Park Avenue Healthcare & Wellness Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to maintain and implement its infection control program by failing to ensure:a. personal toiletries were labeled and not stored inside the shared restroom for three of three sampled residents (Resident 38, Resident 107 and Resident 195), b. the lint trap for one of four sampled dryers (Dryer 4) was clean and did not have an excessive lint buildup.These deficient practices had the potential to spread the transmission of disease, infection, and the potential for a fire hazard, which placed residents including Resident 38, Resident 107 and Resident 195 and the healthcare staff at risk.Findings:a.During a review of Resident 38's admission Record (AR), the AR indicated Resident 38 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including cellulitis (a bacterial infection of the skin's deeper layers) of the right and left lower limbs, local infection of the skin and subcutaneous tissue, unspecified, and…

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

Based on observation and interview, the facility failed to maintain electrical equipment in a safe operating condition when one of one 3-door reach in refrigerator (Refrigerator 1 - a type of commercial refrigerator used in food service that is designed for easy access and storage of items within arm's reach) had water dripping from the condenser fan (a component of the refrigeration system that helps maintain the cooling system) onto the containers below.This failure had the potential to result in food contamination and foodborne illnesses (illness caused by food contaminated with bacteria) for the residents consuming the food at the facility.Findings:During an observation on 7/21/2025 at 8:45 AM in the kitchen, water was observed dripping from the condenser fans located in the ceiling of Refrigerator 1 onto pitchers of juice and water.During an observation and interview on 7/22/2025 at 11:02 AM in the kitchen, with the Dietary Services Supervisor (DSS), water was observed dripping from the condenser fans of Refrigerator 1 onto salad bowls. The DSS stated the salads were prepared…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 offer milk for one of one resident (Resident 113).in accordance with the resident's preference This deficient practice had the potential to result in Resident 113 to feel ignored and to possibly stop verbalizing necessary needs. During a review of Resident 113's admission Record (AR), the AR indicated the facility admitted Resident 113 on 9/27/2010, with diagnoses that included dementia (long term and often gradual decrease in the ability to think and remember, it is severe enough to affect a person's daily functioning), contracture (shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints to the right and left hand). During a review of Resident 113's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 5/1/2025, the MDS indicated Resident 113 had a severe cognitive deficit. The MDS indicated Resident 113 usually understands verbal content and was usually able to express ideas and wants. The MDS indicated Resident 113 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.

Based on interview and record review, the facility failed to complete a Preadmission Screening and Resident Review Level II [2] (PASARR-a federal assessment requirement to help ensure individuals, who have a mental disorders or intellectual disabilities, are placed in facilities that provide appropriate care) screening for one of two sampled residents (Resident 6) when the facility did not reply to recommendations by the California Department of Health Care Services (DHCS-a state agency that oversees the provision of services such as health care and mental health).This failure resulted in Resident 6 not receiving the PASARR level 2 screening for serious mental illness (SMI-a diagnosable mental, behavioral, or emotional disorder that significantly impairs a person's ability to function in major life activities) in a timely manner and had the potential for Resident 6 to not receive specialized services (the services specified by the State that exceed the services ordinarily provided by the nursing facility) for SMI. Findings:During a review of Resident 6's admission Record (AR), the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement care plan interventions and monitor and record pain characteristics every shift for one of one sampled resident (Resident 51) and failed to ensure a comprehensive person - centered care plan was developed and implemented for one of three sampled residents (Resident 2), who received an anticoagulant (blood thinner - e.g., warfarin, heparin, or low-molecular weight heparin) and was at risk for bleeding. This deficient practice had the potential to result in unmet individualized needs for Resident 2 and Resident 51 and had the potential to affect the resident's physical well-being. Findings: A. During a review of Resident 51's admission Record (AR), the AR indicated Resident 15 was admitted to the facility on [DATE], with diagnoses that included COPD (a common lung disease causing restricted airflow and breathing problems), acute respiratory failure with hypoxia (results from acute or chronic impairment of gas exchange between the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure appropriate care and services were provided for two of two sampled residents (Resident 2 and 83) by failing to:A. Ensure Resident 2, who was on anticoagulant (medication that thins the blood) therapy, was monitored for bleeding in the month of June 2025.B. Follow up on an infectious disease consult (a consultation with a specialist [a doctor who has special knowledge and skill relating to a particular area of study] in infectious diseases to help diagnose, manage, or prevent infections) for Resident 83's recurrent urinary tract infections (an infection in any part of the urinary system: kidneys, bladder, or urethra [tube through which the urine leaves the body]) as per the physician's order, dated 7/10/2025.These deficient practices had the potential to result in serious health complications and rehospitalization for Resident 2 and Resident 83. Additionally, the failure resulted in Resident 83 experiencing bladder spasms (a sudden, involuntary…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 up with optometry (a healthcare profession that focuses on the examination, diagnosis, and treatment of eye and vision disorders) to replace a missing pair of glasses for one of one resident (Resident 13) in a timely manner.This deficient practice had the potential to result in worsened eyesight to Resident 13 and resulted in Resident 13 feeling frustrated and ignored.Findings:During a review of Resident 13's admission Record (AR), the AR indicated Resident 13 was admitted to the facility on [DATE] with multiple diagnoses including hemiplegia (muscle weakness or paralysis on one side of the body) affecting the right dominant side and polyneuropathy (condition where multiple peripheral [situated on the edge] nerves are damaged, causing widespread symptoms throughout the body such as numbness and pain.)During a review of Resident 13's Minimum Data Set (MDS - a resident assessment tool) dated 4/18/2025, the MDS indicated Resident 13…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 three sampled residents (Resident 38 and Resident 24), were provided an environment free of accident hazards by failing to ensure:A. Resident 38's bed was in a low position when Resident 38 was at high risk for falls (refers to unintentionally coming to rest on the ground, floor, or other lower level, but not as a result of and overwhelming external force) and had a history of falls.B. Resident 24 did not keep cigarettes and a lighter in Resident 24's possession.This deficient practice had the potential to result in recurrent falls for Resident 38. Additionally, the deficient practice had the potential for Resident 24 to cause a fire and placed the residents and healthcare staff in danger.Findings: A. During a review of Resident 38's admission Record (AR), the AR indicated, Resident 38 was originally admitted to the facility on [DATE] and readmitted on [DATE] with multiple diagnoses including unspecified psychosis (a severe…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 115), who was receiving enteral feeding (nutrition taken through the mouth or through a tube that goes directly to the stomach or small intestine), received appropriate care and services by failing to respond timely to the continuous alarm (beeping) from Resident 115's gastrostomy tube (GT - a type of feeding tube) pump. This deficient practice could lead to GT complications and potentially harm Resident 115.Findings:During a review of Resident 115's admission Record (AR), the AR indicated Resident 115 was admitted to the facility on [DATE] with diagnoses including chronic respiratory failure (a condition that occurs when the lungs cannot get enough oxygen [02] into the blood or eliminate enough carbon dioxide [C02, a colorless, odorless gas that is a waste product made by the body], unspecified whether with hypoxia (low levels of 02 in the body), or hypercapnia (abnormally high level of CO2 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 one of one sampled resident (Resident 115), received proper respiratory (relating to breathing) care by failing to ensure Resident 115's tracheostomy (trach - a surgically created hole [stoma] in your windpipe [trachea] that provides an alternative airway for breathing) mask (T-mask) was properly in place. This deficient practice resulted in Resident 115 not receiving the physician ordered oxygen (02 - a colorless, odorless, tasteless gas essential for living) therapy, could potentially cause Resident 115's respiratory status (the movement of air in and out of the lungs) to be compromised, and could lead to respiratory distress / failure.Findings:During a review of Resident 115's admission Record (AR), the AR indicated Resident 115 was admitted to the facility on [DATE] with diagnoses including chronic respiratory failure (a condition that occurs when the lungs cannot get enough oxygen [02] into the blood or eliminate enough carbon…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 performance evaluations (PEs) were conducted every 12 months for one out of four certified nursing assistants.This deficient practice had the potential to compromise resident safety and well-being. During a record review of CNA 7's personnel file, no PE was due as of 7/25/25 due to a recent date of hire for CNA 7.During a concurrent interview and record review on 7/25/25 at 7:45 a.m. with the Director of Development (DSD), the DSD provided the two most recent PEs for CNA 4, CNA 5 and CNA 6.CNA 4 and CNA 6 received timely PEs or were not yet due for their annual PE as of 7/25/25.CNA 5 was due for a PE on or before 5/26/24 and 5/26/25. The DSD provided 2 PEs for CNA 5, one dated 6/2/25 and the second PE dated 4/10/23. CNA 5's PE dated 6/2/25 indicated the evaluation was signed only by the evaluator and not by CNA 5. The PE date of 6/2/25 indicated it was late by 7 days. There was no record of a PE given to CNA 5 in 2024. During an interview with CNA 5 on 7/25/25 at 11:22 a.m., CNA 5 stated he had not seen or signed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 pharmacist's recommendations, dated 5/31/2025 and 6/30/2025 on the Medication Regimen Review (MRR), related to Tylenol (a pain reliever and fever reducer) was acted upon for one of two sampled residents (Resident 5).This deficient practice placed the resident at risk of not receiving the correct dosage of Tylenol from May 31, 2025 to July 25, 2025. During a review of Resident 5's admission Record, the admission Record indicated Resident 5 was originally admitted to the facility on [DATE] with diagnoses that included non-pressure chronic ulcer of right ankle with unspecified severity, unspecified edema (swelling caused by an accumulation of fluid in the body's tissues) and cellulitis (a skin infection that causes swelling and redness) of right lower limb.During a review of Resident 5's History and Physical (H&P) dated 1/25/2025, the H&P indicated Resident 5 had the capacity to understand and make decisions.During a review of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to document Restorative Nursing Aide (RNA, nursing aide program that helps residents to maintain their function and joint mobility) services provided for one of one resident (Resident 193) as per the facility's policy and procedure (P&P) titled, Documentation, dated 1/1/2012.This deficient practice led to inaccuracies in Resident 193's medical record and had the potential to lead to inconsistent RNA treatments provided to Resident 193.Findings:During a review of Resident 193's admission Record (AR), the AR indicated Resident 193 was admitted to the facility on [DATE] with multiple diagnoses including quadriplegia (paralysis of all four limbs) and cerebral palsy (a group of conditions that affect movement and muscle tone or posture).During a review of Resident 193's Minimum Data Set (MDS - a resident assessment tool) dated 5/6/2025, the MDS indicated Resident 193 had severely impaired cognition (ability to understand and process information) 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 observation, interview, and record review, the facility failed to ensure one of 43 sampled residents (Resident 6) had a call light (a device used to call for assistance) within reach.This failure had the potential to result in Resident 6 being unable to call for assistance and delayed care to Resident 6.Findings:During a review of Resident 6's admission Record (AR), the AR indicated the facility admitted Resident 6 on 12/20/2024 with diagnoses including difficulty in walking and lack of coordination (the ability of the body to work together to perform movements or actions).During a review of Resident 6's Minimum Data Set (MDS- a resident assessment tool), dated 6/19/2025, the MDS indicated Resident 6's cognitive (the ability to think and process information) skills for daily decision making were intact. The MDS indicated Resident 6 was dependent (helper does all the effort) with toileting, shower/bathing, lower body dressing, putting on/taking off footwear, and personal hygiene. The MDS indicated Resident 6 required substantial/maximal assistance (helper does more than half…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 notify Resident 3's doctor of Resident 3's refusals to allow the nurse to perform accu checks (sampling a drop of blood from the finger to determine the blood glucose [sugar] level) on 5/5, 5/8, 5/11, and 5/12/2025. These failures had the potential to result in Resident 3 to not receive treatment to address Resident 3's risks for hypoglycemia (a condition where the level of glucose in the blood drops below a healthy range) or hyperglycemia (having too much glucose in the blood) which could negatively affect Resident 3's health and wellbeing. (Cross Reference F656) Findings: During a review of Resident 3's admission Record (AR), the AR indicated the facility admitted Resident 3 on 11/28/2023 and readmitted Resident 3 on 3/28/2025 with diagnoses including type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar), Alzheimer's disease (a progressive disease that destroys memory and other important mental functions), and dementia (a group of thinking and social symptoms that interferes…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 implement the comprehensive person-centered care plan for one of three sampled residents (Residents 3) when the facility staff failed to notify Resident 3's doctor of Resident 3's refusals of accu checks (sampling a drop of blood from the finger to determine the blood glucose [sugar] level) as indicated in Resident 3's untitled care plan, initiated on 1/3/2024. This failure had the potential to result in Resident 3 to not receive treatment to address Resident 3's risks for hypoglycemia (a condition where the level of glucose in the blood drops below a healthy range) or hyperglycemia (having too much glucose in the blood) which could negatively affect Resident 3's health and wellbeing. (Cross Reference F580) Findings: During a review of Resident 3's admission Record (AR), the AR indicated the facility admitted Resident 3 on 11/28/2023 , and readmitted Resident 3 on 3/28/2025 with diagnoses including metabolic encephalopathy (brain disease that alters brain function or structure), Alzheimer's disease (a progressive 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 ensure one of 10 sampled residents (Resident 5) had a written physician's order to go out on pass (temporary permission of a resident to leave the facility within a specified time) before Resident 5 left the facility to go on an overnight pass on 5/23/2025. This failure had the potential for Resident 5 and other residents to be allowed out of the facility without being properly assessed for safety awareness, decision-making capacity, physical disabilities, and the ability to call for medical assistance if required and when indicated. Resident 5 left the faciity on 5/23/2025 and came back on 5/24/2025 with abrasions and bruises on both arms and legs, and bleeding in the back of the head. (Cross reference F842) Findings: During a review of Resident 5's Face Sheet, the FS indicated Resident 5 was admitted to the facility on [DATE] with diagnoses which included spinal stenosis (when the space inside the spine [backbone] gets too small. This…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 1) was provided wound care treatment as ordered by Resident 1's physician. This failure had the potential for Resident 1's wound to become infected and/or for Resident 1's wound to not heal. Findings: During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident 1 on 2/7/2025 with diagnoses that included chronic kidney disease (a condition in which the kidneys are damaged and cannot filter blood as well as they should), urinary tract infection (UTI, an infection in any part of the urinary system, including the kidneys, bladder, or urethra), and pressure ulcer (also known as bed sore or pressure injury, localized injuries to the skin and underlying tissue caused by prolonged pressure) of the left buttock. During a review of Resident 1's Wound Assessment and Plan (WAP), dated 5/13/2025, the WAP indicated Resident 1 had a pressure injury related to a medical device located on Resident 1's penis. During a review of Resident 1's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the clinical record for one of 10 sampled residents (Resident 5) was complete and accurate when there was no written physician's order to go out on pass (temporary permission of a resident to leave the facility within a specified time) before Resident 5 left the facility to go on an overnight pass on 5/23/2025. This failure had the potential for Resident 5's whereabouts to not be known to facility staff and for Resident 5 to be allowed out of the facility without being properly assessed for safety awareness, decision-making capacity, physical disabilities, and the ability to call for medical assistance if required and when indicated. Resident 5 left the faciity on 5/23/2025 and came back on 5/24/2025 with abrasions and bruises on both arms and legs, and bleeding in the back of the head. Cross reference F684 Findings: During a review of Resident 5's Face Sheet, the FS indicated Resident 5 was admitted to the facility on [DATE] with diagnoses…

