures had the potential to put Resident 4 at risk for aspiration pneumonia (a form of pneumonia that occurs when food particles/foreign materials enter the lungs) and/or choking and had the potential for Resident 8's G-tube to become clogged and/or medications not to be administered correctly. (Cross Reference F656 and F825) Findings: a. During a review of Resident 4's admission Record (AR), the AR indicated the facility admitted Resident 4 on 8/31/2024…

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.

Based on interview and record review, the facility failed to ensure one of one sampled resident (Resident 4) received Physical Therapy (PT, specialized rehabilitative service that helps you improve how your body performs physical movements) and Occupational Therapy (OT, specialized rehabilitative service that helps you improve your ability to perform daily tasks) as indicated in the Resident 4's plan of care. This failure resulted in Resident 4 did not receive PT and OT services as indicated in Resident 4's care plan and had the potential for Resident 4 to not attain, maintain or restore Resident 4's highest practicable level of physical, mental, functional and psycho-social well-being. (Cross Reference F656 and F693) Findings: During a review of Resident 4's admission Record (AR), the AR indicated the facility admitted Resident 4 on 8/31/2024 diagnoses including traumatic subarachnoid hemorrhage (SAH, a type of bleeding in the brain), acute respiratory failure (when the lungs can't get enough oxygen into the blood), and dysphagia (difficulty swallowing foods or liquids). 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.

Based on interview and record review, the facility failed to follow its policy and procedure (P&P) titled, Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, for one of thirteen sampled residents (Resident 12) by failing to: 1. Ensure Housekeeper (HK) 1 timely reported an abuse allegation involving Certified Nursing Assistant (CNA) 3 and Resident 12 to the Housekeeping Supervisor (HS) and/or to the Administrator (ADM). 2. Ensure the facility reported an abuse allegation to the California Department of Public Health (CDPH) immediately but no later than two hours of knowing about the abuse allegation. These deficient practices had the potential to compromise the safety of Resident 12 and exposed Resident 12 to further potential abuse. Findings: During a review of Resident 12's admission Record (AR), the AR indicated the facility originally admitted Resident 12 on 2/15/2023, and readmitted Resident 12 on 4/21/2023, with diagnoses that included hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease (kidney damage caused by…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide the necessary care and services for three of thirteen sampled residents (Residents 1, 2, and 13) as indicated in the facility's policies and procedures (P&P) titled, Neurological Assessment, Charting and Documentation, and Change in a Resident's Condition or Status by failing to: a. Ensure assigned licensed nurses completed neurological (relating to the functioning of the brain, spine, and nerves) assessments for the 72-hour monitoring period after Resident 1 was involved in a resident-to-resident altercation. b. Ensure assigned licensed nurses completed neurological assessments for the 72-hour monitoring period after Resident 2 was involved in a resident-to-resident altercation. c. Ensure assigned licensed nurses monitored and documented Resident 13's condition when Resident 13 tested positive for Covid-19 (a respiratory illness caused by a virus that is easily spread from person to person) and was transferred to the facility'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 to failed ensure two of three sampled residents (Residents 2 and 3) were provided with a safe, clean, comfortable and homelike environment, according to the facility's policy and procedure (P&P) titled, Homelike Environment, by failing to ensure Residents 2 and 3 did not smell the odor of cigarette smoke from facility staff smoking outside Residents 2 and 3's room window. As a result of this failure, Residents 2 and 3 were unable to keep their room window open throughout the day and were exposed to secondhand smoke (SHS- involuntary inhalation of tobacco [a plant with leaves that have levels of nicotine [addictive, poisonous chemical] that is generally smoked or ingested] smoke, that is a mixture of smoke exhaled by smokers and smoke from burning tobacco products). This failure had the potential for Residents 2 and 3 to develop respiratory illness and could affect Residents 2 and 3's psychosocial (mental, emotional, social, and spiritual effects)…

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

Based on observation, interview, and record review, the facility failed to ensure the call bell (device that is used to summon a staff member when needed) for one of three sampled residents (Resident 2) was within reach according to the facility's policies and procedures (P&P) titled, Accommodation of Needs, and Answering the Call Light. As a result of this failure, Resident 2 was unable to reach the call bell when assistance was needed from facility staff. This failure had the potential for Resident 2 to experience pain, distress, a medical emergency, and could lead to psychosocial (mental, emotional, social, and spiritual effects) harm from not being able to call for help when needed. Findings: During a review of Resident 2's admission Record (AR), the AR indicated the facility admitted Resident 2 on 1/10/2025, with diagnoses that included hemiparesis (one-sided muscle weakness caused by a disruption of the brain, spinal cord, or nerves connected to the affected muscles) and hemiplegia (paralysis of one side of the body) following cerebral infarction (CVA- also known as stroke-…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 sanitary (clean) environment to prevent the spread of infection for nine of 13 sampled residents (Residents 1, 2, 5, 6, 7, 9, 10, 12, and 13) during a Coronavirus Disease 2019 (COVID-19, an illness caused by a virus that can spread from person to person) outbreak (OB-two or more linked cases of the same illness or the situation where the observed number of cases exceeds the expected number, or a single case of a disease caused by a microorganism), by failing to: 1. Perform hand hygiene appropriately. 2. Implement Enhanced Barrier Precaution (EBP-an infection control intervention designed to reduce the transmission of multidrug-resistant organisms [MDROs] in the nursing home). 3. Post Enhanced Barrier Precaution sign outside the room of residents who required EBP. 4. Wear N95 masks (a respiratory protective device designed to have a very close facial fit over the nose and the mouth, and filters airborne particles) correctly…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 toenails of one of 13 sampled residents (Resident 1) were kept trimmed according to the facility's Policy and Procedure (P&P) on Care of Fingernails/Toenails. This failure placed Resident 1 at risk for injury, infection, or complications from long toenails. Findings: During a review of Resident 1's admission Record (AR), the AR indicated Resident 1 was originally admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses that included quadriplegia (paralysis from the neck down, including legs, and arms), dysphagia (difficulty swallowing), and respiratory failure (when the lungs cannot get enough oxygen into the blood). The AR indicated Resident 1 had a gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach). During a review of Resident 1's History and Physical (H&P, physician's clinical evaluation and examination of the resident) dated 2/19/24, 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 follow its policy to provide a two-person assist when using a mechanical lift during the transfer of one of four sampled residents (Resident 14). This failure placed Resident 14 at risk for a preventable accident and/or injury. Findings: During a review of Resident 14's admission Record (AR), the AR indicated Resident 14 was readmitted to the facility on [DATE] with diagnoses that included peripheral vascular disease (narrowed blood vessels causing reduced blood flow to limbs) and functional quadriplegia (inability to move due to a severe disability). During a review of Resident 14's History & Physical (H&P), dated 9/22/24, the H&P indicated Resident 14 did not have the capacity to understand and make decisions. During a review of Resident 14's Minimum Data Set (MDS, a resident assessment and care screening tool) dated 11/1/24, the MDS indicated Resident 14 had moderate cognitive impairment (ability to process thoughts and perform various mental…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to administer medication to one of 13 sampled residents (Resident 2) according to the physician's order when Licensed Vocational Nurse 1 (LVN 1) administered Temazepam (a medication to aid sleeping) 7.5 milligrams (mg-a unit of measure) to Resident 2, five (5) hours and 51 minutes before bedtime (9 pm). This failure resulted in unsafe medication administration and had the potential to negatively impact Resident 2's health, safety, and well-being. Findings: During a review of Resident 2's admission Record (AR), the AR indicated Resident 2 was admitted to the facility on [DATE] with diagnoses which included diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 2's Minimum Data Set (MDS - a resident assessment tool) dated 12/20/24, the MDS indicated Resident 2's cognition (ability to think, learn, and understand) was intact. The MDS indicated Resident 2 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 maintain accurate and timely medical records for one of fourteen sampled residents (Resident 11), based on the facility's policy and procedure (P&P) titled, Charting and Documentation, and Change in a Residents Condition or Status, by failing to: 1. Ensure when Resident 11 had a change in condition (CIC- a change in the resident's health or functioning that requires further assessment and intervention) on 11/6/2024 4:26 pm, Licensed Vocational Nurse (LVN) 7, filled out the eINTERACT/situation-background-assessment-recommendation (SBAR- a written communication tool that helps provide essential, concise information, usually during crucial situations) form that day and not on 11/10/2024 at 4:54 pm. 2. Ensure when Resident 11 had a CIC on 11/6/2024 at 4:46 pm, LVN 7 accurately documented Resident 11 developed a diabetic foot ulcer (DFU- open sore that develop on the feet due to poor circulation, nerve damage from chronic high [BG- level of sugar in the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide the care and services for one of 14 sampled residents (Resident 11), according to the facility's policy and procedure (P&P) titled Referrals, Social Services, by failing to: Ensure when Nurse Practitioner (NP) 1's direct referral (referral for a specialist made by a prescribing healthcare provider with an authorization provided before the appointment is scheduled) made on 6/19/2024 for Resident 11 to be assessed by an endocrinologist (medical professional who specializes in diagnosing and treating conditions caused by issues with the endocrine system, which is made up of glands and organs that produce hormones) for treatment of uncontrolled type II diabetes mellitus (DM2- A condition that happens because of a problem in the way the body regulates and uses sugar as fuel) appointment was made promptly by Registered Nurse (RN) 2. As a result of this failure, an appointment for the endocrinologist was not scheduled until 10/8/2024 for 2/12/2025.…

