Citrus Grove Post Acute

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to treat residents with dignity and respect for three of three residents reviewed for dignity (Residents 6, 123, and 124) when:1. Resident 123 did not receive her meal at the same time as her roommate. 2. Resident 6's Foley catheter drainage bag was left uncovered and exposed; and3. A staff entered Resident 124's room without knocking. These failures had the potential to negatively affect the resident's dignity, comfort, and psychosocial well-being.Findings: 1. On December 8, 2025, at 12:55 p.m., Resident 123 was observed exiting her room and asking when her lunch would be arriving. Resident 123 stated that her roommate was already eating her lunch and that she was hungry. During a concurrent observation, Resident 123's roommate was observed with her meal tray approximately halfway consumed. On December 8, 2025, at 1:12 p.m., an interview was conducted with Certified Nursing Assistant 2 (CNA 2). CNA 2 stated she had just served Resident…

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

Based on interview and record review, the facility failed to provide a written notice of bed hold (holding or reserving a resident's bed while the resident is absent from the facility for therapeutic leave or hospitalization) to the resident or resident representative (RP) at the time of transfer to an acute care hospital for one of three residents reviewed for closed records (Resident 3). This failure had the potential for residents and/or their RPs not being fully informed of bed-hold rights or the right to return to the facility following hospitalization which could lead to an inappropriate discharge. Findings:A review of Resident 3's admission Record indicated Resident 3 was admitted to the facility July 7, 2022, with diagnoses which included depression (mood disorder).A review of the Nurse Progress Note dated December 6, 2025, at 8:44a.m., indicated, .Resident departed facility at approx (approximately) 0840 (8:40 a.m.) .Resident was sent to (name of hospital) for further evaluation .Resident alert and verbally responsive at time of departure . A review of the facility document…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow facility's policy and procedures for two of five residents reviewed (Residents 1 and 51) when:1. Staff did not properly identify a resident (Resident 51) and ensure the correct breakfast was served.This failure had the potential to result in adverse reactions due to receiving an incorrect diet and to cause emotional distress. 2. Staff did not change the resident's nasal cannula (a medical device used to deliver supplemental oxygen) on a weekly basis.This failure had the potential to result in cross-contamination and increased risk of infection. 1. On December 10, 2025, at 8:05 a.m. an interview was conducted with Resident 51. Resident 51 stated the breakfast tray that was initially served had another resident's name on the meal ticket and was not intended for him. Resident 51 stated, They didn't even know it was for someone else!A review of Resident 51's admission Record dated December 10, 2025, indicated an admission date of June 11, 2025, with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide the necessary care and services to maintain cleanliness and proper hygiene when staff failed to clean and trim the resident's fingernails, leaving them long and discolored for one of three residents reviewed (Resident 6).This failure had the potential for Resident 6 at risk for infection and injury due to the unhygienic condition of the resident's fingernails.Findings:A review of Resident 6's medical records indicated the resident was admitted to the facility on [DATE], with diagnoses which included dementia (decline in mental ability) and diabetes (high blood sugar).On December 9, 2025, at 11:08 a.m., an observation was conducted of Resident 6. Resident 6 was observed sitting on his bed, awake, with fingernails that were long and yellowish in color.On December 9, 2025, at 11:18 a.m., a concurrent observation and interview were conducted with Certified Nursing Assistant (CNA 1) regarding Resident 6's fingernails. CNA 1 stated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide pharmaceutical services to meet the needs of one of seven sampled residents (Resident 49) when one medication was documented as administered on December 7, 2025, could not be accounted for as being available for administration as the medication was not received by the facility until December 9, 2025.This deficient practice had the potential for Resident 49's health and well-being to be negatively impacted due to unintended consequences, including decreased medication effectiveness and the potential for adverse reactions (an unwanted effect caused by the administration of a drug). Findings: On December 8, 2025, at 3:38 p.m., Resident 49 stated he had not received his medication Nuedexta (a prescription medication used to to treat pseudobulbar affect [PBA - a condition that causes a person to have sudden, uncontrollable episodes of laughing or crying that do not match how they actually feel]) to help control his cognitive abilities…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the physician reviewed and addressed the Consultant Pharmacist (CP) recommendations during the monthly Medication Regimen Review (MRR), for one of five residents reviewed for unnecessary medications (Resident 13) when Resident 13's recommended gradual dose reduction of buspirone (antianxiety medication) was not addressed by the physician.This failure had the potential to result in continued unnecessary psychotropic medication use. Findings:A review of Resident 13's admission Record indicated the resident was admitted to the facility on [DATE], with diagnoses which included dementia (forgetfulness) and bipolar disorder (mental illness).A review of Resident 13's History and Physical Examination dated July 31, 2025, indicated the resident had fluctuating decision making capacity.A review of Resident 13's CP recommendation to the attending Physician dated October 2025, indicated Resident 13 was receiving buspirone (anti- anxiety) 20 mg three times…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 required Enhanced Barrier Precautions (EBP-an infection control intervention to reduce transmission of multidrug-resistant organisms [MDRO- bacteria that have become resistant to multiple antibiotics), for one of ten residents reviewed (Resident 93) when Licensed Vocational Nurse (LVN 5) did not don required personal protective equipment (PPE - equipment, such as gloves and gown, used to protect against infection or illness) while providing direct bedside care to Resident 93, who was on enhanced barrier precaution.This failure had the potential to result in cross-contamination, increasing the risk for transmission of infection among a vulnerable resident population.Findings:On December 10, 2025, at 8:30 a.m., an EBP sign was observed posted outside Resident 93's room. LVN 5 was observed inside Resident 93's room without wearing a gown while administering oral medications, eye drops, and a breathing treatment. On December 10,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, it has been determined that the facility did not ensure that wound and skin documentation accurately reflected the conditions of the residents during daily and weekly assessments, in accordance with current professional standards of practice, for all four sampled residents (Residents 1, 2, 3, and 4). This failure had the potential to result in inadequate monitoring of wounds and skin integrity. missed changes in condition, and delayed interventions, placing residents at risk for complications and worsening existing conditions. Findings: On July 31, 2025, a review of Resident 1's record was conducted. Resident 1 was admitted to the facility on [DATE], and discharged on June 30, 2025, with diagnoses which included cerebral infarction (portion of the brain with debilitated or weakened function) and unspecified convulsions (uncontrolled shaking of the body). A review of the History and Physical, dated June 29, 2025, indicated Resident 1 has the capacity to make decisions.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 conduct an ongoing monitoring and supervision for use of bed rails for four of six residents reviewed, (Residents 1, 2, 5 and 6)This had the potential to cause Residents 1, 2, 5, and 6 to be at risk for entrapment or injury for falls.Findings:On July 31, 2025, Resident 1's record was reviewed. Resident 1 was admitted to the facility on [DATE], readmitted [DATE], and discharged on July 22, 2025, with a diagnosis which included hemiplegia and hemiparesis following cerebral infarction (loss of function of one side of the body with brain dysfunction) affecting the right dominant side, and traumatic brain injury.A review of the History and Physical dated March 13, 2025, indicated, .Resident 1 does not have capacity to understand and make decisions.A review of the Physicians order dated June 14, 2023, indicated, .side rail one half x 2 up in bed as enabler to assist with bed mobility -nonrestraint.active.A review of the Bed safety assessment…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that food provided to a resident on a puree diet ( a type of texture-modified diet where all foods are blended to a smooth, pudding-like consistency) was given as ordered by the physician, when a cotton candy was given for consumption for one of three sampled residents (Resident 1). This failure had the potential to place Resident 1 at risk for choking or aspiration. Findings: On May 13, 2025, Resident 1's record was reviewed. Resident 1 was admitted to the facility on [DATE], with diagnoses which included dysphagia (difficult swallowing). A review of Resident 1's History and Physical dated March 15, 2024, indicated, Resident 1 had the capacity to understand and make decisions. A review of Resident 1's Physician Order, dated June 13, 2024, indicated, Fortified diet [additional nutrients have been added to foods] Puree texture, Nectar/Mildly Thick Liquids consistency, LARGE PORTIONS. A review of Resident 1's Care Plan, dated June 13, 2025,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure that reasonable accommodation were made for one of three sampled residents reviewed (Resident A), when the call light was placed on the weaker side. This failure had the potential to result in Resident A being unable to request assistance, leading to unmet needs and possible delays in care. Findings: On April 9, 2025, at 9:20 a.m., an unannounced visit to the facility was conducted to investigate an allegation of neglect. On April 11, 2025, at 11:38 a.m., Resident A's call light was observed clipped to the bedrails on the left side. A review of Resident A's admission Record, indicated Resident A was admitted to the facility on [DATE], with diagnoses which included cerebral infarction- stroke- death of brain tissue due to inadequate blood supply) and contracture (tightening of muscles and tendon causing shortening and stiffness of joints) left upper arm. A review of Resident A's Minimum Data Set (an assessment tool) dated April 9,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 adequate linens for two of three residents (Resident 2 and 3). This failure had the potential to delay care and unmet needs for Resident 2 and 3. Findings: On February 13, 2025, at 11:05 a.m., during an interview with Resident 2, she stated she had to wait to be changed or showered due to facility had no linens, washcloths and towels available. Resident 2 further stated it gets