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

Based on interview and record review, the facility failed to ensure four of four sampled residents (Resident 1, 4, 5, and 6) call lights (call bell- a device used by a resident to signal his or her need for assistance from staff) were answered promptly. This failure had the potential for Resident 1, 4, 5, and 6 needs not being met. Cross Reference: F689 Findings: During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident 1 on 3/3/2025 with diagnoses including acute kidney failure (a condition in which the kidneys suddenly can't filter waste from the blood), type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar), and history of falling. During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 3/5/2025, the MDS indicated Resident 1 had no impairments in cognitive skills (ability to make daily decisions). The MDS indicated Resident 1 was dependent (helper does all the effort) on staff for bathing and toileting hygiene. The MDS indicated Resident 1 required…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure three of four sampled residents (Resident 1, Resident 7, and Resident 8) received adequate supervision by failing to, a. Ensure Resident 1 ' s call light (a device used by a resident to signal his or her need for assistance from staff) was answered promptly by facility staff. b. Ensure Resident 9 did not physically assault (occurs when a person uses physical violence and causes injury to another person's body) Resident 8 right after Resident 9 physically assaulted Resident 7. These failures resulted in Resident 1 falling to the floor on 4/1/2025, and had the potential for Resident 1 to sustain injuries. Additionally, the failures resulted in Resident 9 holding Resident 7 in chokehold [position] around Resident 8's neck and resulted in redness to Resident 8's neck. Findings: a.During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident 1 on 3/3/2025 with diagnoses including acute kidney failure (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 develop and implement an individualized person-centered care plan (CP), for one of six sampled residents (Resident 7), that addressed a possible head injury to Resident 7 due to being struck in the head multiple times by Resident 9 during a resident-to-resident altercation (fight between two residents). This failure had the potential to result in unmet individualized needs for Resident 7 and the potential to affect the resident's physical and psychosocial well-being. 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 dementia (a group of symptoms affecting memory, thinking, and social abilities), Schizophrenia (a serious mental health condition that affects how people think, feel, and behave) and psychosis (abnormal condition of the mind that involves a loss of contact with reality). During a review of Resident 7's History and Physical (H&P),…

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

Based on interview and record review, the facility failed to ensure licensed nurses (LN) developed and implemented a care plan (CP) for one of three sampled residents (Resident 2) with interventions to help prevent a fall after Resident 2 was determined to be a high-fall risk based off Resident 2 ' s Fall Risk Assessment (FRA) dated 1/11/2025, based on the facility ' s policy and procedure (P&P) titled, Fall Management Program, and Comprehensive, Person-Centered Care Planning. As a result of this failure, on 3/8/2025 at 4:15 pm, Resident 2 fell out of bed and was found on the floor by Certified Nurse Assistant (CNA) 2. Resident 2 sustained a left elbow skin tear (a wound that happens when the layers of skin separate or peel back). Cross Reference: F689 Findings: During a review of Resident 2 ' s admission Record (AR), the AR indicated the facility admitted Resident 2 on 1/11/2025 with diagnoses that included lack of coordination (uncoordinated movement due to muscle control that causes an inability to coordinate movements) and osteoarthritis (a degenerative joint disease where the…

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

Based on interview and record review, the facility failed to provide care and services to prevent a fall (move downward, typically rapidly and freely without control, from a higher to a lower level) for one of three sampled residents (Resident 2) as indicated in the facility ' s policy and procedure (P&P) titled, Fall Management Program, by failing to: 1. Ensure licensed nurses (LN) developed and implemented a care plan (CP) for Resident 2 with interventions to help prevent a fall after Resident 2 was determined to be a high-fall risk based off Resident 2 ' s Fall Risk Assessment (FRA) dated 1/11/2025. 2. Ensure LNs made Resident 2 part of the fall management program on 1/11/2025 when Resident 2 was assessed to be at high-risk for falls. As a result of this failure, on 3/8/2025 at 4:15 pm, Resident 2 fell out of bed and was found on the floor by Certified Nurse Assistant (CNA) 2. Resident 2 sustained a left elbow skin tear (a wound that happens when the layers of skin separate or peel back). Cross Reference: F656 Findings: During a review of Resident 2 ' s admission Record (AR), the…

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

Based on interview and record review, the facility failed to ensure accurate documentation on the Fall Risk Assessment (FRA) for one of three sampled residents (Resident 2), according to the facility ' s policy and procedure (P&P) titled, Completion and Correction, by failing to: Ensure Registered Nurse (RN) 2 accurately assessed and documented Resident 2 ' s FRA on 3/8/2025, after Resident 2 sustained a fall. As a result of this failure, after Resident 2 fell on 3/8/2025, Resident 2 ' s revised FRA was completed, and indicated Resident 2 was not at high-risk for falls. This failure had the potential for Resident 2 to not receive the care and services needed to prevent another fall from happening and could lead to Resident 2 not being monitored appropriately. Findings: During a review of Resident 2 ' s admission Record (AR), the AR indicated the facility admitted Resident 2 on 1/11/2025 with diagnoses that included lack of coordination (uncoordinated movement due to muscle control that causes an inability to coordinate movements) and osteoarthritis (a degenerative joint 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 interview and record review, the facility failed to promptly respond to call lights (a device used by a resident to signal his or her need for assistance from staff) for three of five sampled residents (Residents 7, 11, and 12) according to the facility ' s Policy and Procedure (P&P) titled, Communication - Call System, revised January 1, 2012. This failure had the potential to result in residents care needs not being met. Findings: a. During a review of Resident 7's admission Record (AR), the AR indicated the facility admitted Resident 7 on 8/27/2024 and readmitted Resident 7 on 10/28/2024 with diagnoses including urinary tract infection (UTI, an infection in any part of the urinary system, including the kidneys, bladder, or urethra), type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar), and difficulty in walking. During a review of Resident 7's Minimum Data Set (MDS, a resident assessment tool), dated 12/12/2024, the MDS indicated Resident 7 had no impairments 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.

Based on observation, interview, and record review, the facility failed to ensure two of three sampled residents (Resident 7 and 9) received food that were palatable and attractive according to the facility ' s Policy and Procedure (P&P) titled, Dietary Department – General, revised June 1, 2014. This failure had the potential for Residents 7 and 9 to be at risk of unplanned weight loss, a consequence of poor food intake. Findings: a. During a review of Resident 7's admission Record (AR), the AR indicated the facility admitted Resident 7 on 8/27/2024 and readmitted Resident 7 on 10/28/2024 with diagnoses including urinary tract infection (UTI, an infection in any part of the urinary system, including the kidneys, bladder, or urethra), type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar), and difficulty in walking. During a review of Resident 7's Minimum Data Set (MDS, a resident assessment tool), dated 12/12/2024, the MDS indicated Resident 7 had no impairments in cognitive skills (ability to make daily decisions). The MDS indicated…

