Highland Care Center of Redlands

Based on interview and record review, the facility failed to ensure accurate accountability of controlled substances (medications with a high potential for abuse and dependence) for one of five randomly selected residents reviewed for controlled substance accountability (Resident 83). The facility's Controlled Drug Record (CDR - inventory records used to document receipt, use, and count of controlled substances did not match the Medication Administration Record (MAR- a daily documentation record used by a licensed nurse to document medications and treatments given to a resident).This failure resulted in inaccurate accountability of a controlled substance and had the potential to result in diversion (controlled substances used by someone other than the resident for whom the medication was prescribed) or misuse of controlled substances and compromised resident medication safety. Findings:During an inspection of Medication Cart 1 at Nursing Station A on 6/9/26 at 1:01 PM in the presence of Licensed Vocational Nurse (LVN) 1, Resident 83's blister card (a type of medicine packaging where…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 remove a discontinued medication from active medication storage in one of two medication rooms (Nursing Station A Medication Room).This failure had the potential to result in inadvertent administration of a discontinued medication. Findings: During a medication room inspection on 6/9/26 at 12:13 PM in the presence of the Director of Nursing (DON), a prefilled syringe of Spikevax 2025-2026 (COVID-19 vaccine) labeled for Resident 17 was observed in the medication refrigerator located in Nursing Station A Medication Room with a date of 5/14/26. A review of Resident 17's physician's telephone order, dated 5/13/26, indicated, Moderna COVID-19 Bivalent (a vaccine formulated to protect against two virus strains or variants) Intramuscular (injected into a muscle) Suspension (a liquid medication) 50 MCG/0.5ML (microgram per milliliter - unit of measurement).Inject 0.5 ml intramuscularly one time only for COVID VACCINE until 05/14/2026 23:59 (11:59 PM). A review of Resident 17's Medication Administration Record (MAR -…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 keep the lids of two of three dumpsters closed which exposed the trash inside.This failure had the potential to attract pests to the premises which could spread disease to residents and staff in the facility.Findings:During a concurrent observation tour and interview on 6/8/26, at 8:53 AM, with the Dietary Supervisor (DS), in the facility's outside garbage area, two of three metal dumpsters were open. Several trash bags were exposed inside one dumpster and trash was observed in the other. The DS confirmed the lids of two metal dumpsters were left open and needed to be closed at all times to prevent harboring of pests. A review of the facility's policy and procedure (P&P) titled, Food-Related Garbage and Refuse Disposal, revised 10/2017, indicated, 7. Outside dumpsters provided by garbage pickup services will be kept closed and free of surrounding litter.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement its abuse prevention policies and procedures (P&P), which were designed to prohibit misappropriation of resident property, for one of three sampled residents (Resident 1) when Certified Nurse Assistant 1 (CNA 1) took Resident 1's credit card out of the facility.This failure resulted in Resident 1 to receive fraudulent charges and violation of resident trust in facility safeguards.Findings: During a review of Resident 1's face sheet (contains demographic and medical information), the face sheet indicated, Resident 1 was admitted to the facility on [DATE], with diagnoses which included partial intestinal obstruction (partial blockage of the intestines, but food, gas, and fluids can still get through) and muscle wasting (muscles are shrinking and getting weaker over time).During an interview on September 17, 2025, at 1:48 PM, with Resident 1, Resident 1 stated she requested CNA 1 to buy cigarettes from a local store using Resident 1's own…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 proper care was provided to prevent a right heel pressure ulcer (an injury to the skin or underlying tissue that develop from prolonged pressure), for one of three sampled residents (Resident 1).This failure had the potential to place Resident 1, a clinically compromised resident, at risk for further skin breakdown, which could affect his health and safety.Findings:During a review of Residents 1's admission Record (general demographics), the document indicated Resident 1 was admitted to the facility on [DATE], with diagnoses which included muscle wasting and atrophy (a condition with shrinking and loss of muscle), major depressive disorder (a condition with feeling of sadness and hopelessness), fracture of unspecified part of right clavicle ( broken right collarbone where the specific location of the break has not been detailed), fracture of right ilium (a break in the upper largest part of the hip bone), spinal stenosis (narrowing of the spinal…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 adequate supervision to one of three sampled residents (Resident 1) when Resident 1 eloped from the facility without the facility ' s knowledge on March 12, 2025. This failure had the potential to place Resident 1 at increased risk for falls and injuries, heat or cold exposure, dehydration, and/or death. Findings: During a review of Resident 1 ' s clinical record, the face sheet (contains demographic and medical information) indicated Resident 1 was admitted to the facility on [DATE], with diagnoses which included dementia (brain disorder that causes loss of memory, language, thinking abilities severe enough to interfere with daily life), hypertension (condition where the force of blood pushing against your artery walls is consistently too high), and mood affective disorder (mental health condition that affects your emotional state, causing long periods of extreme happiness or sadness). Further review indicated Resident 1 was 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.