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 follow their policy and procedure (P&P) titled, Answering the Call Light, for two of two sampled residents (Resident 1 and Resident 3) by failing to: 1. Ensure Resident 1 ' s call pad/light was within reach. 2. Ensure Resident 3 ' s call light was answered promptly. These deficient practices had the potential to result in the delay of care for Resident 1 and Resident 3. Findings: 1. During a review of Resident 1 ' s admission Record (AR), the AR indicated the facility admitted Resident 1 on 10/2/2024 with diagnoses of acute (sudden onset) and chronic (continuing for a long time) respiratory failure (a condition where there's not enough oxygen or too much carbon dioxide in the body) with hypoxia (low levels of oxygen in the body tissues), end stage renal disease (irreversible kidney failure), pressure ulcer of sacral region (the triangular-shaped bone at the base of the back), stage 4 (full-thickness skin and tissue loss with exposed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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. Air purifiers were in working condition or set to on. 2. Ventilation system was set to on and not on auto or off. 3. A Licensed Vocational Nurse (LVN 1) was wearing proper personal protective equipment (PPE- protective clothing, helmets, goggles, or other garments or equipment designed to protect the wearer's body from injury or infection) while in a Covid-19 (an infectious disease caused by the SARS-CoV-2 virus) room. 4. LVN 1 wore a N95 (a disposable face mask that covers the user's nose and mouth which offers protection from small solid or liquid droplets found in the air) mask properly while in the Red Zone (unit with Covid-19 confirmed positive residents). 5. Trash was emptied and not overflowing onto the floor in the Red Zone (designated a contaminated area used for isolation and the management of COVID-19 positive residents). These deficient practices had the potential to cause the spread of Covid-19 infection to other…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 comfort and skin integrity for one of two sampled residents (Resident 1) by: 1. Keeping a mechanical lift sling (a harness that supports and wraps around a patient on a device that is used to transfer a patient from one place to another) under Resident 1 for more than six hours while on a low air loss mattress (LALM - a mattress designed to prevent and treat pressure ulcers [bed sores]). 2. Using incorrect bedding for Resident 1's LALM. This deficient practice had the potential to worsen Resident 1's pressure ulcer. Findings: During a review of Resident 1 ' s admission Record (AR), the AR indicated the facility admitted Resident 1 on 10/2/2024 with diagnoses of acute (sudden onset) and chronic (continuing for a long time) respiratory failure (a condition where there's not enough oxygen or too much carbon dioxide in the body) with hypoxia (low levels of oxygen in the body tissues), end stage renal disease (irreversible kidney failure), and pressure ulcer of sacral region (the triangular-shaped bone at…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 four of five sampled residents (Residents 4, 5, 6, and 7), who were incontinent (lacking voluntary control over urination or defecation) of bowel and/or bladder, where promptly changed by facility staff after episodes of incontinence, in accordance with the facility's Policy and Procedure (P&P) on Call System and Urinary Continence and Incontinence -Assessment and Management . This failure had the potential to result in skin breakdown and/or negatively affect the residents' dignity and quality of life for Residents 4, 5, 6, and 7. Findings: 1. During a review of Resident 4's admission Record (AR), the AR indicated Resident 4 was admitted to the facility on [DATE] with diagnoses including congestive heart failure (CHF, the heart doesn't pump enough blood as it should), bladder disorder, and fibromyalgia (a chronic condition that causes widespread pain and tenderness in the body). During a review of Resident 4's Care Plan (CP) for Risk for Skin…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to protect a resident's right to be free from physical abuse (deliberately aggressive or violent behavior with the intention to cause harm) as indicated in the facility's policies and procedures (P&P) titled, Abuse Prevention/Prohibition and Resident Rights for one of four sampled residents (Resident 1). This deficient practice resulted in Resident 1 being subjected to physical abuse by Resident 2 and sustaining an acute fracture of the left nasal bone. Findings: 1. During a review of Resident 1's admission Record (AR), AR indicated, Resident 1 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease (a disease characterized by a progressive decline in mental abilities) with late onset, dementia (a progressive state of decline in mental abilities) in other diseases classified elsewhere, unspecified severity, with other behavioral disturbance, fracture of nasal bones, and initial encounter for closed fracture (broken bone…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 reasonable accommodation of needs for two of two sampled residents (Residents 107 and 181) by failing to ensure the residents' call light were within reach and appropriate to the resident's physical ability. These deficient practices had the potential for residents not to receive necessary care or received delayed services to meet their needs. Findings: a. During a review of Resident 107's admission Records (AR), the AR indicated Resident 107 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included anoxic brain damage (occurs when the brain is deprived of oxygen) and chronic kidney disease (a long-term condition where the kidneys do not work as well as they should). During a review of Resident 107's Care Plan (CP) dated 2/6/2023, the CP indicated Resident 107 had deficit in Activities of Daily Living (ADL) related to quadriplegia (paralysis that affects all a person's limbs and body…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 residents' Advance Directive (AD, a written preferences regarding treatment options, a process of communication between individuals and their healthcare agents to understand, reflect on, discuss, and plan for future healthcare decisions for a time when individuals are not able to make their own healthcare decisions) and Request for admission and Authorization for Treatment and Medication (RAATM, permission given before a resident receive any type of medical treatment, test or examination) were discussed and written information were provided to the residents and/or responsible parties for four of five sampled residents (Residents 18, 66, 182 and 193). These failures had the potential for facility staff to provide medical treatment and services against the residents' will. Findings: a. During a review of Resident 193's admission Records (AR), the AR indicated Resident 193 was initially admitted to the facility on [DATE] and readmitted on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to ensure the assessment entries on the Minimum Data Set (MDS- an assessment and care screening tool) were accurate for two of five sampled residents (Residents 184 and 216) by: a. Failing to assess and submit Resident 184's discharge assessment to the Centers of Medicare and Medicaid Services (CMS, a federal agency that administers the Medicare program and works with state governments to administer the Medicaid and health insurance portability standards) agency timely. Resident 184 was discharge to General Acute Care Hospital (GACH) on 4/5/2024. b. Failing to ensure Resident 216 who was discharged home was coded in the MDS assessment accurately. These deficient practices resulted in an inaccurate reporting to CMS agency and had the potential to result in Residents 184 ad 216 not to receive interventions to address specific care concerns upon discharge. Findings: a. During a review of Resident 184's admission Record (AR), the AR indicated Resident 184…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 an effective communication method to two of two non-English speaking sampled residents (Resident 522 and 136). This failure had the potential to result in resident not receiving necessary care and services. Findings: a. During a review of the Resident 522's admission Record (AR), the AR indicated Resident 522 was admitted on [DATE]. During a review of Resident 522's History and Physical (H&P) examination, dated 8/13/2024, the H&P indicated Resident 522 was admitted to the facility for uterine cancer (cancer of the uterus) and hypertension (increased blood pressure). The H&P indicated Resident 522 had the capacity to make decisions. During a review of Resident 522's Minimum Data Set (MDS, a resident assessment and care screening tool) dated 8/16/2024, the MDS indicated Resident 522's language preference was Spanish. Resident 522 had clear speech, had the ability to understand others and made self-understood. Resident 522 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 observation, interview and record review, the facility failed to promote healing and provide necessary treatments to prevent the development of pressure ulcer (lesion/wound caused by unrelieved pressure that results in damage of underlying tissue) for five of six sampled residents (Residents 64, 91, 141, 162 and 182) by failing to: a. Ensure the low air loss mattress (LAL - a specialty bed that alternates pressure to help heal and prevent pressure injuries) for Resident 64 was set to alternating pressure. b. Ensure the LAL mattress for Resident 162 was set to alternating pressure. c. Ensure the LAL mattress for Resident 141 was set to therapeutic mode and in accordance with the resident's weight. d. Ensure Resident 91 was not lying on the site of the pressure ulcer and was repositioned every two hours while in bed. e. Ensure Resident 182 was wearing heel protectors as ordered. These failures had the potential for the residents to develop pressure ulcer, worsen the pressure ulcer or prevent healing of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure three of five sampled residents (Residents 36, 109 and 135) with limited range of motion (ROM- full movement potential of a joint [where two bones meet]) and mobility (ability to move) received treatment and services to prevent further decline in ROM by failing to: 1. Provide Resident 36 with ROM exercises on both wrists, hands, and ankles in accordance with the physician's orders. 2. Identify and report Resident 36's right elbow splint (material used to restrict, protect, or immobilize a part of the body to support function, assist and/or increase range of motion) was not aligned with Resident 36's right elbow to the Occupational Therapist ([OT] professional aimed to increase or maintain a person's capability of participating in everyday life activities [occupations]). 3. Provide Resident 109 with ROM exercises on the left elbow, both wrists, both hands, the left knee, and both ankles in accordance with the physician orders. 4.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 two of two sampled residents (Residents 199 and 521), the facility failed to: a. Label and date the peripheral intravenous catheter (IV, a thin plastic tube inserted into a vein using a needle allowing for the administration of medications, fluids and/or blood products) for Resident 199 in accordance with facility's Policy and Procedure (P&P) on Administration Set/Tubing Changes and Resident 199's care plan. b. Ensure Resident 521's PICC line (a type of long catheter that is inserted through a peripheral vein into larger vein in the body, used to deliver medications and other treatments directly to the large central veins) dressing was kept clean, not soiled, and changed in accordance with the facility's P&P on Central Venous Catheter Dressing Changes. These failures had the potential to result in infection to Residents 199 and 521. Findings: a. During a review of Resident 199's admission Record (AR), the AR indicated Resident 199 was admitted 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 provide necessary care and services for residents on oxygen therapy (treatment that provides supplemental, or extra oxygen) consistent with professional standards of practice for four of four sampled residents (Residents 23, 92, 130 and 208) by failing to: a. Follow the physician's order to provide two liters of oxygen inhalation through nasal cannula to Resident 23. b. Label tracheostomy drainage bottle with date for Resident 92. c. Label oxygen tubing with date for Resident 130. d. Ensure Resident 208 had a physician's order for the use of oxygen at two liters per minute through nasal cannula. These deficient practices placed Residents 23, 92, 130 and 208 at risk for severe difficulty of breathing and serious respiratory complications. Findings: a. During a review of Resident 23's admission Record (AR), the AR indicated the facility readmitted the resident on 7/6/23, with diagnoses that included chronic obstructive pulmonary disease…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 attempt the use of appropriate alternatives to bed rails before its installation for two of two sampled residents (Residents 26 and 191). These deficient practices placed Residents 26 and 191 at risk for entrapment and injury from the use of bed rails. Findings: a. During a review of Resident 191's admission Record (AR), the AR indicated the facility readmitted the resident on 5/7/24, with diagnoses that included diabetes mellitus (a condition that happens when the blood sugar [glucose] is too high) and chronic obstructive pulmonary disease (COPD, a group of lung diseases that block airflow and make it difficult to breathe). During an observation and concurrent interview on 8/27/24 at 11:14 a.m., Resident 191 was lying on his back in bed with one fourth length bed rails up on both sides. Resident 191 was alert and coherent. Resident 191 stated his bed rails were up since a staff (unidentified) transferred him to room [ROOM NUMBER] from 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 staff failed to respond to the call light and address residents' needs and requests for assistance with toileting and activities of daily living (ADL) in a timely manner for three of six sampled residents. This deficient practice had the potential to negatively affect the residents' quality of life and their feelings of self-worth. Findings: During a Resident Council Meeting on 8/28/2024 at 10:34 am with six cognitively intact residents, three residents felt they did not get the care they needed without waiting a long time and stated staff took too long to answer the call lights. The residents stated they had to wait 10 minutes to one hour to receive assistance when using their call light to request to be changed, had their bed changed or when requesting water to drink. One resident stated, during last week (unable to determine the date), the resident's call light needed to be rung three times before any staff would come and waited 10 to 15 minutes to be changed or requested water. The resident was upset and stated, the staff were…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure medications were administered safely, in a timely manner, and as prescribed to meet the therapeutic needs for 16 of 18 sampled residents (Residents 26, 29, 50, 57, 59, 114, 138, 148, 171, 177, 187, 319, 320, 321, 56, and 569) by failing to ensure: 1. Resident 187, with a diagnosis of dialysis was administered sevelamer (Brands: Renvela and Renagel, to lower the amount of phosphorus in the blood of patients with chronic kidney disease [CKD] who are on dialysis [medical treatment to clean the blood when the kidneys are not working properly]) received the medication with meals and did not receive doses of sevelamer late (over an hour from the scheduled administration time), on 8/13/2024, 8/14/2024, 8/16/2024, 8/17/2024, 8/18/2024, 8/20/2024, 8/21/2024, 8/22/2024, 8/24/2024, 8/25/2024, 8/26/2024, and 8/27/2024, or too close to or at the same time as the next scheduled dose on 8/14/2024, 8/20/2024, 8/24/2024, and 8/27/2024. 2. Residents…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 medication error rate was less than five percent (%). Six medication errors out of 28 total opportunities contributed to an overall medication error rate of 21.43 % for two of four residents (Residents 26 and 187) observed during medication administration (MedPass). a. For Resident 26, the facility failed to ensure Resident 26 received medications within an hour of the administration time to meet the resident's therapeutic needs. b. For Resident 187, the facility failed to ensure Resident 187's order for sevelamer (Brands: Renvela and Renagel, to lower the amount of phosphorus in the blood of patients with chronic kidney disease [CKD] who are on dialysis [medical treatment to clean the blood when the kidneys are not working properly]) was administered with meals in accordance with the physician orders and manufacturer's specification. These deficient practices had the potential for Residents 26 and 187 to experience adverse…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure medications were kept secure with limited access by failing to: 1. Lock the medication cart (MedCart) that contained residents' medications at Station 4 when the MedCart was not attended by a licensed nurse. 2. Ensure medications prepared for Resident 187 was secured and not left on top of the MedCart at Station 4 when the medications were outside of a licensed nurse's view. These deficient practices had the potential for Resident 187's medications to be accessible to other unauthorized staff and residents, and increased the risk for loss of control, safety, and security of all medications. Findings: During a review of Resident 187's admission Record (AR), the AR indicated the resident was admitted to the facility on [DATE], with diagnoses that included end stage renal disease (kidneys have lost their ability to filter waste from the blood), dependence on renal dialysis (a medical treatment to clean the blood when the kidneys are…