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

Based on interview and record review, the facility failed to serve the meal indicated on the facility ' s lunch menu, on 3/9/2025, to one of three sampled residents (Resident 9) according to the facility ' s Policy and Procedure (P&P) titled, Menu, undated. This failure had the potential for Resident 9 to not receive adequate nutrition while in the care of the facility. Findings: During a review of Resident 9's admission Record, AR, the AR indicated the facility admitted Resident 9 on 1/2/2019 and readmitted Resident 9 on 6/27/2023 with diagnoses including atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow), chronic obstructive pulmonary disease (COPD, a group of diseases that cause airflow blockage and breathing-related problems), and type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar). During a review of Resident 9's Minimum Data Set (MDS, a resident assessment tool), dated 9/16/2024, the MDS indicated Resident 9 had no impairments in cognitive skills (ability to make daily decisions). The…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a copy of the Notice of Proposed Transfer and Discharge (NPTD- informs the resident and the resident's representative of the transfer or discharge and the reasons for the move) for a facility-initiated discharge for one of 10 sampled residents (Resident 4) was sent to the Ombudsman (OMB- an advocate for residents of nursing homes, board and care centers, and assisted living facilities) before the resident was discharged from the facility on 12/23/24. This failure had the potential for Resident 4 to not be protected from being inappropriately discharged from the facility. Findings: During a review of Resident 4's admission Record (AR), the AR indicated Resident 4 was admitted to the facility on [DATE] with diagnoses which included aphasia (a disorder that makes it difficult to speak), hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body), and hemiparesis (weakness in the arm, leg, and face on one side of the 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 clinical record for 2 of 10 sampled residents (Resident 1 and Resident 3) was complete and accurate when: 1. Licensed Vocational Nurse (LVN) 1 did not accurately document Resident 1's condition in the Change in Condition Evaluation (CIC), dated [DATE] and timed at 7:30 am. 2. The names of staff who responded to the Rapid Response (facility emergency code that indicates someone is experiencing a medical emergency or critical change in health condition), what time the Rapid Response Team (RRT) got to Resident 1's room, and the names of staff who provided cardiopulmonary resuscitation (CPR, emergency lifesaving procedure, consisting of chest compressions and mouth-to-mouth or mechanical breaths, performed when the heart stops beating or beats ineffectively and/or to restore breathing) to Resident 1 on [DATE] were not documented in Resident 1's clinical record. 3. The names of staff who responded to the Rapid Response, what time the RRT got to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure accurate documentation on the Consent/Declination Influenza Immunization (CDII) forms in seven of 15 sampled residents (Residents 1, 2, 4, 9, 10, 11, and 12), according to the facility's policy and procedure (P&P) titled, Completion and Correction, by failing to: 1. Ensure Infection Preventionist (IP, a healthcare profession who specializes in preventing the spread of infections in healthcare settings) 1 did not willfully falsify Residents 1, 2, 4, 9, 10, 11, and 12's flu vaccine declinations when IP 1 indicated the residents' responsible parties (RPs) did not want Residents 1, 2, 4, 9, 10, 11, and 12 to have the flu vaccine. IP 1 did not speak to Residents 1, 2, 4, 9, 10, 11, and 12's RPs. 2. Ensure the facility had a system in place to track Residents 1, 2, 4, 9, 10, 11, and 12's flu vaccination status for the current flu season from 10/1/2024 to 3/31/2025 by documenting the provision of pertinent information regarding immunizations through…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 policies and procedures (P&P) titled, Hand Hygiene (procedures that included the use of alcohol-based hand rubs (containing 60%-95% alcohol) and hand washing with soap and water), and Enhanced Barrier Precautions (EBP- set of infection control measures that use personal protective equipment [PPE- equipment worn to minimize exposure to hazards] to reduce the spread of multidrug-resistant organisms [MDRO- organism that is resistant to most antibiotics] by wearing a gown and gloves) by failing to: 1. Ensure two of four certified nurse assistants (CNAs 2 and 4) wore appropriate PPE when entering Residents 13 and 14's rooms, who required patient care and were on EBP. 2. Ensure CNA 2 and CNA 4 performed hand hygiene before and after providing care to Residents 13 and 14 and before and after entering Resident 13 and 14's rooms. These failures had the potential to transmit and spread infection from staff to residents that could result…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 standard infection prevention control practices (a set of practices that prevent or stop the spread of infections and/or diseases in the healthcare setting) were followed in accordance with the facility's policies and procedures (P&P) titled, Hand Hygiene (procedures that included the use of alcohol-based hand rubs (containing 60%-95% alcohol) and hand washing with soap and water), and Management of COVID-19 (infections airborne disease caused by SARS-CoV-2 virus) by failing to: 1. Ensure six of 12 sampled staff (Certified Nurse Assistant [CNA] 2, CNA, 3, CNA 4, CNA 5, and CNA 6, and Treatment/Licensed Vocational Nurse [LVN] 6 wore appropriate PPE when entering residents' room and when providing care for residents on TBP (Transmission Based Precautions) for COVID-19. 2. Ensure four of nine sampled residents (Residents 5, 6, 7, and 8) who tested positive for COVID-19 wore a mask when outside Resident 5, 6, 7, and 8's room. 3. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a comprehensive person-centered care plan (CP) was developed and implemented that included appropriate interventions to address individualized needs for one of three sampled residents (Resident 2) in accordance with the facility's policies and procedures (P&P) when the facility determined Resident 2 was at risk for elopement. This failure had the potential to result in unmet individualized needs for Resident 2 and the potential to affect the resident's physical and psychosocial well-being. Findings: During a review of Resident 2's admission Record (AR), the AR indicated, Resident 1 was originally admitted on [DATE] and readmitted on [DATE] with multiple diagnoses including cellulitis (bacterial skin infection) of right lower limb (an arm or leg) and left lower limb, difficulty in walking, not elsewhere classified and essential (primary) hypertension (high blood pressure). During a review of Resident 2's Elopement Evaluation (EE),…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 prevent potential accidents for one of three sampled residents (Resident 6) by failing to ensure: Resident 6, who had a history of seizures (a sudden, uncontrolled burst of electrical activity in the brain), had bilateral padded side rails in bed. This deficient practice had the potential to affect Resident 6's safety and increase the risk for injury in an event of a seizure episode. Findings: During a review of Resident 6's admission Record (AR), the AR indicated, Resident 6 was admitted to the facility on [DATE], with diagnoses that included Alzheimer's Disease (a brain disorder that slowly destroys memory and thinking skills), unspecified, other seizures, and tremors (involuntary shaking or movement), unspecified. During a review of Resident 6's Order Summary Report (OSR), dated 9/19/2023, the OSR indicated, a physician order for Primidone (medication used to treat partial and generalized seizures) Oral…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure two of two sampled residents (Resident 48 and Resident 109) had their call lights within reach. This failure had the potential to result in Residents 48 and 109 not to receive care and services timely. Findings: a.During a review of Resident 48's admission Record (AR), the AR indicated Resident 48 was admitted to the facility on [DATE] with diagnoses including but not limited to transient cerebral ischemic attack (TIA- a temporary blockage of blood flow to the brain), hemiplegia (weakness to one side of the body), anxiety (a feeling of worry, dread, and uneasiness), bipolar disorder (serious mental illness that causes unusual shifts in mood). During a review of Resident 48's Minimum Data Set (MDS- a comprehensive standardized assessment and screening tool), dated 5/9/2024, the MDS indicated Resident 48's cognition (ability to understand and process information) was moderately impaired. During a review of Resident 48's History and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure two of two sampled residents (Resident 57 and Resident 161) had a resident-centered care plan developed and implemented that addressed: a. Resident 57's risk for falls. b. Resident 161's actual fall that occurred on 7/8/2024. These failures had the potential to result in unmet individualized needs for Residents 57 and Resident 161 and the potential to affect the resident's physical well-being. Additionally, there was a potential for Residents 57 and 161to not receive the necessary care and services to achieve their optimal level of functioning. Findings: a. During a review of Resident 57's admission Record (AR), the AR indicated Resident 57 was admitted to the facility on [DATE] with diagnoses including Type 2 Diabetes Mellitus (disease that occurs when a person's blood sugar is too high), with diabetic neuropathy (nerve damage that can occur as a result of diabetes causing pain) and Parkinson's disease (progressive disease of the nervous system…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 comprehensive Care Plans (CP) for two of two sampled residents (Resident 176 and Resident 36). a. Resident 176's CP was not updated following significant weight loss and to include snacks were increased to three times a day (TID) in Resident 176's nutritional regimen. b. Resident 36's CP was not revised following a fall incident that occurred in the restroom on 6/18/2024. These failures had the potential to result in in unmet individualized needs for Residents 176 and 36 and the potential to affect the resident's physical and psychosocial well-being. Findings: a. During review of Resident 176's admission Record (AR), the AR indicated Resident 176 was admitted to the facility 11/1/2023 and readmitted on [DATE] with diagnoses that included unspecified dementia (lose the ability to think, remember, learn, make decisions, and solve problems), heart failure (heart doesn't pump blood as well as it should), and generalized muscle weakness (loss in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow their own policy and procedure (P&P) to ensure safe medication administration for residents with a Gastrostomy tube (G-tube, a tube that placed directly into the stomach through an abdominal wall incision for administration of food, fluids, and medications) for one of two residents (Resident 510). On 7/9/2024, Licensed Vocational Nurse 3 (LVN 3) administered medications through Resident 510's G-tube, LVN 3 failed to stop and reassess Resident 510, notify the supervisor (in general), or contact the physician (MD) when Resident 510's g-tube became clogged for over 30 minutes. This failure increased the risk of pain or discomfort to Resident 510 and had the potential to cause the displacement of Resident 510's G-tube and/or aspiration (inhaling food, stomach acid, medication, or saliva into the lungs). Findings: During a review of Resident 510's admission Record (AR), the AR indicated Resident 510 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 ensure safe medication administration and accurate accountability of all controlled medications (medications with a high potential for abuse) as indicated in the facility's policy and procedures (P&P) by failing to: 1. Ensure one of two sampled resident's (Resident 510) medications for potassium chloride (a medicine used to prevent or treat low potassium levels in the body, side effects include stomach bloating, severe vomiting, severe stomach pain, stomach irritation, or chest pain), administered through a Gastrostomy tube (G-tube, a tube that is placed directly into the stomach through an abdominal wall incision for administration of food, fluids, and medications), was administered with sufficient fluid in accordance with the manufacturer's specification. 