Based on observation, interview, and record review, the facility failed to maintain sanitary conditions in the kitchen as required by the facility policy when: 1.The floors under equipment had accumulation of food crumbs, trash, and black grime (dirt). The food prep sink drain had residue build-up on the drainpipe and the wall. 2. The dry storage room had food crumbs and trash underneath shelves. The shelves had spill of a powder substance. 3. There were broken tiles, which provided a surface for an accumulation of food crumbs, in the dry storage room and in the main kitchen. 4. Food equipment (food processor, plate warmer, blender, and can opener) were stored with food crumbs and build up. 5. The clean utensil bins had food splash and crumbs. 6. The ice machine had black spots in the ice bin ceiling and yellow discoloration (change of natural color) in the ice chute (the part of the ice machine where ice drops into the ice bin). These failures have the potential to compromise food safety and increase the risk of foodborne illness (caused by the ingestion of contaminated food 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.

Based on observation, interview, and record review, the facility failed to ensure dignity was maintained for two of eleven residents (Residents 40 and 475) reviewed for dining observation when: 1. Licensed Vocational Nurse (LVN 2) was standing over Resident 40 while feeding her lunch on February 18, 2025. 2. Certified Nursing Assistant (CNA 4) pulled Resident 475 while he was on his wheelchair into the dining room, with his feet dragging on the floor, on February 18, 2025. These failures resulted in staff not maintaining and enhancing Residents 40 and 475's individuality and dignity, and had the potential to devalue and dishonor their self-esteem and self-worth. Findings: 1. During an observation on February 18, 2025, at 12:54 PM, in the Memory Care Unit's dining room, LVN 2 was standing over Resident 40 while feeding her lunch. During an interview on February 19, 2025, at 4:45 PM, CNA 5 stated the job expectation when feeding residents was to perform hand hygiene before, sit down beside residents hand hygiene after. During an interview with the Registered Dietician (RD), 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 their policy for assistive device and equipment (tool that helps a person with disability perform daily tasks) was being implemented for one of four residents (Resident 8) reviewed for range of motion (ROM - full movement potential of a joint) when Resident 8's hand splint (device applied to prevent or reduce contractures) was not applied as ordered. This failure had the potential to cause further contractures (when muscles, tendons or skin around a joint become permanently tight and shortened) discomfort and loss functional mobility negatively impacting Resident 8's quality of life and increasing the risk for preventable physical deterioration and pain. Findings: During a review of Resident 8's admission Record (contains demographic and medical information), it indicated Resident 8 was admitted to the facility on [DATE], with diagnoses of hemiplegia (paralysis or weakness on one side of the body), and hemiparesis (weakness 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 one of four residents (Resident 16) reviewed for respiratory received proper respiratory care in accordance with physicians' orders and professional standards of practice. Resident 16's oxygen tubing was found disconnected from the oxygen concentrator (medical device that provides extra oxygen) for approximately 15 minutes on February 18, 2025. This failure had the potential to cause respiratory distress, oxygen deprivation and other health complications due to insufficient oxygen supply, placing Resident 16's health at risk. Findings: During a review of Resident 16's admission Record (contains demographic and medical information), it indicated Resident 16 was admitted to the facility on [DATE], with diagnoses of chronic obstructive pulmonary disease (a long-term condition that make it hard to breath), dysphagia (difficulty of swallowing) and hypertension (elevated blood pressure). During a review of Resident 16's Physician Orders…

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

Based on observation, interview, and record review, the facility failed to maintain accurate records of controlled medications (also called narcotics; medications that are controlled by the government because it may be abused or cause addiction) for one of three narcotic medication carts (Unit Station A Cart Number 2). This failure had the potential for a diversion (illegal distribution of controlled drugs for any illicit use) of controlled medications by staff in a highly vulnerable population of 38 residents, who are in Unit Station A. Findings: During a concurrent interview and record review, on February 20, 2025, at 9:20 AM, with the Director of Nursing (DON), the Unit Station A Cart Number 2's Narcotic Count Record (NCR -form used by the facility to verify counting of controlled medications at the change of shift by oncoming and off going licensed nurses), dated February 1, 2025, to February 20, 2025, was reviewed. The NCR indicated the following: a. On February 5, 2025, missing signature from the night shift (11:00 AM - 7:00 PM) off going shift. b. On February 12, 2025,…