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

Based on observation, interview and record review, the facility failed to ensure the standardized recipes for lunch menu was followed on 8/27/2024 by failing to: a. Ensure staff followed food production recipes for the mechanical soft diet (diet for residents who experienced chewing or swallowing limitations, diet is modified to a soft, chopped or ground consistency) during lunch preparation and tray line observation for 33 residents on a mechanical soft diet, and received chopped roast beef with gravy instead of ground roast beef with gravy per menu and spreadsheet (food portion and serving guide.) b. Ensure 26 residents on a pureed diet received pureed green beans instead of pureed spinach au gratin per menu. c. Ensure one resident who was a vegetarian (Resident 220) did not complain that his meals do not have vegetarian protein options and that only starch and the vegetable of the day is served on the plate. These deficient practices had the potential to result in meal dissatisfaction, decreased nutritional intake when the menu is not updated to reflect the needs of the resident…

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

Based on observation, interview and record review, the facility failed to: a. Ensure one resident (Resident 8) on a puree diet (foods that is blended, do not require chewing, and are easily swallowed. Food should be smooth .consistency of pudding) received cottage cheese texture in form that meet their needs when they received regular cottage cheese that was lumpy and had small to medium size cheese curds. b. Ensure one resident (Resident 219) who was on a Mechanical soft texture chopped diet received a grilled cheese sandwich texture in form that meet their needs when the grilled cheese sandwich was dry with hard crust and was not chopped. These deficiencies had the potential to result in decreased intake related to inconsistent texture, meal dissatisfaction and increase choking and aspiration risk. Findings: During an observation of meal preparation on 8/27/2024 at 12:15pm, Resident 8 who was on pureed diet, the cook served puree potato, pureed green beans and a cup of regular cottage cheese. During a concurrent observation and interview, Cook1 stated the resident likes cottage…

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

Based on observation, interview and record review, the facility failed to ensure safe and sanitary food storage and preparation practices in the kitchen by failing to: a. Ensure one Dietary Aide (DA1) working in the dish machine area washed his hands and changed gloves when removing the clean and sanitized dishes from the dish machine. b. Ensure two large packages of previously cooked, frozen, and thawed roasted turkey breast, was not stored in the refrigerator with dates of 8/22/24, which exceeded the storage period for thawed poultry. c. Ensure food brought to residents from outside of the facility, including leftovers stored in the resident food refrigerator and kitchen freezer were dated. These deficiencies had the potential to result in harmful bacteria growth and cross contamination (transfer of harmful bacteria from one place to another) that could lead to foodborne illness in 164 out of 226 residents who received food from the kitchen. Findings: a. During an observation in the dishwashing area on 8/27/2024 at 9:30am, Dietary Aide (DA1) was rinsing soiled dishes and loading…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement infection control practices for seven of 10 sampled residents (Residents 69, 111, 133, 122, 66, 135, and 422) by failing to: a. Ensure staff wore eye protection, including a face shield or eye goggles, upon entering rooms for Resident 69, 111, 133, and 122 who were under observation for exposure to Coronavirus Disease 2019 (COVID-19, a highly contagious viral disease that can cause respiratory illness) in accordance with the facility's Policy and Procedure (P&P) on Coronavirus Disease (COVID-19) - Infection Prevention and Control Measures. b. Ensure staff performed hand hygiene and wore a protective gown while adjusting Resident 66's tracheostomy tube (surgical opening made through the front of the neck and into the windpipe [trachea] to allow air into the lungs) in accordance with the facility's P&P on Infection Control Guidelines for All Nursing Procedures. c. Ensure Resident 135, who had a G-tube and tracheostomy tube, 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 observation, interview, and record review the facility failed to ensure the window screen in a resident's room was intact for one of one sampled resident (Resident 121). This deficient practice had the potential to affect the residents' right to a safe, clean, comfortable, and homelike environment and put the resident at risk for physical discomfort. Findings: During a review of Resident 121's admission Record (AR) the AR indicated Resident 64 was readmitted to the facility on [DATE] with diagnoses that included unspecified open wound of the right and left buttocks. During a review of Resident 121's Minimum Data Set (MDS, a standardized resident assessment and care screening tool) dated 8/19/2024, the MDS indicated Resident 121 was cognitively intact (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) and required partial/moderate assistance (helper does less than half effort. Helper lifts, holds, or supports trunk or limbs, but provides…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 care plan for one of one sampled resident (Resident 66) on bilateral hand mittens in accordance with the facility's Policy and Procedure (P&P) titled Care Plans - Comprehensive. This deficient practice had the potential for Resident 66 to not receive appropriate care treatment and/or services specific to the resident's needs. Findings: During a review of Resident 66's admission Record (AR), the AR indicated the facility admitted Resident 66 on 12/19/2023 with diagnoses that included epilepsy (brain disorder in which a person has repeated seizures [convulsions] over time) and encounter for attention to tracheostomy (surgical opening in the throat in which a tube is placed for the resident's breathing). During a review of Resident 66's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 6/21/2024, the MDS indicated, Resident 66 's cognition (mental action or process of acquiring knowledge and understanding) for daily decision making was severely impaired.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of one sampled resident (Resident 124) had padded siderails as a seizure precaution, as ordered. This deficient practice had the potential to cause injury to Resident 124 during a seizure (abnormal movements or behavior due to unusual electrical activity in the brain) episode. Findings: During a review of Resident 124's admission Record (AR), the AR indicated Resident 124 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included encephalopathy (disease of the brain that alters brain function or structure) and unspecified, intractable (uncontrolled by two or more medications) epilepsy (a chronic brain disorder that causes seizures). During a review of Resident 124's History and Physical (H&P), dated 2/26/2024, the H&P indicated Resident 124 did not have the capacity to understand and make decisions. During a review of Resident 124's untitled Care Plan (CP), dated 2/27/2024, the CP 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.