2. Ensure the Controlled Drug Record form (CDR/Narcotic run sheet- accountability record of medications that are considered to have a strong potential for abuse) coincided with the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of five sampled residents (Resident 84) remained free of unnecessary psychotropic medication (drug prescribed to affect the mind, emotions, or behavior) use when Resident 84 received quetiapine (Brand Name [Seroquel], antipsychotic, a type of psychotropic medication indicated for psychosis [a collection of symptoms that affect the mind, where there has been some loss of contact with reality]) and trazodone (an antidepressant) for inadequate indications. The facility failed to develop and implement person centered non-pharmacological behavioral interventions ([NPI] any intervention intended to improve the health or the well-being of individuals that do not involve the use of medication) in Resident 84's plan of care. This deficient practice had the potential to result in psychotropic medication adverse effects (unwanted, uncomfortable, or dangerous effects that a resident may have due to an administered medication) such as sedation,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 safe and proper storage practices in one of one kitchen (Kitchen 1) in accordance with professional standards for food service safety and the facility's policy and procedure (P&P) by failing to: a. Ensure food items in Kitchen 1 were labeled/dated. b. Ensure dishware/kitchenware were stored under sanitary conditions. c. Ensure food was stored in a sanitary manner to prevent growth of microorganisms that could cause food-borne illnesses (illness caused by food contaminated with infectious organisms) for one of three sample residents (Resident 36) when Resident 36's yogurt and opened nutritional shake were left out at room temperature for more than two hours inside Resident 36's room. These deficient practices had the potential to affect the quality and palatability of food given to the residents could result in serious complications caused by food borne illness. Findings: a-b. During a concurrent observation and interview on 7/8/2024 at 7:52 AM, with the Director of Nutritional Services (DNS) during 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 b-c. During a review of Resident 164's MDS, dated [DATE], the MDS indicated Resident 164 had severe cognitive (processes of thinking and reasoning) impairment. The MDS indicated Resident 164 required set up and cleaning assistance with eating and substantial/maximal assistance with personal hygiene. During a review of Resident 164's AR, the AR indicated Resident 164 was readmitted to the facility on [DATE] with diagnoses that included acute (sudden) respiratory failure (inadequate lung gas exchange), acute pulmonary edema (buildup of fluid in the lungs), and unspecified dementia (lose ability to think, remember, learn, make decisions, and solve problems). During a review of Resident 164's H&P, dated 4/5/2024, the H&P indicated Resident 176 did not have the capacity to understand and make decisions. During a review of Resident 140's AR, the AR indicated Resident 140 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease (progressive disease destroying memory and mental functions)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 offer and provide influenza ([flu] a common, sometimes deadly infection of the nose, throat and lungs) and pneumococcal (a serious bacterial lung infection) vaccinations (a simple, safe and effective way of protecting you against harmful diseases, before you come into contact with them), and ensure education was provided to three of five sampled residents (Resident 14, Resident 196 and Resident 200) and or representatives regarding the risk and benefits and the potential side effects of the vaccinations and whether the resident received the influenza and pneumococcal vaccines, could not receive the vaccines due to medical contraindications, or refused the vaccines, as indicated in the facility's policy and procedures (P&P), titled Influenza Prevention and Control and Pneumococcal Vaccination - Pneumovac or Pneumococcal conjugate vaccines. This deficient practice placed Residents 14, 196, and 200 at greater risk of acquiring, transmitting, or…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 privacy, for one of one sampled resident (Resident 60), was maintained. During initial tour of the facility, on 7/8/2024, Resident 60's privacy curtain remained partially opened and Resident 60's genitals and lower part of the body was exposed while Resident 60 received care. This deficiency resulted in violating Resident 60's right to privacy and dignity and had the potential to result in a decline in psychosocial well-being. Findings: During a review of Resident 60's admission Record (AR), the AR indicated Resident 60 was admitted to the facility on [DATE] with diagnosis that included Dementia (a decline in mental ability severe enough to interfere with daily life), Alzheimer's Disease (a progressive disease that causes memory loss and other mental functions) and muscle weakness. During a review of Resident 60's History and Physical (H&P), dated 8/18/2023, indicated resident 60 did not have the capacity to understand and make…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to accurately code significant weight loss on the Minimum Data Set (MDS, an assessment and screening tool), for one of one resident (Resident 176). This failure resulted in an inaccurate assessment of Resident 176's status and had the potential to result in in unmet individualized needs and affect the resident's physical and psychosocial well-being. Findings: During a review of Resident 176's admission Record (AR), the AR indicated Resident 176 was admitted to the facility 11/1/2023 and readmitted on [DATE] with diagnoses that included unspecified dementia (lose the ability to think, remember, learn, make decisions, and solve problems), heart failure (heart doesn't pump blood as well as it should), and generalized muscle weakness (loss in muscle strength). During a review of Resident 176's undated History & Physical (H&P), the H&P indicated Resident 176 did not have the capacity to understand and make decisions. During a review of Resident 176's Weights…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 36) received treatment and care in accordance with professional standards of practice, physician order, and policy for Medication Administration. The facility failed to ensure Resident 36 who had known and documented allergy with iodine (a chemical element found in small amounts in sea water, used in medicine, photography, and a dye [substance for changing something's color]), was not administered iodine to treat Resident 36's laceration on forehead. This deficient practice had the potential to place Resident 36 at risk for an allergic reaction (are inappropriate responses of the immune system to a normally harmless substance) and could potentially triggered anaphylactic reaction (a severe, life-threatening allergic reaction that needed to be treated right away.). Findings: During a review of Resident 36's admission Record (AR), dated 7/10/2024, the AR indicated the facility admitted Resident 36 on 9/22/2023 with diagnoses including atrial fibrillation (an irregular heartbeat…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a nasal cannula (NC, a device-lightweight flexible plastic tubing used to deliver supplemental oxygen, tubing ending is placed in the nostrils and is fitted over the patient's ears) was labeled with a date and a cautionary sign was posted on the resident's door to indicate oxygen was in use and no smoking in the room, for one of three sampled residents (Resident 61) receiving oxygen therapy. This deficient practice placed Resident 61 at an increased risk of acquiring an infection and the potential for a decline in physical well-being. Findings: During a review of Resident 61's admission Record indicated Resident 61 was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe) and asthma (narrowing of the lung that makes it hard to breathe). During a review of Resident 61's Minimum Data Set (MDS, an assessment…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide one of three sampled residents (Resident 206) with meals that accommodated the resident's food preferences by failing to ensure Resident 206 received coffee with his meal. This deficient practice made Resident 206 feel angry and upset. Findings: During a review of Resident 206's admission Record, indicated Resident 206 was admitted to the facility on [DATE] with diagnoses that included metabolic encephalopathy (a broad term for any brain disease that alters brain function), below the left knee amputation, type 2 diabetes (a metabolism disorder that affects the body's ability to use blood sugar) unspecified severe protein-calorie malnutrition (occurs when not enough protein and calories are consumed or metabolized, resulting in muscle loss) sepsis (a life-threatening complication of an infection) and dysphagia (difficulty in swallowing), muscle weakness and visual loss for both eyes. During a review of Resident 206's Minimum Data…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to offer and provide the COVID-19 (a mild to severe respiratory illness that spread from person to person) immunization (a process by which a person becomes protected against a disease [a disorder of structure or function in a human, animal, or plant]) and ensure education was provided to two of five sampled residents (Resident 196 and 200) and or their representatives regarding the risk and benefits and the potential side effects of the vaccination and whether the residents received the COVID-19 vaccines, could not receive the vaccines due to medical contraindications, or refused the vaccines. This deficient practice had the potential for Resident 196 and 200 to not be provided the opportunity to decline or be currently immunized to lower risk of acquiring, transmitting, or experiencing complications from COVID-19. Findings: During a review of Resident 196's AR, the AR indicated, Resident 196 was originally 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 observation, interview, and record review, the facility failed to maintain and implement its Infection Control Program to prevent the transmission of disease and infection when: a. Certified Nursing Assistant (CNA) 1 failed to report to facility that CNA 1 had a skin rash on CNA 1's arm that stated on 6/1/2024, in accordance with the facility's Policy and Procedure (P&P) titled, Employee Illness, revised January 2019. b. CNA 2's supervisors, (the Treatment Nurse [TN], and the Director of Nursing, DON) failed to prevent CNA 2 from caring for residents (in general) at the facility when CNA 2 informed facility on 6/7/2024 that CNA 2 had a rash. c. CNA 1 and CNA 2 provided care to 29 of 216 residents at the facility while CNA 1 and CNA 2 had scabies (infestation of the skin caused by the human itch mite). These failures had the potential to result in the spread of scabies to the residents residing at the facility. Findings: During a review of Resident 3's admission Record (AR), the AR indicated Resident 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 observation, interview, and record review, the facility failed to ensure one of eleven sampled resident (Resident 4) was free from physical abuse (willful infliction of injury, deliberate aggressive or violent behavior with the intention to cause harm) by failing to protect Resident 4 from physical abuse and remove Resident 4 immediately when Resident 5 physically assaulted (the illegal act of causing physical harm or unwanted physical contact to another person, physical attack) Resident 4. This deficient practice resulted in pain, an abrasion (a cut or a scrape on the skin) that required treatment, and a transfer to the GACH (General Acute Care Hospital) 1's ED (Emergency Department) to further evaluate Resident 4. Additionally, the failure resulted in Resident 4 feeling unsafe and scared in the facility. Findings: a. During a review of Resident 5's admission Record, the AR indicated, Resident 5 was originally admitted to the facility on [DATE] and readmitted on [DATE] with multiple diagnoses including…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 3 of 3 sampled residents (Resident 1, Resident 2, and Resident 3) were provided drinks according to their preferences when: 1. Resident 1 did not have any drinks on Resident 1's lunch tray on 5/13/2024. 2. Resident 2 did not have juice on Resident 2's lunch tray on 5/13/2024. 3. Resident 3 did not have juice and coffee on Resident 3's lunch tray on 5/13/2024. These failures had the potential for Resident 1, Resident 2, and Resident 3 to not receive proper hydration. Findings: 1. During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 to the facility on 1/31/2017, with diagnoses which included cerebral palsy (group of conditions that affect movement and posture caused by damage to the brain before birth) and high blood pressure. During a review of Resident 1's History and Physical (H&P, physician's clinical evaluation and examination of the resident), dated 5/22/2023, the H&P…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 2) did not use a disposable plate for lunch on 5/13/2024. This failure had the potential to violate Resident 2's right to a dignified dining. Findings: 1. During a review of Resident 2's admission Record, the admission Record indicated the facility initially admitted Resident 2 to the facility on 9/15/2023, and readmitted Resident 2 on 2/13/2024, with diagnoses which included heart failure (a serious condition in which the heart did not pump blood as well as it should) and diabetes mellitus (disease that resulted in too much sugar in the blood due to the body's inability to process carbohydrates [one of the basic food groups]). During a review of Resident 2's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 2/2/2024, the MDS indicated Resident 2 verbalized Resident 2's needs, ate on his own, and needed only set-up or clean-up assistance with meals. During a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to honor 2 of 3 sampled residents' food preferences (Resident 1 and Resident 2) when: 1. Resident 1 did not get three over easy eggs for breakfast on 4/26/2024 according to Resident 1's preferences. 2. Resident 2 did not get any meat for breakfast on 5/13/2024 according to Resident 2's preferences. These failures resulted in Resident 1's and Resident 2's food choices to not be honored and had the potential for Resident 1's and Resident 2's nutritional needs to not be met. Findings: 1. During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 to the facility on 1/31/2017, with diagnoses which included cerebral palsy (group of conditions that affected movement and posture caused by damage to the brain before birth) and high blood pressure. During a review of Resident 1's History and Physical (H&P, physician's clinical evaluation and examination of the resident), dated 5/22/2023, the H&P indicated…