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

Based on observation, interview, and record review, the facility failed to ensure their policy for self-administration of medications was being implemented for one of four residents (Resident 50) reviewed for environment when Resident 50's self-administered medications were not stored in a safe and secure place. (Three white elongated pills were found in different areas in Resident 50's room.) This failure had the potential to place 72 medically compromised residents at risk for accidental ingestion or exposure to a medication that was not prescribed by the residents' physician. Findings: During a review of Resident 50's admission Record (contains demographic and medical information), it indicated Resident 50 was admitted to the facility with the diagnoses of multiple sclerosis (chronic autoimmune [the body fights itself] disease that affects the brain and spine), anemia (not having enough healthy red blood cells), and osteomyelitis (bone infection). During a review of Resident 50's Self-Administration of Medications Assessment, dated February 19, 2025, it indicated .6. Resident 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 ensure the diet ordered by the physician was followed for one of eleven residents (Resident 40) reviewed for dining observation when Resident 40 did not receive her physician ordered finger food diet (small, bite-sized foods that can be easily picked up and eaten with the fingers) for lunch on February 18, 2025. (Alternatively, Resident 40 received the regular diet.) This failure had the potential to result in Resident 40 to experience weight loss manifested by Resident 40 not meeting nutritional needs for 1 of 64 medically compromised residents who receive therapeutic food from the kitchen. Findings: During a review of Resident 40's admission Record (contains demographic and medical information), it indicated Resident 40 was admitted to the facility on [DATE], with the diagnoses of dehydration (loss of fluid in the body), Alzheimer's disease (disease that destroys memory) and schizoaffective disorder (chronic mental health 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 ensure proper and safe infection control practices were followed when: 1. Resident 10's oxygen nasal cannula tubing (device used to deliver oxygen into the nose via a tube) was found unlabeled and undated. 2. Resident 16's oxygen nasal cannula tubing was found unlabeled and undated. 3. A warm coffee cup was found on top of an intravenous (IV) medication cart (cart used for storage of intravenous medication solutions). These failures had the potential to result in cross-contamination (the transfer of harmful bacteria) causing a preventable infection to 72 highly vulnerable residents whose health conditions are already compromised. Findings: 1. During a review of Resident 10's admission Record (contains medical and demographic information), it indicated Resident 10 was admitted to the facility with the diagnoses which included acute respiratory failure with hypoxia (lungs are unable to exchange oxygen leading to low levels of oxygen 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.