frustrating, but the staff do what they can and try to find linens. On February 13, 2025, at 11:25 a.m., during an interview with Resident 3, she stated the facility do not have linens, washcloths and towels and she had to wait to be changed or showered until linens become available. On February 13, 2025, at 11:39 a.m., during a concurrent observation and interview of the linen closets in nursing stations one and two, with Licensed Vocational Nurse (LVN) 1, inside the linen closets, there were no linens, washcloths, and towels. LVN 1 stated he had received multiple complaints from Certified Nurse Assistants (CNA's) about not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to complete a post-dialysis (a medical treatment that removes waste, excess fluids, and toxins from the blood when the kidneys are no longer able to function properly) assessments on December 27, 2024, and December 31, 2024, for one of three sampled residents (Resident 1). This failure had the potential to result in an increased risk of undetected complications post hemodialysis and delayed medical interventions. Findings: A review of Resident 1's, admission Record indicated Resident 1 was admitted to the facility on [DATE], with diagnoses which included end stage renal disease (an irreversible kidney failure) and diabetes mellitus (abnormal blood sugar level). A review of Resident 1's Dialysis Communication Record, dated December 27, 2024, and December 31, 2021, indicated no post hemodialysis assessments were completed on December 27, 2024 , and December 31, 2024. On January 29, 2025, at 2:10 p.m., during a concurrent interview and record review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide hand hygiene before a meal to one of three sampled residents (Resident 1). This failure had the potential to expose Resident 1 to bacterial contamination from unclean hands and increasing the risk of infection. Findings: A review of Resident 1's, admission Record indicated Resident 1 was admitted to the facility on [DATE], with diagnoses which included end stage renal disease (an irreversible kidney failure), blind right and left eye category, and osteomyelitis (inflammation of bone). On January 29. 2025 at 1:01 p.m., during an observation of lunch service in Resident 1's room, the CNA was observed serving lunch to Resident 1. The CNA held Resident 1's hand, which had red residue under the fingernails. The CNA had Resident 1 touched the food to identify the meal served. The CNA did not offer or provide hand wipes or hand hygiene before Resident 1 touched and ate his food. On January 29, 2025, at 1:10 p.m., during an interview, CNA…

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

Based on observation, interview, and record review, the facility failed to ensure that staffing information was accesible to residents and visitors. This failure had the potential for residents and visitors from being able to view the level of care provided, including the number of certified nursing assistants, licensed nurses, and other available staff to assist. Findings: On January 2, 2025, at 9:15 a.m., an unannounced visit to the facility was conducted to investigate an allegation regarding a nursing service staffing issue. On January 2, 2025, at 9:20 a.m., during observation at the reception area, the staffing information was found hidden, having fallen between the front glass window and the receptionist desk. On January 2, 2025, at 9:25 a.m., during an interview with the Director of Staff Development (DSD), the DSD stated the staffing information should be posted in a visible area daily at the start of shift. The DSD further stated the posted staffing information did not reflect the current date. The DSD further stated, the Census and Direct Care Service Hours Per Patient Per…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the food preferences of one of three residents (Resident A) were honored when pork loin was served on Resident A's dinner tray. This failure had the potential in the resident eating less or skipping meals, leading to weight loss. Findings: On January 2, 2025, at 9:15 a.m., an unannounced visit to the facility was conducted to investigate an allegation of a dietary service issue. On January 2, 2025, at 9:15 a.m., during an interview with Resident A, Resident A stated that on December 20, 2024, his evening meal tray included pork loin, eventhough his meal ticket clearly indicated in large letters NO PORK. Resident A further stated that his was not an isolated incident and had occurred multiple times in the past. Resident A stated he kept the meal ticket from the days he was served pork. On January 2, 2025, during a review of Resident A ' s admission Record, it indicated Resident A was admitted to the facility on [DATE], with diagnoses which…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 and conduct a self-administration assessment for one of two residents reviewed for self-administration of medication (Residents 34). This failure had the potential to result in an unsafe administration of medication for Resident 34. Findings: 1.On October 14, 2024, at 9:25 a.m., during a concurrent observation and interview inside Resident 34's room. Resident 34 was observed sitting in bed. Two clear cups containing a clear gel was observed on top of Resident 34's bedside table. Resident 34 stated the clear get was an A&D ointment (medication used to treat minor skin irritations). Resident 34 further stated he self-administered the ointment for his scratches on his arms, and the licensed nurses were aware. On October 14, 2024, at 11:00 a.m., Resident 34's record was reviewed. Resident 34 was admitted to the facility on [DATE]. Further review of Resident 34's medical records indicated Resident 34 was not assessed 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.