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

Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1) received foods according to the therapeutic diet (diet ordered by a physician as part of treatment for a disease) prescribed by Resident 1's physician. This failure had the potential for Resident 1's health to be negatively impacted. Findings: During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 to the facility on 1/31/2017, with diagnoses which included cerebral palsy (group of conditions that affect movement and posture caused by damage to the brain before birth) and high blood pressure. During a review of Resident 1's History and Physical (H&P, physician's clinical evaluation and examination of the resident), dated 5/22/2023, the H&P indicated Resident 1 was able to make decisions. During a review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 3/28/2024, the MDS indicated Resident 1 verbalized Resident 1's needs, ate on his own, and needed only…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 dignity and respect during a meal for one of three sampled residents (Resident 7) by failing to ensure the CNA made sure the resident was at eye-to-eye level to assist the resident. This deficient practice had the potential to negatively impact Resident 7's psychosocial well-being. Findings: During a review of Resident 7's admission Record (AR), the AR indicated the facility initially admitted Resident 7 on 9/13/2023 and readmitted Resident 7 on 4/11/2024 with diagnoses of atherosclerotic heart disease of native coronary artery (plaque buildup in the wall of the arteries that supply blood to the heart) with unstable angina pectoris (a condition in which the heart does not get enough blood flow and oxygen) and type 2 diabetes mellitus (characterized by high levels of blood sugar in the blood). During a review of Resident 7's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 1/12/2024, the MDS indicated Resident 7 was understood by others 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 protect the residents' right to be free from physical abuse (willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish) for one of four sampled residents (Residents 1) on 4/33/2024, when Resident 2 physically assaulted (assault, the illegal act of causing physical harm or unwanted physical contact to another person) Residents 1. This failure resulted in Residents 1 to sustain minor injury around Resident 1's right eye as the result of physical abuse by Resident 2 while under the care of the facility. Based on the reasonable person concept (hypothetical [suggested], average person's reaction to the actual circumstances of alleged illegal activities) due to Resident 1's and Resident 2's severely impaired cognition (ability to think and make decisions), an individual subjected to physical abuse has lifetime physical pain and psychological (mental or emotional)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 and implement a person-centered care plan for one of three sampled residents (Resident 7) by not addressing Resident 7's preference (the right or chance to choose) during meals. This deficient practice had the potential to result in inconsistent implementation of care and denied Resident 7's right for having a preference. Findings: During a review of Resident 7's admission Record (AR), the AR indicated the facility initially admitted Resident 7 on 9/13/2023 and readmitted Resident 7 on 4/11/2024 with diagnoses of atherosclerotic heart disease of native coronary artery (plaque buildup in the wall of the arteries that supply blood to the heart) with unstable angina pectoris (a condition in which the heart does not get enough blood flow and oxygen) and type 2 diabetes mellitus (characterized by high levels of blood sugar in the blood). During a review of Resident 7's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 1/12/2024, the MDS indicated Resident 7 was understood 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 interview and record review, the facility failed to ensure medically related social services were provided for one of three sampled residents (Resident 2) by failing to: 1. Ensure the Social Services Assistant (SSA) timely (prompt/without delay) arranged transportation for Resident 2's scheduled appointment to see Resident 2's pain management physician, Medical Doctor 2 (MD 2, physician who specialized in decreasing pain), on 1/29/2024 at 10 am, as ordered by Resident 2's Primary Physician (PP). 2. Ensure SSA or facility staff notified Resident 2's Responsible Party (RP) 1 of the missed transportation arrangement and delay in transporting Resident 2 to his scheduled appointment with MD 2. These deficient practices resulted in Resident 2's appointment being rescheduled at a later time and RP 1 personally transporting Resident 2 to Resident 2's new appointment time. These failures had the potential for Resident 2 to miss the appointment ordered by her PP, which could lead to increased pain and decline 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 a safe and sanitary environment to prevent the spread of infection during a Coronavirus-19 (COVID-19 an illness caused by a virus that can spread from person to person) outbreak (the occurrence of disease cases more than normal expectancy) in the facility, in accordance with the facility's Policy and Procedure (P&P) on Hand Hygiene, facility's Mitigation Plan, Department of Public Health (DPH) recommendation and the local guidelines for preventing and managing COVID-19 in Skilled Nursing Facilities by failing to: 1. Ensure one of one staff (Certified Nursing Assistant 3[CNA 3]) offered and or assisted Residents 1, 2, 3 and 4 to perform hand hygiene before eating lunch, perform hand hygiene before and after entering Residents 1, 2, 3 and 4's room and perform hand hygiene before putting on gloves to assist Resident 4 with lunch. 2. Ensure two of two transport staff (TS) wore the required Personal Protective Equipment (PPE - mask,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 one of 15 sampled resident ' s (Resident 2) allegation of abuse to the California Department of Public Health (CDPH), the Ombudsman (an official appointed to investigate individuals ' complaints against facility administration), and Law Enforcement within two (2) hours. This deficient practice placed Resident 2 and all facility residents at risk for abuse. Findings: During a review of Resident 2 ' s admission Record, the admission Record indicated the facility admitted Resident 2 on 9/13/2023 with diagnoses which included anxiety disorder (feelings of worry, anxiety, or fear that are strong enough to interfere with one ' s daily activities) and bipolar disorder (mental disorder characterized by periods of depression and periods of abnormally elevated mood that each last from days to weeks). During a review of Resident 2 ' s History and Physical (H&P, physician ' s clinical evaluation and examination of the resident), dated 9/13/2023, the H&P…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to protect the resident ' s right to be free from physical abuse (willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish) for one of five sampled residents (Resident 3) on 10/17/2023 when Resident 4 pushed Resident 3 to the floor, got on top of Resident 3, and punched Resident 3. This failure resulted in Resident 3 being subjected to physical abuse by Resident 4 while under the care of the facility. Based on the reasonable person concept (hypothetical [suggested], average person's reaction to the actual circumstances of alleged illegal activities) due to Resident 3 ' s severely impaired cognition (ability to think and make decisions), an individual subjected to physical abuse has lifetime physical pain and psychological (mental or emotional) effects including feelings of embarrassment, humiliation, and emotional distress. Findings: During a review of Resident 3's admission…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 an allegation of abuse to the California Department of Public Health (Department), Ombudsman (an official appointed to investigate individuals' complaints against maladministration), and to the local law enforcement, within two hours, in accordance with the facility ' s policy and procedures (P&P) titled, Abuse -Reporting & Investigations for one of five sampled Residents (Resident 1). This failure had the potential for Resident 1 to be at risk of further abuse by Resident 2. Findings: During a review of Resident 1's admission Record, the admission Record indicated, Resident 1 was admitted to facility on 10/4/2018, and readmitted to the facility on [DATE] with multiple diagnoses including schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly), bipolar disorder (a mental illness that causes unusual shifts in a person's mood), and Type 2 diabetes mellitus (a chronic condition that affects the way the 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 observation, interview and record review, the facility failed provide a safe and functional environment for residents, staff, and the public, regarding unapproved remodeling projects and was non-compliant with the State building codes. This deficient practice of an unsafe and improper functional environment has the potential to have negative effects to the safety, welfare and health of the residents, staff, and the public. Findings: During an observation, on 9/20/23, at 1:05 pm, upon entering the facility, it was noticed that one of the two lobby restrooms had yellow caution tape across the doorway and was in the process of being remodeled. Further observation, of this restroom, revealed the wall paneling were missing and the other public restroom was finished. During an interview, on 9/20/23, at 1:30 pm, with the administrator, the administrator stated that the maintenance staff were in the process of upgrading in the secured unit and that the maintenance supervisor (MS) was at the secured unit. During…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide adequate nutritional and hydration care and services to two of two sampled residents (Resident 2 & 3) by failing to: 1. Assess, provide, and implement nutritional interventions for Resident 2 ' s weight loss. 2. Monitor Residents 2 & 3 ' s weight weekly. These failures resulted in unplanned weight loss for Residents 2 and 3. Findings: A review of Resident 2 ' s admission Record indicated the facility initially admitted the resident on 4/26/2023 with diagnoses that included Alzheimer ' s disease (a brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out simplest task), dementia (loss of cognitive function such as thinking, remembering, and reasoning), dysphagia (difficulty swallowing) and difficulty walking. Review of Resident 2 ' s weight records, indicated the following: 5/2/2023- 123 pounds (lbs, unit of weight) 5/5/2023- 121 lbs 6/6/2023- 117 lbs 6/12/2023- 115 lbs 6/19/2023- 116.4 lbs…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 address and obtain the necessary services for the dementia care needs of one of 12 sampled residents (Resident 2) by failing to: a. Follow up the planned consult with Medical Doctor 1 (MD 1, a psychiatrist). b. Ensure Resident 2's target behaviors and side effects related to the use of psychoactive medications (drugs that affect brain activity associated with mental processes and behavior) were closely monitored and documented accurately in Resident 2's medical records. c. Conduct a review of Resident 2's psychoactive medications, including antipsychotics (also referred to as major tranquilizers), to address Resident 2's problem with excessive sedation (administering of a sedative drug to produce a state of calm or sleep) that interfered with eating, prevented full provision of rehab therapy, and placed Resident 2 at a high risk for falls. These failures had the potential to negatively affect the resident's physical and psychosocial well-being. Please Cross Reference with F605, F657, F692, F756, and F757 Findings: During…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to: 1. Ensure the consultant pharmacist (CP) reported an irregularity of failing to define a specific target behavior (e.g., striking out at staff, resisting care, etc.) for the use of chlorpromazine (a medication used to treat mental illness) in one of three sampled residents (Resident 2) during the Medication Regimen Reviews (MRR - monthly reports completed by the consultant pharmacist highlighting potential issues with a resident's medication therapy) completed between 4/26/23 and 9/8/23. 2. Ensure the CP reported an irregularity of licensed staff failing to monitor for target behaviors tied to the use of chlorpromazine, Zyprexa, Depakote, and Xanax in one of three sampled residents (Resident 2) during the MRRs completed between 4/26/23 and 9/8/23. These deficient practices caused Resident 2 to have continuing daytime drowsiness and sedation due to the use of chlorpromazine. As a result, Resident 2 was occasionally unable to complete meals or therapy…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure residents were free of unnecessary medications by failing to: 1. Ensure licensed staff monitored psychotropic (any medications that affect brain activity associated with mental processes and behavior) medications (Zyprexa, Xanax, Depakote, and chlorpromazine [psychotropic medications used to treat mental illnesses]) for effectiveness by documenting episodes of target behaviors (e.g., striking out at staff, resisting care, etc.) in one of three sampled residents (Resident 2) between 4/26/23 and 9/8/23. 2. Ensure licensed staff documented potential adverse effects (unwanted or dangerous side effects of medications) of sedation (the administration of a drug to induce a state of calm or sleep) due to the use of chlorpromazine in one of three sampled residents (Resident 2) between 4/26/23 and 9/8/23. 3. Evaluate whether continued use of chlorpromazine in the presence of adverse effects (sedation) was warranted in one of three sampled 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 interview and record review, the facility failed to ensure transportation services for radiation [treatment of using beams of intense energy to kill cancer (a disease in which abnormal cells divide uncontrollably and destroy body tissue) cells] treatment planning and oncology (study, treatment, and prevention of tumors) follow-up appointments for one of two sampled residents (Resident 10), as ordered by Resident 10 ' s (MD) 3/Radiation Oncologist 1 [a medical practitioner qualified to diagnose and treat tumors (a solid mass of tissue that forms when abnormal cells group together)] and failed to follow the facility ' s policy and procedure (P&P) titled, Referrals to Outside Services, by failing to: 1. Ensure Registered Nurse 7 (RN 7) kept Resident 10 ' s oncology (the study and treatment of tumors) follow-up appointment with MD 5/Radiation Oncologist 2, at General Acute Care Hospital (GACH) 2, on 3/16/2023. 2. Ensure RN 7 followed up with Resident 10 ' s Case Manager (CM) and the Social Services Director…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 2) was free from chemical restraints (any drug used for discipline or staff convenience and not required to treat medical symptoms) by failing to: 1. Document a clinical rationale for the continued use of chlorpromazine (a medication used to treat mental illness) for Resident 2 between 4/26/23 and 9/8/23. 2. Ensure chlorpromazine used to treat dementia (the loss of cognitive functioning - thinking, remembering, and reasoning - to such an extent that it interferes with a person's daily life and activities) was tied to a specific target behavior (e.g., striking out at staff, resisting care, etc.) for Resident 2 between 4/26/23 and 9/8/23. These deficient practices caused Resident 2 to have continuing daytime drowsiness and sedation (the administration of a drug to induce a state of calm or sleep) due to the use of chlorpromazine. As a result, Resident 2 was occasionally unable to complete meals or therapy…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 each Minimum Data Set (MDS, a standardized resident assessment and care-planning tool) assessment was conducted accurately by the appropriate health professional during the entire observation period (2 weeks or 7 days) for one of 12 sampled residents (Resident 2). This failure had the potential to lead to incorrect treatments and services provided to Resident 2 due to inaccurate MDS assessments. Please cross reference with F756, F757, and F744. Findings: During a review of Resident 2's admission Record, it indicated the facility initially admitted Resident 2 on 4/26/2023 with multiple diagnoses including Alzheimer's disease (type of dementia that affects memory, thinking and behavior severe enough to interfere with daily tasks), schizoaffective disorder (mental illness that affects thoughts, mood, and behavior), psychosis (mental illness characterized by loss of contact with reality), depression (mental disorder characterized by persistently depressed mood or loss of interest in activities), 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 record review and interview, the facility failed to document one of two sampled residents (Resident 2) skin condition in the care plan as indicated in the facility ' s policy and procedures. This failure had the potential to result in an oversight of Resident 2 ' s skin condition. Findings: During a review of Resident 2 ' s admission Record indicated the facility initially admitted Resident 2 on 4/26/2023 with multiple diagnoses including Alzheimer ' s disease (type of dementia that affects memory, thinking and behavior severe enough to interfere with daily tasks), schizoaffective disorder (mental illness that affects thoughts, mood, and behavior), psychosis (mental illness characterized by loss of contact with reality), depression (mental disorder characterized by persistently depressed mood or loss of interest in activities), anxiety disorder (persistent and excessive worry that interferes with daily activities), and difficulty walking. During a review of Resident 2 ' s Minimum Data Set (MDS, a standardized resident screening and care-planning tool), dated 8/2/2023,…