Based on observation, interview, and record review, the facility failed to maintain equipment in safe operating condition when: 1. One of three refrigerators in the kitchen had missing side screws on the front grill leading to a detachment (falling off). 2. Resident Refrigerator had condensation (excessive moisture or water) on the back wall. 3. The electrical panel in the memory care unit (units designed to prevent wandering and specialized care for people with memory loss) was found open and unlocked These failures had the potential to place the health and safety of 72 of 72 medically compromised residents at risk. It had the potential to cause food to not be cooled properly, compromising 64 residents who could receive food from these refrigerators. And it also had the potential to place 34 medically compromised memory care residents at risk for accidental electrical shock. Findings: 1. During a concurrent observation and interview on February 18, 2025, at 8:10 AM, with the Dietary Services Supervisor (DSS), Refrigerator # 1, which was near the main entrance to the kitchen, 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 five residents (Resident 28) reviewed for environment was provided with adequate access to their call light system when Resident 28's call light was not accessible. This failure had the potential to place Resident 28's health and safety at risk because it could lead to delayed care and increased risk of harm in an emergency. Findings: During a review of Resident's 28's admission Record (contains demographic and medical information) indicated Resident 28 was admitted to the facility on [DATE], with diagnoses of hemiplegia (paralysis on one side of the body), and hemiparesis (weakness on one side of the body) following cerebral infarction affecting right dominant side, dysphagia (difficulty of swallowing) and hypertension (elevated blood pressure). During a review of Resident's 28's Care Plan for Risk for Fall/Injury, dated January 31, 2025, it indicated, Interventions .Call light within reach . During an observation 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 medication was administered according to the facility ' s policies and procedures (P&P) for one of three sample resident (Resident 1) when Keppra (medication used to treat and prevent seizures—an abnormal electrical activity in the brain that temporarily affects consciousness, muscle control, and behavior) was not administration to Resident 1. This failure potentially has caused Resident 1, who is clinically compromised, being transferred to Hospital for Seizure evaluation on May 3, 2024. Findings: During the review of Resident 1 ' s admission record (a document that gives a summary of resident's information), the document indicated Resident 1 was admitted to the facility on [DATE], with a diagnosis that included Epilepsy (a brain condition where a person experience recurring seizures), and Hemiplegia (a condition that causes paralysis or weakness on one side of the body). During a review of Resident 1 record titled Change 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, interviews, and record reviews the facility failed to ensure a resident Care Plan was fully implemented for one of four sampled residents (Resident 1) when Resident 1was not placed closer to the nursing station as indicated in the plan of care as a specified intervention following a fall. This failure had the potential to put a clinically compromised resident (Resident 1) at risk for serious injury due to falling. Resulting in Resident 1falling and being transferred to a general acute hospital for evaluation and treatment of injuries. Findings: During a review of Resident 1's clinical record, the face sheet (contains demographic and medical information), indicated Resident 1 was admitted on [DATE], with a diagnosis that included repeated falls, degenerative disease of the nervous system (progressive conditions that occur when nerve cells in the brain or peripheral nervous system [part of your nervous system that lies outside the brain and spinal cord. It plays a key role in both sending…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 allow one of three sampled residents (Resident 1) to return to the facility after a transfer to the hospital for evaluation. This failure resulted in the resident being denied reentry and being transferred to another acute hospital where he remains until new placement is found. Findings: During review of Residents 1 ' s admission Record (general demographics), the document indicated Resident 1 was admitted to the facility on [DATE], with diagnoses to include complication of ventricular intracranial shunt (shunt drains excess cerebrospinal fluid), hydrocephalus (buildup of fluid in the brain), muscle weakness, altered mental status (change in mental function delirium, dementia and psychosis) hypertension (high blood pressure). During a concurrent interview and record review of Resident 1 ' s Medical Record with the Administrator, reviewed are as follows: 1. Phone Order dated December 05, 2023, at 18:28: Resident may send out to Acute Hospital 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 follow the physician's order to monitor the whereabouts for one of six sampled residents (Resident 5). This failure had the potential to result in accident hazards and safety concerns for Resident 5. Findings: During an observation on September 5, 2023, at 10:30 AM, Resident 5 was observed to be in the dining room, sitting on a chair, at the table with other residents. During a review of Resident 5's admission Record, (contains demographic and medical information), the admission Record indicated, Resident 5 was admitted to the facility on [DATE], with diagnoses which included Alzheimer's disease ( brain disorder that slowly destroys memory and thinking skills), schizoaffective disorder (a mental illness that can affect your thoughts, mood and behavior), and bipolar disorder (a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration). During a concurrent interview and record review 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 protect the resident ' s right to be free from abuse (the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish), for two of three sampled residents (Residents 1 and 2), when: 1. A dietary staff member (Cook 1) yelled at Resident 1 on multiple occasions, when Resident 1 approached [NAME] 1 to request for meals alternatives. 2. A dietary staff member (Cook 1) yelled at Resident 2 on multiple occasions, when Resident 2 approached [NAME] 1 to request for meals alternatives. These failures had the potential for Resident 1 and 2 to experience psychosocial harm. Findings: 1. During a review of Resident 1 ' s admission Record (clinical record with demographic information), it indicated Resident 1 was admitted to the facility on [DATE], with diagnoses which included spastic quadriplegic cerebral palsy (brain damage causing stiff muscles in all extremities) and…

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

Based on observation, interview, and record review, the facility failed to ensure their abuse investigation and reporting policy and procedure was being implemented for two of three residents (Residents 1 and 2), when Residents 1 and 2 reported an allegation of verbal abuse (act of harassing, labeling, insulting, scolding, rebuking or excessive yelling towards an individual) from [NAME] 1, on July 11, 2023, and facility reported incident on July 14, 2023 (3 days after the allegation was made). This failure had the potential for Residents 1 and 2 not be protected from further potential abuse and experience psychosocial harm. Findings: During a concurrent observation and interview, on July 18, 2023, at 12:00 PM, inside of Resident 1 ' s room, Resident 1 was sitting on her wheelchair, in front of the nurses ' station. Resident 1 stated, on July 11, 2023, during the Resident Council Meeting, Resident 1 reported [NAME] 1 was rough when talked to. Resident 1 further stated she was afraid of her, when she needs to go to the kitchen for any request. Resident 1 stated it was an ongoing…