Based on observation, interview, and record review, the facility failed to ensure expired medications were discarded and not readily available for use when multiple oral medications were observed in the medication cart. This failure had the potential to result in the administration of expired medications to residents. Findings: On October 16, 2024, at 2:42 p.m., during a concurrent observation and interview with Licensed Vocational Nurse (LVN) 5 of the medication cart in Station One, the following were observed: - Gabapentin (medication use to treat nerve pain and seizures) 100 mg (milligram - unit of measurement) capsule with an expiration date of May 21, 2024. - Tramadol HCL (Narcotic - a drug that can cause insensibility or stupor) 50 mg tablet with an expiration date of October 9, 2024. - Dicyclomine (medication use to treat abdominal pain and spasm) 20 mg tablet with an expiration date of October 12, 2024. LVN 5 stated expired medication should be removed from the medication cart and destroyed or given to the Director of Nursing (DON) for disposal if the medication is 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 ensure two dietary staff members were able to provide proper nutrition services for a population of 95 residents who eat in the facility when: 1. The Dietary Aide was unable to accurately demonstrate the concentration of the chlorine sanitizing solution (solution used killing bacteria on food contact surfaces); and 2. The [NAME] was unable to verbalize proper cool down process for food. These failures had the potential to expose residents to foodborne illnesses (illnesses resulting from eating contaminated food). Findings: 1. On October 16, 2024, at 9:09 a.m., a concurrent observation, interview, and review of the manufacturer's instruction for the chlorine test paper were conducted with the Dietary Aide (DA). The DA was observed testing the concentration of the chlorine sanitizing solution. The DA obtained a test strip from the chlorine test paper container, dipped the strip into the chlorine sanitizing solution for five seconds, and then compared the strip to a color chart on the container. The DA read 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 proper infection control measures were implemented when: 1. The Licensed Vocational Nurse (LVN 1) did not change gloves and perform hand hygiene during wound care for one of one resident reviewed for pressure injury (Resident 67). 2. Two clean linen closets were not kept clean. 3. A licensed nurse did not wear PPE (Personal Protective Equipment- equipment use to protect against infection or illness) in transmission based precaution room (room used to isolate residents). These failures had the potential to result in cross-contamination, increasing the spread of infection to an already vulnerable population of residents in the facility. Findings: On October 15, 2024, at 9:45 a.m., during a wound care observation in Resident 67's room, with LVN 1, LVN 1 removed and discarded the soiled wound dressing (a type of bandage used to cover a wound) and proceeded to clean Resident 67's wound with normal saline (a sterile solution of salt 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 ensure dignity was provided for two of two residents reviewed for dignity (Residents 2 and 27) when: 1. The Certified Nursing Assistant (CNA) did not provide assistance and allowed Resident 2 to soil herself; and 2. Resident 27's lunch tray was not provided at the same time as the other residents. These failures had the potential to affect Residents 2 and 27's self-worth and self-esteem. Findings: 1. On October 16, 2024, at 4 p.m., during an observation inside Resident 2's room, Resident 2 stated, she needed assistance to go to the bathroom. CNA 1 came in and Resident 2 requested assistance to go to the bathroom. CNA 1 told Resident 2 to use her incontinence pad and he would change it later. On October 16, 2024, a review of Resident 2's admission Record indicated, Resident 2 was admitted to the facility August 16, 2021, with diagnoses which included Alzheimer's disease (a brain disorder that affects memory). On October 16, 2024, a review of Resident 2's Care plan indicated .Focus- The Resident has Bowel…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 physical abuse involving Residents 30 and 310 to the California Department of Public Health (CDPH) immediately, and no later than two hours after the allegation was made, for two of two residents reviewed for abuse (Residents 30 and 310). This failure had the potential to delay the implementation of appropriate action and protection for the residents, placing them at risk for further abuse. Findings: On October 14, 2024, a review of Resident 310's admission Record, indicated, Resident 310 was admitted to the facility on [DATE], with diagnoses which included anxiety (feeling of fear, dread, and uneasiness). During a review of Resident 310's Change in Condition, dated October 13, 2024, indicated, .Resident stated another resident (Resident 30) .allegely (sic) bumped into her wheelchair with her walker intentionally. Resident she feels threatened by this resident and due to this incident, resident is now undergoing 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure the plan of care (POC) was updated for one of 21 residents reviewed (Resident 83). This failure resulted in the licensed nurse being unaware of Resident 83's current condition and POC. Findings: On October 16, 2024, at 8:09 a.m., during the medication administration observation