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 staff failed to update the falls care plan for one of 12 sampled residents (Resident 2) after the fall incidents on 8/9/2023 and 8/19/2023 to address Resident 2's use of psychoactive medications (drugs that affect brain activity associated with mental processes and behavior), which placed Resident 2 at a higher risk for falls. This failure had the potential to cause more injuries due to recurrent falls. Please cross reference with F756, F757, and F744 Findings: During a review of Resident 2's admission Record, it indicated the facility initially admitted Resident 2 on 4/26/2023 with multiple diagnoses including Alzheimer's disease (type of dementia that affects memory, thinking and behavior severe enough to interfere with daily tasks), schizoaffective disorder (mental illness that affects thoughts, mood, and behavior), psychosis (mental illness characterized by loss of contact with reality), depression (mental disorder characterized by persistently depressed mood or loss of interest in activities), anxiety disorder (persistent and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure one of three sampled residents (Resident 13) was provided a communication tool or resources to effectively communicate the resident's needs. Resident 13 who spoke a Chinese dialect, was not provided a communication tool. This deficient practice had the potential to result in the resident ' s care needs not effectively conveyed to the staff which could lead to a decline in the resident ' s quality of life. Findings: During a review of Resident 13's admission Record indicated Resident 13 was admitted to the facility on [DATE] with diagnosis which included hypertension (elevated blood pressure) and dementia (a disorder that affect the brain). During a review of Resident 13 ' s care plan, titled Cognitive short/long term memory loss causing passive participation, dated 10/25/21, indicated Resident 13 had a language barrier (Chinese only). During a review of Resident 13 ' s care plan, titled Communication Problem, revised on 6/29/23,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 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 provide tracheostomy (incision made in the windpipe to relieve an obstruction to breathing) care by a licensed nurse or Respiratory Therapist (RT), when Certified Nursing Assistant staff reattached the tracheostomy tubing (tubing that connects the tracheostomy to oxygen) to the tracheostomy cannula (used for general ventilation) for one of 14 sampled residents (Resident 10). This failure had the potential for Resident 10 to experience worsening respiratory distress or respiratory failure due to unqualified staff caring for Resident 10 ' s tracheostomy. Findings: During a review of Resident 10 ' s admission Record, the admission Record indicated Resident 10 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of oropharynx and tonsillar cancer, and lymph (small lumps of tissue that contain white blood cells and fight infection) node cancer of head, neck, and face, and required the use of a tracheostomy…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 pharmaceutical services that assure accurate acquiring of pain medication such as Morphine Sulfate (MS, a controlled pain killer), baclofen (a medication to treat muscle spasms [painful contractions and tightening of your muscles]) and tizanidine (medication treats muscle spasms) to meet the needs for one of three sampled residents (Resident 4). This deficient practice in Resident 4 had pain without pain relief medications and had the potential for exacerbate (worsen symptoms) medical conditions which could lead to physical decline, psychosocial harm. Findings: During a review of Resident 4's admission Record indicated Resident 4 was admitted to the facility on [DATE] with diagnosis that included paraplegia (paralysis of the legs or lower body), chronic pain (persistent pain that lasts weeks to years) and muscle spasms. A review of Resident 4's Minimum Data Set (MDS, a resident assessment and care-screening tool), dated 4/10/23,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 infection control practices during a Coronavirus (COVID 19, a mild to severe respiratory illness that spread from person to person) outbreak (a sudden increase in occurrences of a disease when cases are in excess of normal expectancy for the location or season) in accordance with the Department of Public Health's (DPH) guidelines and the facility's Policy and Procedure (P&P) by failing to: a. Annually conduct an N95 mask (a respiratory protective device designed to achieve a very close facial fit and very efficient filtration of airborne particles) fit testing (the use of a protocol to evaluate the fit of a respirator on an individual) for two of two Licensed Vocational Nurses (LVN 1 and LVN 2). b. Ensure to keep a monitoring log for cleaning and disinfecting of high touch areas (surfaces that are frequently touched) in the facility's Red Zone (an area dedicated for residents who are positive for COVID 19). These deficient practices had the potential to result in the transmission of COVID 19 to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of 10 sampled residents (Resident 5) was free of physical restraints (any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident ' s body that the individual cannot remove easily which restricts freedom of movement or normal access to one ' s body) by failing to: 1. Provide alternative interventions prior to positioning Resident 5 ' s bed against the wall. 2. Ensure Resident 5 ' s middle bed rail (metal or plastic bars positioned along the side of the bed) did not block Resident 5 ' s access to and from the bed. 3. Remove cushions from underneath Resident 5 ' s bed mattress which prevented Resident 5 from getting out of bed. These deficient practices had the potential to increase Resident 5 ' s anxiety (feelings of worry or fear) and restlessness, decrease the resident ' s quality of life and had the potential to result in injury to Resident 5. Cross reference F700. Findings:…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to ensure Restorative Nursing Services (RNS, nursing-based rehabilitative care aimed at maintaining and/or improving self-involvement in ADLs) were provided as ordered by the physician and indicated in the care plan for ten of 14 sampled residents (Residents 5, 6, 7, 8, 9, 10, 11, 12, 13, and 14). This failure had the potential to cause a decline in the residents ' physical and psychosocial well-being related to the inability to carry out activities of daily living (ADLs, tasks related to personal care including bed mobility, transfers, walking, locomotion on and off unit, dressing, eating, toilet use, personal hygiene, and bathing). Findings: A. During a review of Resident 5 ' s admission Record, indicated the facility initially admitted Resident 5 on 8/5/2022, with multiple diagnoses including altered mental status (change in mental function due to an illness, disorder, or injury affecting the brain) and a history of stroke (brain damage 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.

Based on interviews and record review, the facility failed to ensure sufficient Certified Nursing Assistants (CNAs) were assigned to provide care to two of 14 sampled residents (Residents 2 & 4) in accordance with the facility's policy and procedures. For Residents 2 and 4, staff was not able to answer the call lights timely due to the workload constraints. This failure had the potential to result in a decline in the residents' physical and psychosocial well-being due to poor quality of care and staff burnout. Cross Reference with F676 Findings: During a review of Resident 2's admission Record, it indicated the facility initially admitted Resident 2 on 7/12/2023 with multiple diagnoses including type 2 diabetes mellitus (chronic condition wherein the body does not produce enough insulin or resists insulin, causing increased blood sugar), hyperlipidemia (high level of fat particles in the blood), anemia (lack of healthy red blood cells in the blood), hypertensive heart disease (abnormal structural and functional changes in the heart due to chronic elevated blood pressure), obesity…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 menu when preparing food for 188 of 215 residents (a total of 188 residents) who eat food from the kitchen This deficient practice had potential to result in meal dissatisfaction, decreased intake and placed 188 residents at risk for unplanned weight loss. Findings: A review of resident council meeting minutes, dated 7/12/23, indicated that residents complained about Menu has not been followed. During initial kitchen tour on 8/23/23, at 10:30 AM, there were 5 large trays of fillets of fish stored in the walk-in refrigerator. Some of the fish fillets were plain white fillets and some of the fish fillets had brown color seasoning. During a concurrent observation and interview in the walk-in refrigerator, the Director of Nutrition Services (DNS) stated the fish fillets were for today's lunch. During an observation and interview in the kitchen on 8/23/23 at 11:30 AM [NAME] 1 was preparing the vegetables in water. [NAME] 1 said she will add Italian seasoning and butter to the cooked…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 prepare food by methods that conserved flavor, texture, and appearance for 2 of 3 sampled Residents (Residents 1 and 15). This deficient practice resulted in meal dissatisfaction for Residents 1 and 15. Findings: During initial kitchen tour on 8/23/23 at 10:30AM, there were 5 large trays of fillets of fish stored in the walk-in refrigerator. Some of the fish fillets were plain white fillets and some of the fish fillets had brown color seasoning. During a concurrent observation and interview in the walk-in refrigerator, the Director of Nutrition Services (DNS) said the fish fillets were for today's lunch. During an initial facility tour and a concurrent interviews, on 8/23/23 at 11:00AM, Residents 1 and 15 complained regarding facility's food texture, and flavor. Resident 1 stated facility's food did not taste good. Resident 15 stated facility's food used to taste good but not anymore. Resident 15 stated the bake potato was yellow and 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 therapy services, including Occupational Therapy [OT, profession aimed to increase or maintain a person's capability of participating in everyday life activities (occupations)] and Physical Therapy (PT, profession aimed in the restoration, maintenance, and promotion of optimal physical function) services to one of three sampled residents (Resident 2) in accordance with the OT and PT treatment plans. These failures had the potential for Resident 2 to decline in Resident 2's mobility (ability to move), activities of daily living (ADLs, tasks related to personal care including bathing, dressing, hygiene, eating, and mobility), and overall psychosocial (combination of the mind, feelings, and social aspects of a person's health) well-being. Findings: During a review of Resident 2's admission Record, the facility admitted Resident 2 on 7/12/23 with diagnoses including displaced intertrochanteric (part of the hip) fracture (break) 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 one of four sampled residents (Resident 4) received assistance from two staff members while transferring from the bed to the wheelchair in accordance with Resident 4's Minimum Data Set (a standardized assessment and care planning tool) assessment and the facility policy on Fall Prevention and Management Program. This deficient practice resulted in Resident 4's assisted fall (unintentionally coming to rest on the ground, floor, or other lower level ) during a transfer from the bed to the wheelchair. Findings: During a review of Resident 4 ' s admission Record, the admission record indicated the facility admitted Resident 4 on 4/20/18 with diagnoses including unspecified dementia (decline in mental ability severe enough to interfere with daily life), muscle weakness, lack of coordination, and contracture (chronic loss of joint motion associated with deformity and joint stiffness) of both ankles. During a review of Resident 4 ' s…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to assess one of 10 sampled residents (Resident 5) for the use of bed rails (also known as side rails, metal or plastic bars positioned along the side of the bed) by failing to: 1. Prevent the use of bed rails in accordance with Resident 5's Bed Rail Assessments on 2/10/23 and 5/11/23. 2. Perform an interdisciplinary (two or more branches of knowledge) approach to assess Resident 5 for bed rails, including the risk of entrapment (an event in which a resident is caught, trapped, or entangled in a space in or about the bed rail) prior to installation. 3. Develop a care plan for the placement and use of Resident 5's bed rails. 4. Ensure Resident 5's bed, which was replaced on 8/24/23, included bilateral (both sides) half (½) bed rails in accordance with the physician's order on 4/25/23. These failures resulted in Resident 5 repeatedly hitting the head against the middle bed rail (bed rail attached to the middle of the bed frame) and the left…

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

Based on interviews and record review, Certified Nursing Assistant 3 (CNA 3) failed to deliver the correct meal tray with the therapeutic diet (prescribed diet to treat a disease or clinical condition) as ordered by the physician to one of 14 sampled residents (Resident 2). This failure had the potential to negatively affect Resident 2's health and safety due to inaccurate meal tray distribution. Findings: During a review of Resident 2's admission Record, it indicated the facility initially admitted Resident 2 on 7/12/2023 with multiple diagnoses including type 2 diabetes mellitus (chronic condition wherein the body does not produce enough insulin or resists insulin, causing increased blood sugar), hyperlipidemia (high level of fat particles in the blood), anemia (lack of healthy red blood cells in the blood), hypertensive heart disease (abnormal structural and functional changes in the heart due to chronic elevated blood pressure), obesity (disorder involving excessive body fat), and dysphagia (difficulty swallowing). During a review of Resident 2'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.

Based on observation, interview, and record review, the facility failed to accommodate the needs and preferences of one of four sampled residents (Resident 2) by failing to: 1. Assist in dressing Resident 2 with an outer garment covering the lower half of the body from the waist to the knees/ankles as the resident requested. 2. Ensure Resident 2 ' s call light (device used by a resident to signal his need for assistance from the facility staff) was within while resident was in bed. These failures had the potential to result in a decline in Resident 2 ' s psychosocial well-being due to loss of dignity and a homelike environment. Cross Reference: F584 Findings: 1. During a review of Resident 2 ' s admission Record, it indicated the facility initially admitted Resident 2 to the facility on 6/1/2023 with multiple diagnoses including hemiplegia (paralysis of one side of the body) and hemiparesis (one-sided muscle weakness) following a stroke (damage to the brain from interruption of its blood supply), affecting the left side, aphasia (loss of ability to understand or express speech due…

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

Based on observation, interview, and record review, the facility failed to protect the inventoried belongings for one of four sampled residents (Resident 2) from loss. This failure had the potential to result in a decline in Resident 2 ' s psychosocial well-being due to loss of personal property and homelike environment. Cross Reference: F558 Findings: 1. During a review of Resident 2 ' s admission Record, it indicated the facility initially admitted Resident 2 to the facility on 6/1/2023 with multiple diagnoses including hemiplegia (paralysis of one side of the body) and hemiparesis (one-sided muscle weakness) following a stroke (damage to the brain from interruption of its blood supply), affecting the left side, aphasia (loss of ability to understand or express speech due to brain damage), generalized muscle weakness, difficulty in walking, and end-stage renal disease (failure of the kidneys to perform their function) with dependence on renal dialysis (process of removing excess water, solutes, and toxins from the blood in people whose kidneys have failed). 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, interviews, and record review, the facility failed to ensure the admission assessment of one of four sampled residents (Resident 2) was accurate and reflective of the resident ' s condition. This failure had the potential to result in incorrect treatments provided to Resident 2 due to inaccurate assessments. Findings: During a review of Resident 2 ' s admission Record, it indicated the facility initially admitted Resident 2 to the facility on 6/1/2023 with multiple diagnoses including hemiplegia (paralysis of one side of the body) and hemiparesis (one-sided muscle weakness) following a stroke (damage to the brain from interruption of its blood supply), affecting the left side, aphasia (loss of ability to understand or express speech due to brain damage), generalized muscle weakness, difficulty in walking, and end-stage renal disease (failure of the kidneys to perform their function) with dependence on renal dialysis (process of removing excess water, solutes, and toxins from the blood in people whose kidneys have failed). During a review of Resident 2 ' 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 provide rehabilitative treatment and services to one of four sampled residents (Resident 2) with mobility and range of motion [ROM, full movement potential of a joint (where two bones meet)] concerns by discontinuing rehab therapy prior to Resident 2 ' s attainment of his highest potential related to his functional mobility. This failure had the potential to cause a decline in Resident 2 ' s ROM, including the development and worsening of contractures (deformity and joint stiffness) in the left upper extremity and both lower extremities. This failure also had the potential to cause increased pain with movement. Findings: During a review of Resident 2 ' s admission Record, it indicated the facility initially admitted Resident 2 to the facility on 6/1/2023 with multiple diagnoses including hemiplegia (paralysis of one side of the body) and hemiparesis (one-sided muscle weakness) following a stroke (damage to the brain from interruption of its blood supply), affecting the left side, aphasia (loss of 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.