Based on observation, interview and record review, the facility failed to provide appropriate care to prevent Urinary tract Infection ([UTI] an infection in any part of the urinary system [kidneys, bladders, ureters and urethral]) for one of two sampled residents (Resident 192) who was on Foley catheter (a thin, sterile tube inserted into the bladder to drain urine) by failing to ensure: Licensed staff monitor Residents 192's urine output and notify the physician promptly for signs and symptoms of UTI. This deficient practice placed Resident 192 at risk for delayed treatment and worsening of infection. Findings: During a review of Resident 192's admission Record (AR), the AR indicated the facility admitted the resident on 6/21/24, with diagnoses that included hypertension (high blood pressure) and epilepsy (a brain disorder that causes recurring, unprovoked seizures). During a review of Resident 192's Physician Order Sheet (POS) dated 6/23/24, the POS indicated an order for Foley catheter attached to bedside drainage bag for diagnosis of neurogenic bladder (a person lacks bladder…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 one of two sampled residents (Resident 205) who was fed by enteral means received appropriate treatment and services by failing to elevate the head of the bed while the resident was receiving formula through the gastrostomy tube (GT - a tube inserted through the abdomen that delivers nutrition directly to the stomach) and failing to ensure the GT flush was connected to Resident 205 in accordance with the resident's care plan and the facility's Policy and Procedure (P&P) titled Enteral Feedings - Safety Precaution. This deficient practice had the potential to cause aspiration (inhalation of foreign materials) and lead to other adverse consequences for the resident. Findings: During a review of Resident 205's admission Record (AR), the AR indicated the facility admitted Resident 205 on 7/19/2024 with diagnoses that included encounter for attention to gastrostomy (creation of an artificial external opening into the stomach for nutritional support) and encounter for attention to tracheostomy (surgical…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 post accurate nurse staffing information of actual hours worked by the licensed and unlicensed nursing staff directly responsible for resident care per shift daily and was not posted in a prominent location readily accessible to residents and visitors for viewing in accordance with the facility's Policy and Procedure (P&P) titled Posting Direct Care Daily Staffing Numbers for three of three days ( 8/26/2024, 8/28/2024 and 8/29/2024). This deficient practice of posting inaccurate nurse staffing information would mislead the residents and visitors of the actual staffing in the facility that may affect the quality of nursing care provided to the residents. Findings: During a concurrent interview on 8/29/2024 at 10:09 am with the Assistant Director of Staff and Development (ADSD) and record review of the nurse staffing information and the actual staffing sign in sheet for the staff who worked in the facility, the ADSD stated ADSD missed to post the nurse staffing information on 8/26/2024 in the Sub Acute Unit.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 obtain an informed consent when the physician ordered psychotropic medication (any drug that affects behavior, mood, thoughts, or perception), buspirone (an antipsychotic medicine, it works by changing the actions of chemicals in the brain) for one of five sampled residents (Resident 210). This failure had the potential risk to place the resident at risk for unnecessary psychotropic medications. Findings: During a review of Resident 210's admission Record (AR), the AR indicated Resident 18 was readmitted to the facility on [DATE]. During a review of Resident 210's Order Summary Report (OSR), the OSR indicated an order on 7/22/2024 for licensed staff to administer to Resident 210 buspirone oral tablet 5 milligrams (mg- unit of measurement), 0.5 tablet by mouth two times a day for anxiety. During a review of Resident 210's Minimum Data Set (MDS, a resident assessment and care screening tool) dated 7/28/2024, the MDS indicated Resident 210…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 offer preferences regarding food choices for one of one sampled resident (Resident 8). This deficient practice had the potential to result in insufficient meal intake and potentially result to weight loss for Resident 8. Findings: During a review of Resident 8's admission Record (AR), the AR indicated Resident 8 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included chronic respiratory failure (a condition caused by inadequate supply of oxygen and/or the inability to remove carbon dioxide from the lungs). During a review of Resident 8's Minimum Data Set (MDS, a standardized resident assessment and care screening tool) dated 6/18/2024, the MDS indicated Resident 8 was cognitively intact (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) and Resident 8 thought it was somewhat important to have snacks available between meals.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 10 Restorative Nursing Aides (RNA, certified nursing aide program that helps residents to maintain their function and joint mobility) did not perform job duties out of the State certification, including managing feeding through a gastrostomy tube (G-tube, tube placed directly into the stomach for long-term feeding) for one of four sampled residents (Resident 109) with limited range of motion [(ROM) full movement potential of a joint (where two bones meet)] and mobility (ability to move). This failure had the potential for Resident 109 to have complications related to the G-tube. Findings: During a review of Resident 109's admission Record (AR), the AR indicated the facility admitted Resident 109 on 3/20/2024 and re-admitted on [DATE]. The AR indicated Resident 109's diagnoses included parkinsonism (group of conditions with symptoms including slow movements, stiffness, tremors, and balance issues), dementia (decline in mental…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to explain the Agreement To Arbitrate Disputes Related To Medical Malpractice Binding Arbitration Agreement (AA, Binding Arbitration Agreement), signed 8/12/2024, for one of three sampled residents (Resident 522), in a language Resident 522 understood when agreement was entered for binding arbitration (involves the submission of a dispute to a neutral party who hears the case and makes a decision). This failure had the potential to result in Resident 522 to not be able to make an informed decision and/or his rights to be denied. Findings: During a review of the Resident 522's admission Record (AR), the AR indicated Resident 522 was admitted on [DATE]. During a review of Resident 522's History and Physical (H&P) dated 8/13/2024, the H&P indicated Resident 522 was admitted to the facility for uterine cancer (cancer of the uterus) and hypertension (increased blood pressure). The H&P indicated Resident 522 had the capacity to make decisions. During a review…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure infection prevention and control practices were implemented for one of two sampled residents (Resident 6) and a census of 205 residents as indicated in the facility's policy and procedure (P&P) titled Policies and Practices- Infection Control, and the Los Angeles County Department of Public Health guidelines titled, Scabies Prevention and Control Guidelines for Healthcare Settings, by failing to: 1. Ensure Resident 6 did not experience a delay in treatment when Resident 6 tested positive for Scabies (a highly contagious skin condition caused by tiny insects called mites that infest and causes intense itching) on 7/31/2024. 2. Ensure the Infection Preventionist (IP; healthcare professional that is trained to develop ways to detect, prevent, and control the spread of disease in healthcare settings) reported the facility's Scabies Outbreak (two or more clinically suspect or confirmed cases of scabies identified in residents, healthcare workers,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement a comprehensive person-centered care plan for ADL (Activities of Daily Living, daily tasks that people perform to care for themselves and maintain independence) and Fall Risk for one of one sampled resident (Resident 1), who was assessed as high risk for falls ( to move downward, typically rapidly and freely without control, from a higher to a lower level). This deficient practiced placed Resident 1 at risk for falls. As a result, on 8/3/2024, Resident 1 fell in the bathroom. Resident 1 experienced pain (unrated) on the left shoulder and was transferred to General Acute Care Hospital 1 (GACH 1) via 911 (an emergency telephone number) for further evaluation. At GACH 1 Resident 1 was found to have a left humeral (upper arm bone) neck impacted fracture (occurs when the broken ends of the bone are jammed together by force of the injury) and the greater tuberosity (bony bump at top of humerus) mildly displaced fracture fragment (occurs when a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide copies of medical records upon request within two working days for two of three sampled residents (Resident 7 and Resident 8). This deficient practice had the potential to violate Resident 7's, Resident 8's, and/or their representative's right to obtain copies of their medical records in a timely manner. Findings: 1. During a review of Resident 7's Face Sheet (FS- admission Record), the FS indicated, the facility admitted Resident 7 on 8/31/21, with diagnoses that included Alzheimer's disease (irreversible, progressive brain disorder that slowly destroys memory and thinking skills, and eventually the ability to carry out the simplest tasks,) epilepsy (brain disorder in which a person has repeated seizures [episodes of disturbed brain activity that cause changes in attention or behavior] over time). The FS indicated, Resident 7's responsible party (RP) was RP 1. During a review of Resident 7's Minimum Data Set (MDS - a standardized assessment…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop a scabies (skin infestation caused by the human itch mite; a parasite that lives on the exterior of its host) line list (a table that contains key information about each case in an outbreak) of all residents, staff, visitors, and family members who may have had direct and physical contact with Resident 1 after General Acute Care Hospital (GACH) 1 reported to the facility on 7/8/24, that Resident 1 had a positive scabies result. This failure had the potential outcome to spread scabies to 51 residents in the Subacute Unit of the facility. Findings: 1. During a review of Resident 1's admission Record (AR), the AR indicated, the facility initially admitted Resident 1 to the facility on [DATE], and readmitted Resident 1 on 2/13/24, with diagnoses that included respiratory failure, unspecified with hypoxia (occurs when you do not have enough oxygen in your blood) or hypercapnia (occurs when there is too much carbon dioxide in your 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 ensure sufficient Licensed Vocational Nurses (LVNs) and Certified Nursing Assistants (CNAs) provided care and services to residents in accordance with the facility's policy and procedure (P&P) and the Facility Assessment Tool (used by the facility to evaluate what resources are necessary to care for the facility's residents) for four of four sampled residents ( Residents 8, 9, 10 and 11). As a result, Residents 8, 9, 10 did not receive showers. For Resident 8 for not getting up the resident out of bed and into the wheelchair, for Resident 8 and Resident 9 for allowing to sit on soiled adult brief for an extended period of time, and for Resident 11 to wait for assistance from staff for an extended period of time. These failures had the potential to result in a decline in the residents' physical and psychosocial well-being due to poor quality of care. Findings: a. During a review of Resident 8's Face Sheet (FS - document that contains a patient'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 follow its Policy and Procedure on Charting and Documentation by failing to document accurately and completely on the Certified Nursing Assistant (CNA) flowsheet the bowel and bladder function and communicate between the interdisciplinary team regarding the resident's condition for 3 of 42 residents in Station 4 (Residents 7, 8 and 9). This deficient practice had the potential to affect the provision of care and services to the residents and result in adverse consequences for Residents 7, 8 and 9. Findings: During a review of Resident 7's Face Sheet (FS), the FS indicated the facility admitted the resident on 5/21/24, with diagnoses that included muscle wasting and atrophy (decrease in size or wasting away of a body part or tissue) and dysphagia (difficulty swallowing). During a review of Resident 7's Minimum Data Set (MDS - a standardized assessment and care planning tool) dated 5/27/24, the MDS indicated Resident 7 had intact cognition (ability 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 report suspected physical abuse within two hours on 5/1/2024 to the California Department of Public Health (CDPH), local enforcement, and Ombudsman for one of three sampled residents (Resident 1). Resident 1 reported to staff on 5/1/24 that Certified Nursing Assistant 1 (CNA 1) hurt Resident 1 when changing Resident 1 ' s adult brief. This failure had the potential to result in a delay in investigating potential abuse and expose Resident 1 to further abuse. Findings: During a review of Resident 1 ' s admission Record (AR), the AR indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included fibromyalgia (condition that causes pain all over the body), hypothyroidism (conditions when the thyroid gland does not make enough thyroid hormones), and heart failure (condition when the heart does not pump enough blood in the body). During a review of Resident 1 ' s History and Physical (H&P) dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure hazardous chemicals were kept in a secure area for one of three sampled units, (Unit 3), when one bottle of Melt Down Emulsifier stripper (removing multiple coats of finish from floors), one bottle of Pro-look wet shine floor finish (protects interior floors from stains, scuffs and provides a gloss finish to floors), and two bottles of undercoat sealer (used to seal absorbent surfaces and prevent the topcoat from being absorbed into the surface) were left in an open cart in the hallway, unattended. This failure had the potential to result in residents in Unit 3 to have access to toxic chemicals and possibly, ingest toxic chemicals and sustain a serious injury. Findings: During a concurrent observation and interview on 5/7/2024 at 12:16 PM, two bottles of undercoat sealer, one bottle of Pro-look wet shine floor finish, and one bottle of Melt Down Emulsifier Stripper were placed in an open cart with no lock, unattended, 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.

Based on observation, interview, and record review, the facility failed to provide a safe, clean, comfortable, and homelike environment for one of five sampled residents (Resident 1) in accordance with the facility's policy and procedure (P&P) titled, Homelike Environment, by failing to ensure Resident 1's room walls and ceilings were free of water damage, peeling paint, and discoloration from leaking water when the facility's roof sustained a leak due to rain on 4/17/2024. This failure had the potential for Resident 1 to be uncomfortable, not have a homelike environment, and be exposed to mold (fungus organism that grows in damp, dim areas) due to water damage that could lead to a decline of health. Findings: During a review of Resident 1's Face Sheet (FS- admission record), the FS indicated, the facility initially admitted Resident 1 to the facility on 3/26/2024, and readmitted Resident 1 on 4/10/2024. The FS indicated, Resident 1 had diagnoses of respiratory failure (serious condition that makes it breathe on one's own) and endocarditis (inflammation of the inside lining 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 ensure call lights were answered in a timely manner and/or within reach for four of four sampled residents (Residents 3, 4, 2, and 5) in accordance with the facility's policy and procedures (P&P) titled, Answering the Call Light and Call System, Resident. These deficient practices had the potential for Residents 3, 4, 2, and 5 to not receive assistance when needed which could result in harm, physical injury, and/or death. Findings: 1. During a review of Resident 3's Face Sheet (FS), the FS indicated, the facility admitted Resident 3 on 4/01/2024, with diagnoses that included wedge compression fracture (the fracture occurs when the bone actually collapses and the front part of the vertebral [bones that make up the spine] body forms a wedge shape) of T11-T12 (bones in the middle section of the spine) vertebra and parkinsonism (brain conditions that cause slowed movements, stiffness, and tremors [shaking or trembling]). During a review of…

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

Based on observation, interview, and record review, the facility failed to provide treatment and care to maintain foot health for one of four sampled residents (Resident 2) by failing to: 1. Ensure Certified Nursing Assistant (CNA) 1 and/or Licensed Vocational Nurse (LVN) 1 provided nail care to Resident 2 as indicated in the facility ' s policy and procedure (P&P) titled, Fingernails/Toenails, Care of. 2. Ensure Social Service Designee (SSD) 2 arranged podiatry services (services provided by a podiatrist [a health professional trained to diagnose and treat diseases and other disorders of the feet]) for Resident 2 as indicated in Resident 2's care plan titled Baseline Care Plan. 3. Develop a comprehensive resident-centered care plan for foot care for Resident 2 as indicated in the facility's policy and procedure (P&P) titled, Care Plans - Comprehensive. These deficient practices had the potential to cause inconsistent care and services provided to Resident 2 and could cause pain and podiatric complications for Resident 2. Findings: During a review of Resident 2's Face Sheet (FS),…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 properly maintain the bed frame for two out of three sampled residents (Resident 1 and Resident 3) by failing to: Inspect and ensure Resident 1 and Resident 3's bed frame did not have any chipped wood and was in good condition. This deficient practice had the potential for Resident 1 and Resident 3 to sustain injuries and feel their environment was not homelike. Findings: During an observation on 4/10/24 at 11:58 am, a small portion of the bed frame was missing and had chipped wood on Resident 3's right side of the footboard of Resident 3's bed frame. Resident 3 stayed in the same room and used the same bed after Resident 1 was discharged from the facility. During a concurrent observation and interview with the Maintenance Supervisor (MS) on 4/10/24 at 12:09 pm, MS stated Resident 3's footboard of the bed frame was cracked. MS stated Resident 3's bed frame was not supposed to be like that and needed to be changed. MS stated MS would get on the phone to order a new one. MS stated that MS changed the broken beds…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 secure and protect the personal belongings of one of three sampled residents (Resident 1) from loss or theft. This deficient practice had the potential to result in loss or theft of other residents ' personal belongings in the facility. Findings: During a review of Resident 1's Face Sheet (FS), the FS indicated the facility re-admitted Resident 1 to the facility on 2/3/2024 with diagnoses that included encephalopathy (a change in one ' s brain function due to injury or disease), dysphagia (difficulty swallowing), and respiratory failure (a serious condition that makes it difficult to breathe on your own). During a review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 2/27/2024, the MDS indicated, Resident 1 was understood by others and had the ability to understand others. During an interview on 3/6/2024 at 12:29 pm, with Resident 1, Resident 1 stated she was missing personal items, which was reported to the staff last month, in February 2024. Resident 1 also stated 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.