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

Based on observation, interview, and record review, the facility failed to maintain professional standards for food service safety when: 1. The top of the mantle above the stove, the coffee maker, and the beverage machine were dusty. 2. Inside the fridge, there was an opened package of slice ham in a closed plastic container, labeled with an expiration date of July 23, 2022 (three days expired), and one plastic four-quart container, which had unlabeled Styrofoam cups containing pink yogurt. 3. Two (2) sinks in the kitchen did not have an air gap (a separation of the drainpipe on a sink to prevent backflow of contaminated water during negative pressure). 4. The floors under the stove had broken pieces of a plate, food crumbs, and trash. These failures had the potential to expose 74 highly vulnerable residents who received food from the kitchen to food-borne illness (food poisoning). Findings: 1. During a concurrent observation and interview, with the Dietary Services Supervisor (DSS), on July 26, 2022, at 8:55 AM, in the kitchen, the top of the mantle above the stove, the coffee…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 dignity was maintained for one resident (Resident 64) reviewed for urinary catheter (a flexible tube used to empty the bladder and collect urine in a drainage bag) which was not covered by a dignity bag (bag that covers the urine collection bag). This failure had the potential to compromise Resident 64's dignity and violate his right to privacy, which could cause psychosocial harm and lead to low self-esteem, feeling irritated, sad, and anxious. Findings: During a review of Resident 64's clinical record, the admission Record (contains demographic and medical information) indicated, Resident 64 was admitted to the facility on [DATE], with diagnoses which included urinary tract infection (infection in any part of the urinary system), type 1 diabetes (a condition where the body does not produce enough insulin), depression (always feeling sad), and mild cognitive impairment (some loss of memory). During an observation in Resident 64's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure personal belongings were inventoried and documented upon admission, in accordance with the facility's policy and procedure, for one resident (Resident 181) reviewed for personal property. This failure had the potential to hinder the facility's ability to investigate any allegations of theft or loss due to a result in a lack of documentation of Resident 181's personal belongings. Findings: During a review of Resident 181's medical record, the admission Record (contains demographic and medical information), indicated Resident 181 was admitted to the facility on [DATE], with diagnoses which included muscle wasting and atrophy (loss of muscle mass), depression (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), and obesity. During a concurrent interview and record review, with the Social Services Director (SSD), on July 29, 2022, at 11:55…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 prior or upon admission, the staff inquired about any existing advance directive (a legal document that explains how an individual wants medical decisions to be made if the individual is incapable of making their own decisions) for four of five residents (Residents 19, 59, 73, and 75) reviewed for advance directives. This failure had the potential for Residents 19, 59, 73, and 75 to receive an end of life care which was not in accordance with their wishes, and to recieve life sustaining measures to be rendered against what the residents wanted. Findings: 1. During a review of Resident 19's clinical record, the admission Record (contains demographic and medical information) indicated, Resident 19 was admitted to the facility on [DATE], with diagnoses which included hypotension (low blood pressure), type 2 diabetes mellitus (chronic condition in which the body does not produce enough insulin) and asthma (condition in which airways…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 the Minimum Data Set Assessment (MDS- a computerized assessment instrument) for one resident (Resident 41) reviewed for restraints. This failure had the potential to cause inaccuracy in identifying Resident 41's care and support needs. Findings: During a review of Resident 41's clinical record, the admission Record (contains demographic and clinical data), indicated, Resident 41 was admitted to the facility on [DATE], with diagnoses which included dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life) and bipolar disorder (mental health problem). A review of Resident 41's physician's order, dated November 22, 2021, indicated .Order Summary: .May apply lap buddy [a cushioned device that snugs into the frame of the wheelchair, placed across the lap] when up in w/c [wheelchair] for proper body alignment and positioning due to poor body trunk control; and 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 the safe oxygen administration for two of four residents (Residents 59 and 79) reviewed for respiratory care, when Residents 59 and 79's rooms did not have oxygen in use/no smoking signs posted outside their entrance doors as indicated in the facility's policy and procedure. This failure had the potential to increase the risk of fire in the facility, due to the lack of signage indicating a gas (oxygen) was in use in the rooms of Residents 59 and 79. Findings: 1. During a review of Resident 59's medical record, the admission Record (contains demographic and medical information), indicated Resident 59 was admitted to the facility on [DATE], with diagnoses which included chronic obstructive pulmonary disease (COPD- disease which makes it difficult to breathe), asthma (narrowing of the airways in the lungs), and malignant neoplasm of bronchus or lung (lung cancer). A review of Resident 59's physician's orders, dated June 27, 2022,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 oxygen administration were provided in accordance with the physician's orders and care plans (an individualized plan for the medical care of a resident) for two of four residents (Residents 59 and 53) reviewed for respiratory care when Residents 59 and 53's nasal cannulas (a device which delivers oxygen utilizing a tube) were not replaced after seven days of use. This failure had the potential for unmet care needs for Resident's 59 and 53 due to them not receiving care and services specified in their physician's and care plan. Findings: 1. During a review of Resident 59's medical record, the admission Record (contains demographic and medical information), indicated Resident 59 was admitted to the facility on [DATE], with diagnoses which included chronic obstructive pulmonary disease (COPD - disease which makes it difficult to breathe), asthma (narrowing of the airways in the lungs), and malignant neoplasm of bronchus or lung…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 staff members were provided training on advance directives (a legal document that explains how an individual wants medical decisions to be made if the individual is incapable of making their own decisions) in accordance with the facility's policies and procedures. This failure had the potential for 76 residents to not be properly assessed for current existing advance directives, or educated on, and assisted with the process of establishing a new advance directive. Findings: During an interview, with the Social Services Director (SSD), on July 29, 2022, at 9:00 AM, the SSD stated her department was responsible for educating residents and assisting them in establishing an advance directive if they desired. The SSD further stated she had not conducted any staff training regarding advance directives. During an interview, with a Licensed Vocational Nurse (LVN 4), on July 29, 2022, at 9:54 AM, LVN 4 stated she had worked at the facility for 10 months but had not received any training regarding advance directives. 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.