Based on observation, interview, and record review, the facility failed to put measures in place to ensure safety and supervise residents who were diagnosed with dementia (a decline in mental ability severe enough to interfere with daily life) from wandering out, placing residents who reside in the locked unit (locked, secured, or alarmed units) at risk from elopement (occurs when a resident leaves the premises or a safe area without authorization) by failing to: 1. Ensure Resident 138 who was diagnosed with dementia and assessed as a high risk for elopement by the facility, did not walk out of the facility's locked unit unsupervised. 2. Implement Resident 138's plan of care who had a history of walking out of the facility, by placing a monitoring device (continuously keeps track) on the resident to monitor the resident's whereabouts. 3. Ensure CNA (Certified Nursing Assistant 2 [CNA 2]), was able to identify Resident 138, who walked out of the facility unsupervised, was a current resident residing in the facility. On 5/18/2021 at 1 pm, Resident 138 was observed walking alone…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 3 of 5 sampled residents (Resident 8, 259, and 106) with an indwelling urinary catheter (a flexible tube inserted into the bladder to provide continuous urinary drainage to a collection bag) received appropriate treatments and services by: 1. For Resident 8, the facility failed to assess and document evidence for the presence of sediment (cells, debris and other solid matter) in the urine. 2. For Resident 106, the facility failed to secure the urinary catheter device to prevent accidental pulling or dislodgement that can cause pain. 3. For Resident 259, the facility failed to obtain a physician's order for the urinary catheter; failure to measure the urinary output in volume. Accurate urine output measurement essential in evaluating both fluid status and renal perfusion (flow of the urine). These deficient practices had the potential to result in catheter related complications such as a urinary tract infections (UTI, an infection…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 4 sampled residents (Resident 137 and 559) receiving enteral tube feeding (nutrition taken through the mouth or through a tube that goes directly to the stomach or small intestine) received appropriate care and services. 1. For Resident 137, the facility failed to ensure the resident received the total dose of feeding formula ordered by the physician. 2. For Resident 559, the facility failed to ensure the feeding formula and tubing were changed every 24-48 hours in accordance with the physician's order and facility's policy and procedures. These deficient practices had the potential to result in complications of the enteral feeding such as infection and inadequate nutrition. Findings: 1.A review of Resident 137's Face Sheet (admission record) indicated the facility admitted Resident 137 on 8/25/2020 with diagnoses of Emphysema (a condition in which the air sacs of the lungs are damaged and enlarged, causing breathlessness),…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 and interview the facility failed to provide adequate staff to provide necessary care and services for 5 of 37 sampled residents (Residents 64, 139, 46, 11, and 16). 1. Residents 64 and 139 stated the facility did not have enough staff to provide assistance when needed. 2. During a group meeting Residents 46, 111, and 16, stated the facility did not have sufficient staff to assist with activities of daily living (ADL's) when requested. Findings: 1. A review of Resident 64's Face Sheet indicated the facility admitted the resident on 10/23/2019 with diagnoses of quadriplegia (paralysis of all four limbs), and dependent on a ventilator (machine that blows air into the airways and lungs) for breathing. A review of Resident 64's Minimum Data Set (MDS, a comprehensive standardized assessment and care screening tool) dated 3/11/2021, indicated Resident 64 was able to make himself understood, able to understand others and cognitively intact, and was total dependent on staff with one person physical…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 all controlled medications (generally a drug or chemical whose manufacture, possession, or use is regulated by a government, such as illicitly used drugs or prescription medications that are designated by law) were properly accounted for when several dates had no signature to verify staff had counted the controlled drugs with another staff. This deficient practice had the potential to cause a discrepancy in medication management in the facility and account for residents' medications accurately. Findings: During an observation and interview on 05/18/2021 at 11:15 am, Registered Nurse 1 (RN 1) stated the Medication cart 1 in station 4, the Narcotic Count Signature Sheet had missing signatures to verify that two staff had verified the amount of Narcotics in the medication carts were accounted for on 2/3/2021, 2/22/2021, 2/23/2021, 2/29/2021, 3/16/2021, 3/24/2021, 3/25/2021, 3/31/2021 incoming 7AM shift, 3/31/2021, 5/7/2021, and 5/12/2021. During an interview on 5/18/2021 at 12:04 pm, RN 1 stated two…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 documented evidence the monthly medication review (MMR) for three of 37 residents (Resident 29, 106, and 148) was reviewed by a licensed pharmacist at least once a month This deficient practice had potential to cause adverse consequences related to the medications that could affect the resident's quality of life. Findings: a. A review of Resident 29's Face Sheet indicated the facility admitted the resident on 8/31/2018, with diagnoses of schizophrenia, respiratory failure (a serious condition that develops when the lungs can't get enough oxygen into the blood), gastrostomy (GT-a surgical operation for making an opening in the stomach for introduction of food and medication) and dependence on respirator ventilator (a breathing machine that blows air into lungs and removes carbon dioxide out of your lungs). A review of Resident 29's physician order dated 8/31/2018, indicated for the resident to receive Abilify 30 mg daily via GT for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure to have a medication error rate of less than five percent during medication administration. Twelve medication errors were observed out of twenty-five opportunities which resulted in a medication error rate of 48%. 1. For 4 of 4 sampled residents (Residents 82, 153, 139 and 10), medications were administered late. 2. For 1 of 4 sampled residents (Resident 10) no apical pulse (is the vibration of blood as the heart pumps can be found in the left center of the chest, just below the nipple), or respiratory rate were taken. These deficient practices had the potential to result in harm to the residents. Findings: 1. A review of the Face Sheet (admission record) indicated the facility admitted Resident 82 to the facility on 9/2/2020 with diagnoses of epilepsy (neurological disorder marked by sudden recurrent episodes of sensory disturbance, loss of consciousness, or convulsions, associated with abnormal electrical activity in the brain),…