Based on interview and record review, the facility failed to provide adequate supervision to ensure safety and prevent elopement (to leave or run away) of one of three sampled residents (Resident 2). This deficient practice had the potential to affect Residents 2's safety and increase the risk for injury and/or death. Findings: During a review of Resident 2's Face Sheet (FS), the FS indicated the facility admitted Resident 2 on 11/10/2023 with diagnoses that included metabolic encephalopathy (a disorder where medical problems such as blood infections or liver or kidney failure cause brain damage), dementia (loss of memory and other mental abilities severe enough to interfere with daily life), and type 2 diabetes mellitus (characterized by high levels of blood sugar in the blood). During a review of Resident 2's Care Plan (CP) for elopement, dated 11/13/2023, the CP indicated, Resident 2 was at risk for injuries secondary to (relating to) elopement. The CP indicated Resident 2 had the potential for elopement due to cognitive impairment (problems with a person ' s ability to think,…

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

Based on interview and record review, the facility failed to ensure social services was provided for one of three sampled residents (Resident 1) to resolve Resident 1 ' s grievance (a complaint) relating to missing personal items. This deficient practice had the potential to cause Resident 1 emotional and psychological (related to the mental and emotional state of a person) distress (a feeling of extreme worry, sadness, or pain). Findings: During a review of Resident 1's Face Sheet (FS), the FS indicated the facility most recently re-admitted Resident 1 on 2/3/2024 with diagnoses that included encephalopathy (a change in one ' s brain function due to injury or disease), dysphagia (difficulty swallowing), and respiratory failure (a serious condition that makes it difficult to breathe on your own). During a review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 2/27/2024, the MDS indicated, Resident 1 was understood by others and had the ability to understand others. During an interview on 3/6/2024 at 12:29 pm, with Resident 1, 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 implement the care plans for two of three sampled residents (Residents 1 and 3), as indicated in the facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, by failing to: 1. Ensure Resident 1 and Resident 3 had daily body checks to monitor for skin injury (bruising, redness, cuts, scratches), or skin tear (a wound that happens when the layers of skin separate or peel back) while giving care and keep Resident 3's bed dry and wrinkle-free, as indicated on Resident 1's and Resident 3's Care Plan (CP) titled, Risk for Skin Breakdown. This deficient practice could cause a delay in assessment/identification of new skin injuries or wounds and provision of necessary treatment for Resident 1 and 3 and placed Resident 3 at risk for developing new pressure ulcers (PU- localized injury to the skin and or underlying tissue usually over a bony prominence as result of pressure). 2. Ensure Resident 1 was monitored for 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 care and services for two of three sampled residents (Residents 1 and 3), who were assessed as being high risk for developing pressure ulcers (PU- localized injury to the skin and or underlying tissue usually over a bony prominence as result of pressure or pressure in combination with shear [mechanical force that cause the skin to break off] and/or friction [movement of one surface of the skin against the others]), to prevent the development of new PU) by failing to: 1. Ensure facility staff accurately assessed and monitored Resident 1's and Resident 3's skin condition. 2. Ensure Treatment Nurse (TN) 1, TN 2, TN 3, and TN 4 assessed and documented Residents 1's and 3's risk for developing a pressure ulcer weekly as indicated in the facility's policies and procedures (P&P) titled, Prevention of Pressure Injuries (PU), and Pressure Injury Risk Assessment. As a result, Resident 1's pressure ulcers of different stages (to determine…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 keep the mouth clean for one of three sampled residents (Resident 3) by failing to: Ensure Resident 3 was provided oral care (also known as oral hygiene- the practice of keeping the mouth clean and free of disease and other problems by regular cleaning of teeth, gums, and/or dentures). This failure had the potential for Resident 3 to develop an infection and put Resident 3 at risk for a decline in health. Findings: During a review of Resident 3 ' s admission Record (AR), the AR indicated, the facility admitted Resident 3 to the facility on [DATE], with diagnoses of dysphagia- oropharyngeal phase (difficulty or discomfort in swallowing), dementia (progressive impaired ability to think, remember or make decisions that interferes with doing everyday activities), and gastro-esophageal- reflux (GERD- condition in which the stomach contents move up into the esophagus tube [muscular tube] from the throat to the stomach that connects mouth 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 interview and record review, the facility to failed to follow their policy and procedure (PP) titled, Emergency Procedure- Cardiopulmonary Resuscitation, by failing to: 1. Ensure three (3) Certified Nursing Assistants (CNAs) 5, 8, 12, eight (8) Licensed Vocational Nurses (LVNs) 1, 2, 3, 6, 10, 21, 23, and 24, and two (2) Respiratory Therapists (RTs) 2 and 4, had updated (not expired) Basic Life Support (BLS- set of essential emergency procedures designed to sustain life in victims experiencing cardiac arrest) certification cards while working at the facility. 2. Ensure Certified Nursing Assistant (CNA) 15 received BLS certification from either the American Red Cross (ARC) or the American Heart Association (AHA). These failures had the potential for all residents who had a full code status (resident ' s heart stopped beating and/or the resident stopped breathing, the resident or their representative wishes for all lifesaving procedures to be provided to keep them alive) to be put at risk for not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to develop a plan of care to address the Stage 3 pressure ulcer (full-thickness loss of skin, in which subcutaneous fat may be visible in the ulcer and granulation tissue and epibole [rolled wound edges] are often present) on the left clavicle (collar bone) of one of seven sampled residents (Resident 3) in accordance with the facility ' s policy and procedure (PP) titled, Care Plans, Comprehensive Person-Centered. As a result of this failure, Resident 3 went five days without care and treatment for Resident 3 ' s pressure ulcer on the left clavicle which had the potential to worsen Resident 3's pressure ulcer and/or cause infection. Cross Reference F686 Findings: During a review of Resident 3 ' s Face Sheet (admission Record- AR), the AR indicated the facility initially admitted Resident 3 on 10/27/2023 and readmitted the resident on 1/17/2024, with diagnoses of anoxic brain injury (stopping of blood flow into and within the brain due 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 implement its policy and procedure (P&P) titled, Care of Fingernails/Toenails, for two of three sampled residents (Resident 9 and Resident 10) who were on dialysis (a procedure where a machine cleans the blood because the kidneys can no longer clean the blood) by failing to: 1. Ensure Resident 9 ' s and Resident 10 ' s fingernails were cleaned daily and kept trimmed. 2. Provide Resident 9 and Resident 10 assistance with personal hygiene (includes combing hair, brushing teeth, shaving, applying make-up, nail care, washing/drying face, and hands) as indicated by Resident 9 ' s and Resident 10 ' s activities of daily living (ADLs) care plan. 3. Ensure provision of nail care was documented in Resident 9 ' s and Resident 10 ' s medical record according to the facility ' s P&P. These failures had the potential for Resident 9 and Resident 10 to sustain skin injuries from scratching and to develop an infection. Findings: 1. During a review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide wound care services to promote healing and prevent infection for one of seven sampled residents (Resident 3) by failing to: 1. Assess and monitor Resident 3 ' s Stage 3 pressure ulcer (full-thickness loss of skin, in which subcutaneous fat may be visible in the ulcer and granulation tissue and epibole [rolled wound edges] are often present) on the left clavicle (collar bone) when Resident 3 was readmitted to the facility on [DATE]. 2. Provide care and treatment to Resident 3 ' s Stage 3 pressure ulcer on the left clavicle from 1/17/2024 to 1/21/2024 (total of 5 days). As a result of these failures, Resident 3 went five days without care and treatment for Resident 3 ' s pressure ulcer on the left clavicle which had the potential to worsen Resident 3's pressure ulcer and/or cause infection. Cross reference F656 Findings: During a review of Resident 3 ' s Face Sheet (admission Record- AR), the AR indicated the facility initially…

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

Based on interview and record review, the facility failed to maintain consistent communication and collaboration with the dialysis facility regarding care and services for 1 of 3 sampled residents (Resident 8) who was on dialysis (a procedure where a machine cleans the blood because the kidneys can no longer clean the blood) by failing to ensure: 1. Licensed Vocational Nurse 20 (LVN 20) reviewed Resident 8 ' s Dialysis Communication Record after Resident 8 came back from the dialysis center on 1/9/2024 and documented on the Communication Record any follow-up done to address the dialysis nurse report. 2. LVN 22 reviewed Resident 8 ' s Dialysis Communication Record after Resident 8 came back from the dialysis center on 1/16/2024 and documented on the Communication Record any follow-up done to address the dialysis nurse report. These failures had the potential for Resident 8 to receive inadequate nursing care and treatment after Resident 8 received dialysis treatment. Findings: During a review of Resident 8 ' s Face Sheet (admission Record), the admission Record indicated 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 on observation, interview, and record review, the facility failed to provide proper nail hygiene to two of three sampled residents (Resident 9 and Resident 10) who were on dialysis (a procedure where a machine cleans the blood because the kidneys can no longer clean the blood) by failing to: 1. Ensure Resident 9 ' s and Resident 10 ' s fingernails were cleaned daily and kept trimmed. 2. Provide Resident 9 and Resident 10 assistance with personal hygiene (includes combing hair, brushing teeth, shaving, applying make-up, nail care, washing/drying face, and hands) as indicated by Resident 9 ' s and Resident 10 ' s activities of daily living (ADLs) care plan. 3. Ensure provision of nail care was documented in the resident ' s medical record according to the facility ' s Care of Fingernails/Toenails policy and procedure (P&P). These failures had the potential for Resident 9 and Resident 10 to sustain skin injuries from scratching and to develop an infection. Cross Reference F677 Findings: 1. During a review of…