Based on observation, interview, and record review, the facility failed to maintain accurate records of controlled medications (medications that are controlled by the government because it may be abused or cause addiction) for two of three medication carts (Unit A Cart 2 and Unit B Cart 3). These failures had the potential for drug diversion (illegal distribution of controlled drugs for any illicit use) of controlled medications by staff in a highly vulnerable population of 76 residents. Findings: 1. During a concurrent observation and interview, with the Director of Nursing (DON) and Licensed Vocational Nurse (LVN 3), on July 27, 2022, at 8:07 AM, the Unit A Medication Cart 2's Narcotic Count Record (NCR- narcotic records, a form used by the facility to verify counting of controlled drugs at the change of shift by oncoming and off going licensed nurses), dated July 1, 2022, to July 27, 2022, was reviewed. The NCR indicated the following: a. On July 17, 2022, missing signature from the night shift (11:00 PM- 7:00 AM) oncoming nurse. b. On July 18, 2022, missing signatures from the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure accurate documentations for three residents (Residents 73, 24, and 26) when: 1. For Resident 73, the code status (the type of emergent treatment a person would or would not receive if their heart or breathing were to stop) was documented as full code (attempt full resuscitation measures) in the physical chart, and indicated Do Not Resuscitate (DNR - do not attempt resuscitative measures) in the electronic health record (EHR). This failure had the potential for a delay in treatment due to conflicting documented code status for Resident 73. 2. For Resident 24, Resident 24 had a physician's order of fortified (nutrients added to food that don't naturally occur in the food to improve nutrition and add health benefits) high protein mechanical soft (texture-modified diet) and was observed on two separate occasions with a tray card (contains what diet the resident must recieve) which indicated regular mechanical soft. This failure had the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure their infection control program was implemented for one resident (Resident 64) reviewed for urinary catheter (a bag that collects urine, which connects to a tube that drains the bladder) when Resident 64's urinary catheter bag was found completely resting on the floor. This failure had the potential to jeopardize Resident 64's health and safety due to cross contamination of infectious microorganisms via his urinary catheter bag. Findings: During a review of Resident 64's clinical record, the admission Record (contains demographic and medical information) indicated, Resident 64 was admitted to the facility on [DATE], with diagnoses which includes urinary tract infection (infection of the kidneys or bladder), type 1 diabetes (a condition where the body does not produce enough insulin), and mild cognitive impairment (some loss of memory). During a concurrent observation and interview, with Certified Nursing Assistant (CNA 2), 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.