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

Based on observation and interview, the facility failed to ensure sanitary conditions were maintained in the kitchen. This deficient practice had the potential for unsanitary food practices. Findings: During the initial tour of the kitchen on 5/17/21, at 8:10 am, the following were observed: 1. The kitchen floor under the preparation (prep) table was littered with bits of food debris. The prep table had an undershelf where multiple chopping boards were stored. A staff (Staff 1) observed sweeping the floor with food particles and dust around and under the preparation table. 2. Four uncovered storage bins were utensils were stored with dust and food debris. 3. Food debris found inside a microwave. During an interview on 5/17/21 at 8:40 am, dietary supervisor stated the storage bins should always be cleaned and covered and the microwave should be cleaned after each use.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow infection control practices by failing to: 1. Ensure staff (Certified Nursing Assistant 6 [CNA 6]) donned (put on) personal protective equipment (PPE, protective clothing, gloves, face shields, goggles, facemasks and/or respirators or other equipment designed to protect the wearer from the spread of infection or illness), gown before entering Resident 359's room located in the yellow zone (area where residents under investigation are allocated). 2. Ensure two of five sampled residents (Resident 144 and 361) urinary catheter's (a flexible tube inserted into the body for removal of urine) bags did not touch the floor. 3. Ensure to have paper towels in the bathroom for room [ROOM NUMBER]C on 5/17/2021 and on 5/18/2021, and ensure the wall mounted alcohol-based hand sanitizer (ABHS) dispenser in room [ROOM NUMBER] was not empty. 4. Ensure the ice tray with ice was not left exposed and unattended in the hallway of the yellow zone. These…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 monitor the use of antibiotic (a medication used to treat bacterial infections), for residents on the Antibiotic Stewardship Program (refers to a set of commitments and actions designed to optimize the treatment of infections while reducing the adverse events associated with antibiotic). This deficient practice had the potential to cause unnecessary or inappropriate antibiotic use for the residents. Findings: During an interview on 5/20/2021 at 10:40 am, the facility's Infection Preventionist (IP, nurse who helps prevent and identify the spread of infectious agents like bacteria and viruses in a healthcare environment), stated if any resident was prescribed an antibiotic, the Surveillance Data Collection Form should be filled out prior and an updated care plan would be needed to address the need for the antibiotic. The IP nurse stated the form was incomplete for seven residents and did not indicate whether or not the antibiotic prescribed had been reviewed to determine if it was needed or effective. During an interview 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 ensure adequate bed linen for one of two sampled residents (Resident 359) as indicated on the facility policy. Resident 359's mattress did not have a fitted sheet and the Resident was laying on a bare mattress. This deficient practice resulted with Resident 359 feeling uncomfortable and had the potential to negatively impact the resident's psychosocial well-being. Findings: A review of the Face Sheet (admission Record) indicated Resident 359 was admitted to the facility on [DATE]. Resident 359's diagnoses included type 2 diabetes (persistently high levels of sugar in the blood), muscle weakness, shortness of breath, and sepsis (life threatening complication of an infection). During an observation and concurrent interview on 5/17/21 at 10:21 am, Resident 359 was lying in bed and a flat sheet was placed on the top portion of the mattress. The mattress was bare from Resident 359's shoulders down to his foot. One of Resident 359's two pillows…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to inform one of 37 sampled Residents (Resident 40) total health status and medical condition in a language Resident can fully understand. This failure violated Resident 40's right to be informed and had the potential for the resident not to make choices regarding her medical condition. Findings: During a review of an admission Record, it indicated Resident 40 was admitted to the facility on [DATE]. Resident 40's diagnoses included paraplegia (paralysis of the legs or lower body) and osteoarthritis (degeneration of joint cartilage and the underlying bone). During a record review of a History and Physical (H&P), dated 10/9/20, H&P indicated Resident 40 had the capacity to understand and make decisions. During a review of a Minimum Data Set (MDS, a resident assessment and care-screening tool), dated 2/15/21, indicated Resident 40 had clear speech, was understood (ability to express ideas and wants) and had the ability to understand others. The MDS also…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure oxygen was not self- administered for one of two sampled residents (Resident 16). Resident 16 had an inhaler (also known as a puffer, pump or allergy spray, which is a medical device used for delivering medicines into the lungs through the work of a person's breathing) and oxygen concentrator at bedside. This deficient practice had the potential for Resident 16 to administer the oxygen inaccurately, unauthorized access to the oxygen and complications due to inadequate or excessive oxygen intake. Findings: A review of the admission Record indicated Resident 16 was admitted to the facility on [DATE]. Resident 16's diagnoses included diabetes mellitus (high sugar content in the blood), chronic obstructive pulmonary disease (COPD, an ongoing, progressive disease of the lower respiratory tract in the lungs creating difficulty with breathing that slowly gets worse over time) and hypertension (high blood pressure). A review of the Minimum…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to promote care that maintains the resident's dignity for one of 37 sampled residents (Resident 75). During a dining observation, Certified Nurse Assistant 4 (CNA 4) was observed standing while feeding Resident 75. This deficient practice had the potential to violate Resident 75's right to be treated with respect and dignity. Findings: During a dining observation on 5/18/2021 at 8:52 am, Resident 75 was in bed, fed by CNA 4. CNA 4 was standing next to the resident. During an interview on 5/18/2021 at 8:53 am, CNA 4 stated she was supposed to be sitting down while feeding Resident 75 but she did not know why she should be sitting down while feeding residents. During an interview on 5/18/2021 at 2:48 pm, the Director of Staff Development (DSD) stated staff who assist residents while eating should be seated to respect the resident's dignity and ensure the resident is comfortable A review of Resident 75's Facesheet indicated the resident 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 one of 1 sampled residents (Resident 11) needs are met by making sure resident's call light is within reach. Resident 11's call light was observed on the floor behind the resident's bed and out of Resident 11's reach. This deficient practice had the potential for Resident 11 to not be able to call staff for help or assistance when needed. Findings: A review of Resident 11's face sheet (admission record) indicated Resident 11 was admitted to the facility on [DATE], with diagnoses that included acute and chronic Respiratory Failure (condition that develops when the lungs can not get enough oxygen into the blood), unspecified abnormalities of gait and mobility (when a person is unable to walk in the usual way), and anxiety disorder (intense, excessive and persistent worry and fear about everyday situations) among others. A review of Resident 11's minimum data set (MDS, a standardized assessment and care planning tool), dated 4/28/2021,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 an allegation of abuse and mistreatment to the authorized agencies by no less than 2 hours, in accordance to state law for one of one sampled resident (Resident 40) who alleged Certified Nurse Assistant 6 (CNA 6) did not change her and left a scratch on her. This deficient practices violated the Resident 6's right and had the potential to place the resident's safety at risk. Findings: A review of Resident 40's admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses that included paraplegia (paralysis of the legs or lower body) and osteoarthritis (degeneration of joint cartilage and the underlying bone). A record review of the History and Physical, dated 10/9/20, indicated Resident 40 had the capacity to understand and make decisions. A review of a Minimum Data Set (MDS, a resident assessment and care-screening tool), dated 2/15/21, indicated Resident 40 had clear speech, was understood (ability to express…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 assess one of 2 sampled residents (Resident 16) to determine the resident's capacity for safe use of oxygen. Staff did not aware that Resident 16 administered the oxygen on her own. This deficient practice resulted in Resident 16 not receiving enough oxygen and placed the resident at risk for respiratory distress. Findings: A review of Resident 16's admission face indicated the resident was admitted to the facility on [DATE], with diagnoses that included diabetes mellitus (high sugar content in the blood), chronic obstructed pulmonary disease (COPD-an ongoing, progressive disease of the lower respiratory tract in the lungs creating difficulty with breathing that slowly gets worse over time) and hypertension (high blood pressure). A review of the Minimum Data Set (MDS), a standardized assessment tool, dated 2/7/21, indicated the resident was able to understand others and make herself understood, and required supervision from staff 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 interview and record review, the facility staff failed to accurately document the Pre-admission Screening And Resident Review (PASARR- federal requirement to help ensure that individuals who have a mental disorder or intellectual disabilities are not inappropriately placed in nursing homes for long term care) for one of 37 sampled residents (Resident 19). This failure had the potential for Resident 19 not to be screened or receive services related to mental illness. Findings: A review of Resident 19's admission face sheet indicated the resident was admitted to the facility on [DATE] with diagnoses that included anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety/fear strong enough to interfere with one's daily activities) and unspecified psychosis (severe mental disorder in which thought and emotions are so impaired that contact is lost with external reality) not due to a substance or known physiological condition and schizoaffective disorder (a mental condition 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 establish care areas into the comprehensive care plan for 4 of 37 sampled residents (Residents 106, 148, 259, and 103) 1. For Resident 106, there was no care plan for the use of Ambien (medication for sleep). This deficient practice placed Resident 106 at risk for staff not to provide specific care to the resident while using Ambien. 2. For Resident 148, there was no care plan for Eliquis (medication to prevent blood clot formation). This deficient practice placed Resident 148 at risk for staff not to provide specific care to the resident while using Eliquis. 3. For Resident 259, a newly admitted resident, the facility failed to ensure a care plan was initiated in a timely manner, regarding the use of urinary catheter (a tube placed in the body to drain and collect urine from the bladder). This deficient practice placed Resident 259 at risk for not receiving the appropriate care and treatment and potentially result in bladder infection. 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 interview and record review the facility failed to provide assistance with activities of daily living (ADL's) for one of 37 sampled residents (Resident 139). This failure had the potential for Resident 139 not to receive necessary care and services needed. Findings: A review of Resident 139's Facesheet indicated the resident was admitted to the facility on [DATE] with diagnoses that included muscle weakness and lack of coordination. A review of Resident 139's Minimum Data Set (MDS, a comprehensive standardized assessment and care screening tool) dated 4/16/2021 indicated the resident was able to make herself understood, able to understand others and intact cognition (process of acquiring knowledge and understanding). The MDS indicated Resident 139 required extensive assistance from staff with one person physical assist for activities of daily living (ADL's) including dressing, eating, toileting and personal hygiene. A review of Resident 139's Care Plan dated 10/18/2020 indicated the resident requires…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility staff failed to follow physician's orders for three of 37 sampled residents (Residents 10, 57, and 85). 1. For Resident 10, the facility staff failed to follow physician's order to check the residents's respiratory rate (number of breaths in a minute) and apical pulse (point of maximal impulse and is located at the apex [the base] of the heart) as ordered. 2. For Resident 57, the facility staff failed to follow physician's order to pad the resident's bed side rails. 3. For Resident 85, the facility staff failed to follow physician's orders to pad the resident's bed side rails. These failures had the potential to result in harm or injury to Residents 10, 57 and 85. Findings: 1. A review of Resident 10's Facesheet indicated Resident 10 was admitted to the facility on [DATE] with diagnoses that included congestive heart failure (a chronic condition in which the heart cannot pump blood as it should) and presence of implanted pacemaker (device that is…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide treatment consistent with professional standards of practice and in accordance with the facility's policy and procedure by failing to ensure the low air loss mattress (LAL, special type of mattress used for both the prevention and treatment of pressure ulcer) was set according to resident's weight for one of four sampled residents ( Resident 559). This deficient practice had the potential to result in delayed healing of Resident 559's existing pressure ulcer (injury to the skin and/or underlying tissue resulting from prolonged pressure) and risk of developing new pressure ulcers. Findings: A review of Resident 559's Facesheet indicated the resident was admitted to the facility on [DATE] with diagnoses that included respiratory failure (a condition when the lungs cannot get enough oxygen into the blood) and pressure ulcer of sacral (area above the tailbone) region, unspecified stage. A review of Resident 559's Minimum Data Sheet…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 perform nutritional evaluation one of 5 sampled residents (Resident 259). For Resident 259, the facility failed to assess Resident 259's height and weight and possible nutritional problems related to the diseases and conditions. The facility also failed to perform an initial dietary evaluation that included food preferences upon the resident's admission to the facility These deficient practices had the potential of not meeting Resident 259's nutritional needs. Findings: A review of Resident 259's Face Sheet indicated the facility admitted the resident on5/8/2021, with diagnoses of benign prostatic hyperplasia (a condition in men in which the prostate gland is enlarged and not cancerous), pneumonia (infection of the lungs), alcohol abuse and unspecified protein-calorie malnutrition (not enough intake of food rich in important nutrients). A review of Resident 259's physicians order dated 5/8/2021, indicated to provide regular diet with thin liquids. A review of Resident 259's nursing admission assessment, height…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure two of two sampled residents (Resident 16 and 70) received appropriate respiratory care services. 1. For Resident 16, the facility failed to document the resident's respiratory status that included assessment and treatment prior to discontinuing albuterol (medication used to prevent and treat difficulty breathing, wheezing, shortness of breath, coughing, and chest tightness caused by lung diseases such as asthma and other lung and airway diseases). 2. For Resident 70, the facility failed to ensure the oxygen tubbing was labeled. These deficient practices had the potential to result in an ineffective respiratory treatment, respiratory distress and decline in resident's health condition. Findings: 1. A review of Resident 16's Face Sheet indicated the facility admitted the resident to the facility on 2/10/2018, with diagnoses of diabetes mellitus (high sugar content in the blood), chronic obstructed pulmonary disease (COPD-is 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 observation, interview, and record review, the facility failed to ensure one of 37 sampled residents (Resident 85) was assessed for bed rails (are adjustable metal or rigid plastic bars that attach to the bed) entrapment (is an event in which a resident is caught, trapped, or entangled in the space in or about the bed rail). This deficient practice resulted in Resident 85 getting her left leg caught in the bed rails and had the potential for injury and death. Findings: A review of Resident 85's Face sheet (admission Record) indicated the facility admitted the resident on 12/8/2020 with diagnoses of schizophrenia (Schizophrenia is a serious mental illness that affects how a person thinks, feels, and behave, is characterized by delusions, unusual thoughts or beliefs, hallucinations, hearing, seeing, smelling or feeling things that aren't there) and seizures (a burst of uncontrolled electrical activity between brain cells that causes temporary abnormalities in muscle tone or movements (stiffness, twitching or limpness). A review of Resident 85's History and Physical (H&P)…

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

Based on observation, interview, and record review, the facility failed to obtain physician orders for the use of indwelling urinary catheter (tube inserted into the bladder to drain urine), for 1 of 5 sampled residents (Resident 259) with indwelling urinary catheters. This deficient practice had the potential for injury for Resident 259 and had the potential for unnecessary use of the catheter. Findings: A review of Resident 259's Face Sheet indicated the facility admitted the resident on 5/8/2021 with diagnoses of benign prostatic hyperplasia (a condition in men in which the prostate gland is enlarged and not cancerous), pneumonia (infection of the lungs), alcohol abuse and unspecified protein-calorie malnutrition (not enough intake of food rich in important nutrients). During a tour observation on 5/17/2021 at 10 am, Resident 259 was lying in bed with an indwelling urinary catheter hung on the side of the bed. During an interview and record review on 5/19/2021 Licensed Vocational Nurse 1 (LVN 1) stated Resident 259's physician's order did not indicate an order for the urinary…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 adequately monitor signs and symptoms of bleeding for one of 37 sampled residents (Resident 148) who was taking Eliquis (medication that reduces or prevent blood from clotting) This deficient practice had the potential for Resident 1 to not receive adequate monitoring while taking Eliquis. Findings: A review of Resident 148's Face Sheet indicated the facility admitted the resident on 8/14/2020 with diagnosis of chronic obstructed pulmonary disease (COPD, an ongoing, progressive disease of the lower respiratory tract in the lungs creating difficulty with breathing that slowly gets worse over time), end stage renal disease, diabetes mellitus and dependence on renal dialysis (treatment for kidney failure that rids your body of unwanted toxins, waste products and excess fluids by filtering your blood). A review of Resident 148's physician's order dated 8/14/2020, indicated to administer Eliquis 2.5 milligrams (mg, a unit of measurement) one tablet by mouth twice a day for deep vein thrombosis (DVT, condition that 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 observation, interview and record review, the facility failed to administer psychotropic medications (any medication capable of affecting the mind, emotions, and behavior), without documented indication, attempt for Gradual Dose Reduction (GDR, is the stepwise tapering of a dose to determine if symptoms, conditions, or risks can be managed by a lower dose or if the dose or medication can be discontinued), and as ordered by the physician for three of 37 sampled residents (Residents 29, 106, and 67). 1. For Resident 29, there was no documented evidence that a GDR was attempted for the use Abilify (medication used to treat certain mental/mood disorders) 30 milligrams (mg, a unit of measurement), daily for schizophrenia (a long-term mental disorder involving a breakdown in the relation between thought, emotion, and behavior, leading to faulty perception, inappropriate actions and feelings, withdrawal from reality and personal relationships), since 8/31/2018. 2. For Resident 106, there was no adequate…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 Medication Storage policy and procedure by failing to: 1. Ensure Resident 111's reusable medication (eye drop) was properly labeled. 2. Ensure staff's belongings were not stored inside the medication cart. 3. Ensure to monitor the room temperatures were medications were stored. 4. Ensure Resident 67 did not have a medicine cup with six pills unlabeled and unattended on her bedside table. These deficient practices had the potential to alter the use, effectiveness, and potency of medications. Findings: 1. During an observation and interview on [DATE] at 9:12 am, Licensed Vocational Nurse (LVN 4) stated the medication cart 1 at station 1 had an unlabeled GeriCare Artificial Tears Lubricant Eye Drops that belonged to Resident 111. During an interview on [DATE] at 9:14 am, LVN 4 stated there was no open date labeled for the eye drops. LVN 4 stated that any reusable medication that was opened, such as Resident 111's eye drops should…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 failed to accurately document medical records for two of 37 sampled residents (Resident 10 and 139). This deficient practice had the potential for an inaccurate record or lack of care being provided for the residents. Findings: a. A review of Resident 10's Face Sheet (admission record) indicated the facility admitted Resident 10 on 11/13/2017 with diagnoses of congestive heart failure (a chronic condition in which the heart cannot pump blood as it should which can potentially lead to heart failure) and presence of implanted pacemaker (a small device that is placed under the skin in the chest to help control one's heartbeat). A review of Resident 10's Minimum Data Set (MDS, a comprehensive standardized assessment and care screening tool) dated 5/3/2021 indicated Resident 10 was rarely understood, rarely ever able to understand others and cognitively impaired (when a person has trouble remembering, learning new things, concentrating or making decisions 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.