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

Based on observation, interview, and record review, the facility failed to ensure the environment for one (Resident 7) of one resident, reviewed for elopement, was free of accident hazards and Resident 7 was provided adequate supervision. As a result of this deficient practice, Resident 7 eloped from the facility possibly through a double glass exit door by her room that led to the outside of the facility which put Resident 7 at risk for injury from being on her own and unsupervised outside of the facility. Findings: During a review of Resident 7's admission Record (Face Sheet), the admission Record indicated the facility admitted Resident 7 on 12/14/23 at 5:51 PM, with diagnoses that included schizoaffective disorder (a mental illness that can affect your thoughts, mood, and behavior), and dementia (loss of cognitive functioning, thinking, remembering, and reasoning, to such an extent that it interferes with a person's daily life and activities). During a review of Resident 7's History and Physical (H&P), dated 12/15/23, the H&P indicated Resident 7 did not have 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 observation, interview, and record review, the facility failed to follow their policies and procedures (P&P) titled, Departmental (Respiratory Therapy) - Prevention of Infection and CPAP (continuous positive airway pressure - a machine that uses mild air pressure to keep breathing airways open while you sleep) / BiPAP (bilevel positive airway pressure - a machine that helps you breathe) Support, by: 1. Failing to ensure a nasal cannula (NC - a device that delivers extra oxygen through a tube and into your nose) tubing was changed every seven days for one of two sampled residents (Resident 1). 2. Failing to ensure a No Smoking sign was posted for two of six rooms (R2 and R3) with oxygen concentrators (a medical device that gives you extra oxygen) being used. These deficient practices had the potential to result in a respiratory infection to Resident 1 and the potential for risk of fire due to oxygen use. Findings: 1. During a review of Resident 1's Face Sheet indicated Resident 1 was readmitted 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 interview and record review, the facility failed to update the inventory list for one of three sampled residents (Resident 2) by failing to follow the facilities policy and procedure (P&P) titled, Personal Property. This deficient practice had the potential for theft or loss of Resident 2's personal belongings. Findings: A review of Resident 2's Face Sheet indicated Resident 2 was most recently re-admitted to the facility on [DATE]. Resident 2's diagnoses included respiratory failure (a serious condition that makes it difficult to breathe on your own) and asthma (a long-term condition that affects the airways in the lungs). A review of Resident 2's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 1/2/23, indicated Resident 2 was understood by others and had the ability to understand others. A review of Resident 2's Resident Inventory of Personal Effects, dated 5/15/23, did not indicate a laptop computer on the inventory list. During an interview on 11/7/23 at 11:23 am,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 3) who had long and dirty fingernails, was provided nail care. This deficient practice placed Resident 3 at risk of skin breakdown and developing an infection. Findings: During a review of Resident 3's Face Sheet indicated Resident 3 was most recently admitted to the facility on [DATE]. Resident 3's diagnoses included end stage renal disease (the last stage of long-term kidney disease in which the kidneys can no longer function on their own), dependence on renal dialysis (a type of treatment that helps the body remove extra fluid and waste products from the blood when the kidneys are not able to), and muscle weakness. During a review of Resident 3's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 9/8/2023, indicated Resident 3 was understood by others and had the ability to understand others. The MDS indicated Resident 3 required total dependence (full staff…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 their policy and procedure (P&P) titled, Change in a Resident's Condition or Status, by not notifying one of three sampled residents (Resident 3's) Representative 1 (R1) when Resident 3 was transferred to a General Acute Care Hospital 1 (GACH 1). This failure resulted in the violation of Resident 3's right to notify Resident 3's R1 of any changes of condition/status to Resident 3. Findings: During a review of Resident 3's Face Sheet, the Face Sheet indicated Resident 3 was admitted to the facility on [DATE] with diagnoses of lymphoid leukemia (cancer of the blood and bone marrow), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), and lack of coordination (not able to move different parts of the body together well or easily). The Face sheet listed R1 as a contact person for Resident 3. During a review of Resident 3's admission Nursing Assessment, dated 10/2/23, the assessment indicated Resident 3 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 observation, interview, and record review, the facility failed to ensure a staff (Licensed Vocational Nurse 1 [LVN 1]) properly sanitized a glucometer machine (a small, portable machine that is used to measure how much glucose [a type of sugar] is in the blood) between two of three sampled residents (Resident 1 and Resident 2). This deficient practice had the potential to increase the risk of spreading infection between Resident 1 and Resident 2. Findings: During an observation on 10/19/23 at 12:30 pm in Resident 1 and Resident 2's room, LVN 1 was observed checking Resident 2's blood sugar with a glucometer machine and test strip (a small plastic strip used to test and measure blood glucose levels). After LVN 1 checked Resident 2's blood sugar, LVN 1 discarded the test strip and placed the glucometer machine on top of the medical cart (a movable piece of equipment used in healthcare facilities to store, transport, and dispense medications and medical supplies and equipment). LVN 1 prepared the glucometer machine by putting a new test strip and proceeded to check Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure two of five sampled residents (Resident 1 and Resident 2), who had diabetes mellitus (disease that results in too much sugar in the blood), received care, treatment, and services in accordance with the care plan, the physician's order, and the facility's policy and procedures by failing to ensure: 1. Medications and treatment were provided according to the physician's orders. 2. Residents' blood sugar level was documented in the clinical record. These failures had the potential to result in uncontrolled blood sugar levels, administration of inaccurate amounts of insulin (medication used to treat high blood sugar), and health complications resulting in hospitalization for Resident 1 and Resident 2. Findings: During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident 1 on 5/27/2023 with diagnoses that included diabetes mellitus. During a review of Resident 1's Minimum Data Set (MDS, a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to administer medications and complete documentations for two of five sampled residents (Resident 1 and Resident 2) according to the facility ' s policy and procedure and failed to document by failing to ensure: 1. Medications and treatment were provided according to the physician ' s orders. 2. Residents ' blood sugar level was documented in the clinical record. These failures had the potential for Resident 1 ' s and Resident 2 ' s blood sugar level to not be controlled and monitored, for Resident 1 and Resident 2 to receive inaccurate amounts of insulin (medication used to treat high blood sugar), and possibly lead to health complications resulting in hospitalization. Cross reference F684 Findings: During a review of Resident 1 ' s admission Record, the admission Record indicated the facility admitted Resident 1 on 5/27/2023 with diagnoses which included diabetes mellitus. During a review of Resident 1 ' s Minimum Data Set (MDS, a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure accuracy of medical records for one of two sampled residents (Resident 1) by failing to: 1. Complete a Fall Risk Assessment (FRA) for Resident 1 upon admission to the facility on 7/28/2023, in accordance with the facility's Policy and Procedure on Fall Risk Assessment. 2. Complete an accurate FRAs for Resident 1 on 8/22/2023 and 8/23/2023. These deficient practices had the potential for Resident 1 to not receive the appropriate care and interventions needed to prevent a fall. Findings: 1. During a review of Resident 1's Face Sheet (admission record), the admission record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including right hemiplegia (paralysis of one side of the body) following cerebral infarct (stroke- disruption of blood flow to the brain), lack of coordination (uncoordinated movement) and aphasia (disorder that affects how one communicates). During a review of Resident 1's admission Nursing Assessment,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to develop and implement toileting schedule for one of two sampled residents (Resident 1), based on Resident 1's Bowel and Bladder Assessment and Interventions (BBAI), dated 7/28/2023. This deficient practice placed Resident 1 at risk for urinary tract infection (UTI- infection that affects part of the urinary tract). Cross Reference: F656 Findings: During a review of Resident 1's Face Sheet (admission record), the admission record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including right hemiplegia (paralysis of one side of the body) following cerebral infarct (stroke- disruption of blood flow to the brain), lack of coordination (uncoordinated movement) and aphasia (disorder that affects how one communicates). During a review of Resident 1's Bowel and Bladder Assessment and Interventions (BBAI), dated 7/28/2023, the BBAI indicated Resident 1 had a frequency of voiding (urinating) higher than eight times per day. The BBAI…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 and implement a toileting schedule on 7/31/2023 based on Resident 1's care plan for, At Risk for Fall Related to Diagnosis of Status-Post Cerebral Vascular Accident (CVA- stroke; disruption of blood flow to the brain) and Bladder Functions: Always Incontinent for one of two sampled residents (Resident 1). This deficient practice placed Resident 1 at risk for urinary tract infection. Cross Reference: F690 Findings: 1. During a review of Resident 1's Face Sheet (admission record), the admission record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including right hemiplegia (paralysis of one side of the body) following cerebral infarct (stroke- disruption of blood flow to the brain), lack of coordination (uncoordinated movement) and aphasia (disorder that affects how one communicates). During a review of Resident 1's Bowel and Bladder Assessment and Interventions (BBAI), dated 7/28/2023, the BBAI indicated if 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.

Based on observation, interview, and record review, the facility staff failed to ensure the availability of clean bed and bath linens at designated times in three of six sampled linen closets (Closets 4N, 4S, and 6S). This failure had the potential to cause a decline in the residents' psychosocial and physical well-being due to inadequate linens available for use to ensure a homelike, sanitary environment for the residents. Findings: During an interview on 8/14/2023 at 11:58 a.m., Certified Nursing Assistant 3 (CNA 3) stated there was a shortage of linens-towels, wash cloth, underpads (absorbent material used in nursing facilities to tend incontinence issues), blankets, and pillowcases-especially in the morning. CNA 3 stated the facility used to provide wet/dry wipes to be used when providing incontinence care to residents, but CNAs currently use towels and wash cloths to clean the residents. During a concurrent observation and interview on 8/14/2023 at 12:17 p.m. with CNA 3, the sampled linen closets in Stations 4, 5, and 6 were inspected. CNA 3 stated the following: 1. In Closet…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure two of two sampled residents (Residents 5 and 6) who had limited English proficiency (LEP) receive translation support and services provided by the facility according to the facility's policy and procedure (P&P) titled, Translation and/or Interpretation of Facility Services, by failing to: 1. Provide a communication board and/or oral interpretation of Residents 5 and 6's primary languages of Mandarin (dialect of Chinese) and Cantonese (dialect of Chinese), respectively. 2. Not rely on family members and friends to provide interpretation services for Residents' Five and Six and produce written consent for disclosure of protected health information. These failures had the potential for Residents 5 and 6 not being able to communicate their basic needs in their primary languages and had the potential for Residents 5 and 6 to suffer cognitive (ability to think, remember, and reason) decline. Findings: 1. During a review of Resident 5's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow their policy and procedure (P&P) titled, Pressure Injury Risk Assessment to ensure skin assessment was conducted for one of three sampled residents (Resident 10). This failure had the potential for Resident 10 to be at risk for worsening skin condition and/or pressure injury. Findings: During a review of Resident 10's Face Sheet, the Face Sheet indicated Resident 10 was admitted to the facility on [DATE]. Resident 10's diagnoses included multiple sclerosis (a disease in which the immune system eats away at the protective covering of nerves), enterocolitis (inflammation in the small intestine and large intestine) due to clostridium difficile (a germ that causes diarrhea and inflammation in the intestines), and urinary tract infection (an infection in any part of the urinary system, the kidneys, bladder, or urethra). During a review of Resident 10's Minimum Data Set (MDS, a standardized resident screening and care-planning tool), dated 6/16/2023,…

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

Based on interviews and record review, the facility failed to ensure Certified Nursing Assistant (CNA) staffing requirements were met in accordance with the Facility Assessment, for eight of nine sampled dates 8/5/2023 to 8/11/2023 and 8/13/2023. This failure had the potential to result in a decline in the physical and psychosocial well-being due to poor quality of care from staff burnout for residents located in Stations 4, 5, and 6. Findings: During an interview on 8/14/2023 at 11:02 a.m., CNA 1 stated her facility unit was always short-staffed, at least twice or thrice a week with about 11-12 residents assigned per CNA during the 7 a.m. - 3 p.m. shift (Day shift). CNA 1 stated the CNAs (in general) do not get assistance with feeding residents in their unit. CNA 1 stated residents could only be changed twice per shift-once before lunch and another time after lunch. CNA 1 stated residents (in general) must be changed and repositioned at least every 2 hours per shift. CNA 1 stated she felt she could not provide quality care. During an interview on 8/14/2023 at 11:58 a.m., CNA 3…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 their policy and procedure (P&P) titled, Release of Information by not providing a copy of medical records within the policy ' s time frame for one of three sampled residents' (Resident 10) representative. This failure resulted in Resident 10 ' s Representative 1 ' s (R 1) right being violated when the facility did not provide access to Resident 10 ' s medical record from dates [DATE] to [DATE] (total 6 days). Findings: During a review of Resident 10 ' s Face Sheet, indicated Resident 10 was admitted to the facility on [DATE] with diagnoses of multiple sclerosis (MS, decreased nerve function with initial inflammation of the protective myelin nerve covering) and chronic kidney disease (gradual loss of kidney function over several years). The Face Sheet indicated Resident 10 was self-responsible. During a review of Resident 10 ' s Minimum Data Set (MDS, a standardized resident screening and care-planning tool), dated [DATE], indicated Resident 10…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 the integrity of the dialysis access site during bathing for one of three sampled dialysis residents (Resident 1) by failing to keep it clean and dry. This failure had the potential to increase Resident 1 ' s risks for infection. Findings: During a review of Resident 1 ' s Face Sheet, indicated the facility initially admitted Resident 1 on 7/14/2023 with multiple diagnoses including end-stage renal disease (irreversible and permanent kidney impairment) with dependence on renal hemodialysis (renal dialysis, process of purifying the blood of a patient whose kidneys failed to function normally), and type 2 diabetes mellitus (chronic condition wherein the body does not produce enough insulin or resists insulin, causing abnormal blood sugar). During a review of Resident 1 ' s Minimum Data Set (MDS, a standardized resident screening and care-planning tool), dated 7/20/2023, indicated Resident 1 did not have an impairment in cognition (mental action or process of acquiring knowledge and information). 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 one of two sampled residents (Resident 6) who was diagnosed with dementia (progressive impaired ability to think, remember or make decisions that interferes with doing everyday activities) received appropriate recreational activities based off the facility ' s policy and procedure (P&P) titled, Dementia- Clinical Protocol. This failure had the potential for Resident 6 to develop further cognitive decline and isolation. Cross Reference: F676 Findings: During a review of Resident 6 ' s Face Sheet, indicated Resident 6 was admitted to the facility on [DATE]. Resident 6 ' s diagnoses included dementia and retinal edema (buildup of fluid in the macula, an area at the back of the eye causing blurry vision). During a review of Resident 6 ' s MDS (MDS- a standardized resident assessment and care screening tool) dated 7/6/2023, indicated Resident 6 ' s primary language was Chinese. The MDS indicated Resident 6 had severely impaired…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure the Resident's responsible party (RP) receive information on resident's clinical condition, healthcare information and plan of care for one of 35 sampled Residents (Resident 187). This failure had the potential to violate the resident's or RP's rights to be informed and to choose the type of care or treatment to be received, or alternatives the resident or responsible party preferred. Findings: A review of the Face Sheet (admission Record) indicated Resident 187 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis of Alzheimer's disease (a progressive disease that destroys memory and other important mental functions). A review of the Minimum Data Set (MDS, standardized assessment and care screening tool), dated 1/11/21, indicated Resident 187 was unable to speak and was severely impaired with cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision making. During a telephone…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 c.1 A review of the Face Sheet indicated Resident 75 was admitted to the facility on [DATE]. Resident 75 diagnoses included were fracture (broken bone) of the right femur (thighbone), chronic obstructive pulmonary disease (COPD, progressive disease that gets worse over time and makes it hard to breath), dementia (gradual loss of brain function and a decline in mental functioning) and psychosis (severe mental disorder in which you lose touch with reality). A review of the MDS, dated [DATE], indicated Resident 75 had short and long-term memory problems, was able to make herself understood and had the ability to understand others. Resident 75 required total assistance with activities of daily living. During observation on 5/3/21, at 10:39 am, two staff were observed assisting Resident 75 with bed bath. During this observation, Resident 75 told the staff twice that she was feeling cold. On both times, the staff ignored Resident 75 and told the resident the water was warm. One of the staff covered Resident 75's upper…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 normal water temperatures. This deficient practice had the potential for the residents to experience uncomfortable water temperatures. Findings: 1. During an interview on 5/5/21, at 9:15 AM, Resident 40 stated the hot water temperature for bed baths (a cleansing of a person in bed) has been too cold for months. During an observation, on 5/5/21, at 9:15 AM, in the bathroom of room A, the hot water temperature from the faucet was 96.3 degrees Fahrenheit (F - a scale of temperature measurement) using a digital thermometer. During a concurrent observation and interview, on 5/5/21, at 9:20 AM, in the bathroom of Room A, the Maintenance Supervisor recorded a water temperature of 101 degrees F using a dial thermometer. Maintenance supervisor stated the hot water temperature should register between 105 and 120 degrees F. During a concurrent observation and interview, on 5/5/21, at 9:23 AM, in the bathroom of Room B, the hot water temperature was 78.5 degrees F using the digital thermometer. 2. During an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to indicate in writing the address where three of three sampled residents (Residents 249, 250, and 253) were discharged to. This deficient practice had the potential for the residents who left the facility not knowing whether their destination was safe and not be able to receive the continuity of care they needed. Findings: a. A review of Resident 249's admission Record indicated the facility readmitted the resident on 4/5/2021, with diagnoses of tracheostomy (surgical procedures on the neck to open a direct airway through an incision in the trachea or windpipe) and dependence on respirator (use of a machine to help in breathing). A review of Resident 249's Physicians Discharge summary dated [DATE] indicated the resident was discharged to the hospital on 4/8/2021. A review of Resident 249's Notice of Proposed Transfer and discharge date d 3/26/2021, indicated there was no address where the resident was discharged to. During an interview on 5/7/2021 at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to develop and implement a comprehensive, resident specific plan of care for nine of 35 sampled Residents (Residents 27, 48, 167, 75, 133, 91, 146 and 163) a. Resident 27 did not have a care plan to address hearing difficulties. This deficient practice had resulted in the resident's difficulty in miscommunication and a potential not to receive neccessary care and services. b. Resident 48's care plan was not implemented to monitor the resident for bleeding and bruising while receiving Xarelto ( a medication to prevent development of blood clot or blood thinner). c. Resident 167's care plan was not implemented to monitor the resident for bleeding and bruising while receiving Coumadin (a medication to prevent development of blood clot or blood thinner). These deficient practices had the potential for the residents to experience bleeding or bruising and result in lack of immediate care or complications related to bleeding. d. Resident 75 did not…

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

Based on observation, interview, and record interview, the facility failed to provide assistance with communication for one of one sampled resident (Resident 187). This deficient practice had the potential for Resident 187 not to communicate effectively. Findings: A review of Resident 187's Face Sheet (admission record) indicated the facility admitted Resident 187 on 1/31/2012 and readmitted the resident on 11/17/2019 with diagnoses of Alzheimer's disease (a progressive disease that destroys memory and other important mental functions). A review of Resident 187's Minimum Data Set (MDS, a resident assessment and care screening tool), dated 1/11/2021, indicated Resident 187 was unable to speak, and was severely impaired in cognitive skills for daily decision making. During an observation on 5/4/2021 at 10:41 am, Resident 187 was awake nonverbal and made an incomprehensible sound. During an interview and concurrent observation on 5/4/2021 at 11:10 am Licensed Vocational Nurse 17 (LVN 17) stated there was no communication board or device. LVN 17 stated Resident 187 could benefit from 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 assist three of three sampled residents (Residents 27, 91 and 187) with proper treatment and assistive device to improve hearing abilities. The residents were not referred to the physician to assess the cause of and treatment for hearing impairment. This deficient practice had resulted in Residents 27, 91 and 187 not able to hear staff effectively during care and had the potential to result in miscommunication about their healthcare plans that could result in decline in the quality of care and life. Findings: a. A review of Resident 27's Face Sheet (admission record), indicated the resident was admitted to the facility on [DATE] with diagnoses that included atrial fibrillation (irregular heart beat) and neuralgia (an intense, typically intermittent pain along the course of a nerve, especially in the head or face). A review of the Minimum Data Set (MDS, a resident assessment and care screening tool), dated 2/2/21, indicated Resident 27 had…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 care and services for 7 of 11 sampled residents (Residents 75, 136, 146, 163, 650, 653, and 103) with or at high risk for developing pressure injuries (area of damaged skin caused by staying in one position for too long) as indicated in the physician's order, plan of care and policy and procedures by failing to:. 1. For Resident 75, the staff did not apply a heal protector (devices that reduces pressure on bony areas) and did not reposition the resident at least every two hours. 2. For Resident 146 who had a stage 4 pressure ulcer (injury to the skin and underlying tissue, primarily caused by prolonged pressure on the skin), was not repositioned every two hours. 3. For Resident 163, who had a pressure injury Stage 3 (full thickness tissue loss, subcutaneous [under the skin] fat may be visible but bone, tendon or muscle are not exposed), was not repositioned every two hours. 4. For Resident 650 who was at risk for developing pressure…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to monitor, supervise and provide assistive device to prevent accidents and injuries for two of two sampled residents (Residents 649 and 174) by failing to: a. For Resident 649, the resident had recent history of fall and the pad alarm (a pad place on the bed that alarms when the person move off the bed) was found on the floor. b. For Resident 174, the resident had a physician's order to not give resident a straw due to the risk of aspiration (inhalation of food or fluids into the lungs) and the resident was observed to have a straw in her drink. These deficient practices had the potential to result in the aspiration for Resident 649 and fall with injury for Resident 174 that could lead to decline in the resident's well being of both residents. Findings: a. A review of Resident 649's Face Sheet (admission record), indicated the resident admitted to the facility on [DATE] with diagnoses that included left side hemiphlegia (paralysis to one…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 provide sufficient nursing staff to provide range of motion, application of splints (material used to restrict, protect, or immobilize a part of the body to support function, assist and/or increase range of motion), and ambulation to 129 residents requiring a Restorative Nursing Assistant (RNA, nursing aide program that helps residents to maintain their function and joint mobility) program. This deficient practice had the potential to decrease the residents' range of motion and mobility, which could affect the residents' overall function. Cross reference F688 Findings: A review of the facility's policy entitled, Rehabilitative Nursing Care, revised in July 2013, indicated the facility's rehabilitation nursing care program is designed to assist each resident to achieve and maintain an optimal level of self-care and independence. The policy indicated the program included assisting residents to carry out prescribed therapy exercises. During an interview on 5/4/21, at 8:32 AM, the Director of Staff Development (DSD) 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 observation, interview and record review, the facility failed to ensure 4 of 5 sampled residents (Residents 96, 95, 117 and 146) were free of unnecessary medications. a. For Resident 96, the resident was not provided non pharmacological (non-medication options) interventions for inability to sleep, and all hours of sleep were not measured during the day, evening and nights while receiving Trazodone (a medication used to relieve falling or remaining asleep) for inability to sleep. This deficient practice had resulted in Resident 96's hours of sleep were not counted properly which had the potential to result in adverse side effect (untoward effect or reaction) to the medication. b. For Resident 95, the resident's gradual dose reduction (GDR, slowly reducing the frequency and dose of drug) was not performed while receiving Seroquel (medication that affects mental, mood and behavior). This deficient practice placed Resident 95 at risk of receiving unnecessary medications that could result in adverse (harmful)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 medication error rate was not 5 percent or greater. There were 2 errors observed during medication pass observation with 25 opportunities which yield 7.69% error rate. a. For Resident 103, the Vitamin C ( a vitamin supplement) morning dose was omitted from the medication administered. This failure had the potential to cause a Vitamin C deficiency in resident 103 which could result in delayed wound healing, bruising, and painful and swollen joints. b. For Resident 101, the gastric tube (a tube surgically inserted into the stomach to deliver fluids and medications) was not flushed prior to medication administration. This deficient practice had the potential for the GT to clogged and adverse (undesired effect) drug reaction to the medications administered. Findings: a. A review of Resident 103's admission Record indicated the resident was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure all drugs and biological used in the facility are labeled in accordance with professional standards and failed to remove expired medications from medication carts and storage rooms. a. Resident 192's medication was found outside of its protective packet and with out an open and expiration dates. b. Resident 71's medication was found stored past the use by date. These failure had the potential for Resident 192 and Resident 71 receiving medications that past the use by date and were not stored properly and placed the residents at risk for receiving ineffective medications. c. Station 6's medication cart and Medication Storage room [ROOM NUMBER] had expired medications. These deficient practices had the potential for residents to receive expired medication which can affect the residents' well-being. Findings: a During a concurrent inspection of the medication cart (Med cart 1-1) and interview with Licensed Vocational Nurse 1 (LVN 1) 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.

Based on observation, interview, and record review, the facility failed to ensure that food items were stored under sanitary conditions as indicated in the policy and procedure by failing to: 1. Ensure not to store a dented food can in the pantry. 2. Ensure to maintain the floors behind standing refrigerators clean. These deficient practices had the potential for residents to be at risk for contracting food-borne illnesses. Findings: During an initial tour of the kitchen and an interview on 5/3/2021 at 8:35 am, the Director of Nutrition/Environment stated there was one 110 ounce (a unit of weight) tomato dented can stored with other non-dented cans on the rack, and there was an accumulation of dust particles on floors behind standing refrigerators. The Director of Nutrition/Environment stated the dented cans should be separated from the non-dented cans. A review of the facility's Food Service Management policy and procedure dated 2018, indicated damaged cans and packages to be returned to Vendor and to have an inspection system of cans and packages that were delivered to ensure…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 develop, implement, and evaluate the appropriate plan of action to correct identified quality deficiencies by failing to: 1. Ensure residents at risk of developing or with contractures (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints that could cause pain) were provided range of motion (ROM) exercises by the RNA (Restorative Nursing Assistant). The 11 of 11 sampled residents with contractures or at risk for developing contractures were not provided ROM exercises and/or placed assistive device to prevent contractures. There were 36 residents out of 107 residents developed contractures at the facility. This deficient practice had resulted in severe contractures and potential to result in additional contractures or worsened contractures of the residents with and at risk in developing contractures. 2. Ensure residents with pressure injuries (a skin tissue injury that result due to prolonged unrelieved pressure) were repositioned at…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, sanitary environment to help prevent the spread of infections during the Coronavirus-19 (COVID-19, a respiratory illness that can spread from person to person) as indicated in the facility's policy and procedure by failing to: 1. Ensure Resident 75's call light (device used by a patient to signal his or her need for assistance from professional staff), was disinfected after the call light was found on the floor. 2. Ensure contaminated dust mops were covered. 3.Ensure to have personal protective equipment (PPE refers 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) readily available for staff and visitors to use for Resident 19 in the yellow zone (unit for residents who have been in close contact with known cases of COVID-19) . 4. Ensure licensed nurses label the enteral feeding…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 an environment that promoted the dignity and respect during meals for one of 35 sampled residents (Resident 75) as indicated in the facility's policy and procedure. This deficient practice had the potential to negatively impact the resident's psychosocial well-being. Findings: A review of Resident 75's Face Sheet (admission Record) indicated the facility admitted Resident 75 on 4/19/2019 and readmitted the resident on 11/15/2019 from a general acute care hospital (GACH) with diagnoses of right intertrochanteric femur fracture (broken hip), dementia (loss of memory and other mental abilities severe enough to interfere with daily life), and history of falling A review of Resident 75's Minimum Data Set (MDS, a comprehensive care planning tool), dated 2/18/2021, indicated Resident 75 was totally dependent for eating and required one person to assist. During an observation on 5/3/2021, at 12:33 p.m., Resident 75 was eating lunch while lying in bed with the head of bed elevated. Certified Nursing Assistant…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure the resident assessment accurately reflected the resident's status for one of 35 sampled Residents ( Resident 27). Resident 27 with hearing impairment was assessed and recorded as no hearing difficulties This had the potential for the resident not to receive the appropriate and necessary care, treatment and services, which can adversely affect quality of life Findings: A review of the Face Sheet (admission Record) indicated Resident 27 was admitted to the facility on [DATE] with diagnoses that included atrial fibrillation ( irregular heart beat) and neuralgia (an intense, typically intermittent pain along the course of a nerve, especially in the head or face). A review Minimum Data Set (MDS, resident assessment and care screening tool), dated 2/2/21, indicated Resident 27 had no impairment in cognitive skills for daily decision making. The MDS also indicated Resident 27 had adequate ability to hear, no hearing aide and no difficulty…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 evaluate Resident 75's treatment for skin rash. This deficient practice had the potential for Resident 75 not to receive the appropriate care and treatment and inadequate monitoring of the resident's progress and changes in condition. Findings: A review of Resident 75's Face Sheet (admission Record) indicated the facility admitted Resident 75 on 4/19/2019 and readmitted the resident on 11/15/2019 from a general acute care hospital (GACH) with diagnoses of right intertrochanteric femur fracture (broken hip), dementia (loss of memory and other mental abilities severe enough to interfere with daily life), and history of falling A review of Resident 75's Minimum Data Set (MDS, a comprehensive care planning tool), dated 2/18/2021, indicated Resident 75 was totally dependent for eating and required one person to assist. During an observation on 5/3/2021 at 9 am, Resident 75 was lying in bed and was scratching her upper body, both arms and neck. On closer observation, resident was observed with multiple raised bumps…

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

Based on observation, interview and record review, the facility failed to ensure that a resident with an indwelling catheter (known as Foley catheter, a tube that allows urine to drain from the bladder into a bag that is usually attached to the thigh) tubing was not kinked for one of one sampled resident (Resident 183). This deficient practice had the potential to result in recurrence of urinary tract infection (UTI-an infection involving any part of the urinary system, including urethra, bladder, ureters, and kidney) that could to lead to urosepsis (a potentially life-threatening complication of urinary tract infection). Findings: A review of Resident 183's Facesheet (admission Record) indicated the facility readmitted Resident 183 on 6/29/20. Resident 183's diagnoses included neuromuscular dysfunction of bladder (also known as neurogenic bladder, condition in which problems with the nervous system affect the bladder and urination, dysphagia (difficulty swallowing), and hyperlipidemia (an abnormally high concentration of fats or lipids in the blood). A review of Resident 183'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 ensure staff assessed and placed dressing on hemodialysis catheter (hallow tube inserted into a large vein for exchanging blood to and from a blood filtering machine and a patient) access site for one of three residents (Resident 103). This failure place Resident 103 at risk for developing an infection of the skin where the hemodialysis catheter is inserted or infection of the blood stream. Findings: During an observation on 5/4/21, at 8:00 AM in Resident 103's room, Residents 103's right chest hemodialysis catheter had no dressing over the insertion site. Insertion site is dry and crusted, no redness, swelling or drainage noted. During an interview on 5/4/21, at 12:20 PM LVN 1 stated, there should be Dressing on Resident 103's hemodialysis catheter. LVN 1 stated the resident had dialysis yesterday and dialysis nurses were supposed to put the dressing on the catheter insertion site. LVN 1 stated she will put one on now, so the resident would not get infection at the site. During a concurrent observation and…

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

Based on observation, interview and record review, the facility failed to ensure the nurse staffing information on the posting was accurate for 3 of 5 days (5/3/21, 5/4/21, 5/5/21). This deficient practice had the potential to result in misinformation to the residents and the public regarding the facility's nursing staffing data. Findings: During an observation with Registered Nurse 6 (RN 6), on 5/3/21 at 2:12 PM, a daily nurse staffing information was posted by the sub-acute nursing station, and next to the entrance of the front lobby. During a review of the actual staffing sign in sheet on 5/3/21, at 3:01 PM with Director of Staff Development (DSD 1), the nurse staffing information and the actual staffing sign in sheet for the staff who worked reflected the following: 1. On 5/3/21 for the 11 PM to 7 AM shift, there were 16 certified nurse assistants (CNAs) on the nursing staffing posting while the sign in sheet reflected 14 CNAs. 2. On 5/4/21 for the 7 AM to 3 PM shift, there were 19.2 CNAs on the nursing staffing posting while the sign in sheet reflected 15 CNAs. 3. On 5/5/21 for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure an inventory list of personal belongings was completed for one of 35 sampled Residents (Resident 75). The facility also failed to follow the facility's policy on narcotic (controlled substance) medication administration for one of one sampled resident (Resident 710). These deficient practices placed Resident 75's personal property at risk for theft and loss and had the potential to result in Resident 710's controlled medication diversion (a medical and legal concept involving the transfer of any legally prescribed controlled substance from the individual for whom it was prescribed to another person for any illicit use). Findings: a. A review of the admission Record indicated Resident 75 was initially admitted to the facility on [DATE] and re-admitted on [DATE]. Resident 75's diagnoses included fracture (broken bone) of the right femur (thighbone), chronic obstructive pulmonary disease (COPD, progressive disease that gets worse over time 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 the current physician certification for hospice (providing care for the sick or terminally ill) benefit was renewed for one of 4 sampled residents (Resident 75). This deficient practice had the potential for miscommunication regarding Resident 75's hospice care. Findings: A review of Resident 75's admission Record indicated the facility admitted the resident on [DATE], with diagnoses of fracture (broken bone) of the right femur (thighbone), chronic obstructive pulmonary disease (COPD- progressive disease that gets worse over time and makes it hard to breath), dementia (gradual loss of brain function and a decline in mental functioning) and psychosis (severe mental disorder in which you lose touch with reality). A review of Resident 75's physician's order dated [DATE], indicated to admit Resident 75 under hospice care (providing supportive care to people in the final phase of a terminal illness and focus on comfort and quality of care, rather…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 provide a functional phone connection for the residents and visitors. This deficient practice resulted for the residents' family members not to be able to communicate with the residents and with facility staff. a. During an interview on 5/7/21, at 8:53 a.m., RP 1 stated the biggest complaint about the facility was the terrible phone service. RP 1 attempted to call multiple times this past week, but the receptionist did not pick up. A review of the map indicated the facility had six nursing stations. A review of the facility's census, dated 5/3/21, indicated the facility had 212 residents. During an interview on 5/7/21, at 1:03 p.m., Administrator (ADM) stated the facility had only three telephone lines. Director of Nursing (DON) was aware the phone lines were problem since physicians had difficulty calling the facility. The facility contacted the phone company and installed another router. ADM and DON were aware the additional router did not resolve the telephone service problem. b. During an interview on 5/3/21 01:47 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.