with Licensed Vocational Nurse (LVN) 4 a Contact Precaution (measures used to prevent the spread of infections) sign was observed outside Resident 83's room. LVN 4 entered and exited the room, provided care, and administered oral medications to Resident 83 without donning (putting on) and doffing (taking off) PPE (Personal Protective equipment - equipment worn to prevent exposure and spread of illness and infection) On October 16, 2024, at 9:35 a.m., during an interview with LVN 4, she stated she did not know the reason Resident 83 was on contact precautions. On October 16, 2024, Resident 83's record was reviewed. Resident 83 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 that two out of three residents reviewed for quality of care (Residents 34 and 55) had a physician's order for medication administration. This failure had the potential to result in medical complications and unforeseen side effects related to unprescribed medications. Findings: 1. On October 14, 2024, at 9:25 a.m., during a concurrent observation and interview inside Resident 34's room. Resident 34 was observed sitting in bed. Two clear cups containing a clear gel was observed on top of Resident 34's bedside table. Resident 34 stated the clear gel was an A&D ointment (medication used to treat minor skin irritations). Resident 34 further stated he self-administered the ointment for his scratches on his arms, and the licensed nurses were aware. On October 14, 2024, at 11:00 a.m., Resident 34's record was reviewed. Resident 34 was admitted to the facility on [DATE]. Further review of Resident 34's Order Summary Report, for the month…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the care plan intervention for fall was implemented for one of one resident reviewed for fall (Resident 209). This failure had the potential to increase the risk of further falls or injury for Resident 209. Findings: On October 16, 2024, at 11:30 a.m., during an observation, Resident 209 was inside his room, lying in bed with no floor mat in place. A review of Resident 209's admission Record, indicated, Resident 209 was admitted to the facility on [DATE], with diagnoses that included altered mental status and unsteadiness on feet. A review of Resident 209's care plan, dated June 30, 2024, indicated, Resident is at risk for falls r/t (related to) history of falls .Interventions: fall mats (equipment used to protect patients from serious injuries) . On October 16, 2024, at 12:15 p.m., during a concurrent observation and interview with Licensed Vocational Nurse (LVN) 3, LVN 3 stated Resident 209 was a fall risk and had an order 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 that proper care and treatment services for oxygen (O2) were provided for two of three sampled residents (Residents 34 and 59) when: 1. Oxygen tubing for Residents 34's and 59's was not date-labeled. 2. Resident 59 did not have a physician's order for oxygen therapy. These failures had the potential to place Residents 34 and 59 at risk of respiratory infection and unnecessary respiratory care. Findings: 1a. On October 14, 2024, at 10:18 a.m., Resident 34 was observed sitting in bed with a nasal cannula (a device used to deliver oxygen) attached to his nose with oxygen set at two liters per minute (LPM- unit of measurement). Resident 34's nasal cannula tubing was not date-labeled. A review of Resident 34's Order Summary Report for the month of October 2024, indicated, May have PRN (as needed) O2 on 2L (two liters) for SOB as needed. On October 14, 2024, at 3:30 p.m., during an observation and interview with the Licensed Vocational…

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

Based on observation, interview, and record review, the facility failed to ensure that food brought by visitor and family members was not expired and was safe for consumption. This failure had the potential for the residents to be exposed to foodborne illness. Findings: On October 16, 2024, at 8:40 a.m., a concurrent observation of residents' food refrigerator and interview with Assistant Director of Nursing (ADON) were conducted. Food items in a freezer bag, belonging to Resident 26 were observed in residents' food refrigerator. The following food items were noted: a. Eight cooked hot dogs placed in four ziplock bags, not date-labeled; b. One piece of croissant bread with a discard date of August 30, 2024; c. One turkey provolone and pesto ciabatta sandwich, labeled enjoy by August 31, 2024; and d. One egg sandwich with a discard date of July 20, 2024. The ADON stated, these food items should have been discarded and it would be unsafe to serve the food to the resident due to potential for foodborne illness. During a review of undated facility policy and procedure titled Foods…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 physician order was transcribed into the resident's electronic medical record (EMR) for one of 21 residents reviewed (Resident 83). This failure had the potential to affect Resident 83's overall health and well-being. Findings: Resident 83's admission Record was reviewed. Resident 83 was admitted to the facility on [DATE], with diagnosis which included sepsis (life threatening complication of an infection). A review of Resident 83's Order Summary Report for the month of October 2024, indicated Resident 83 did not have a physician order for contact isolation (a type of precaution to prevent the spread of infectious agents that can be transmitted through direct or indirect contact). On October 16, 2024, at 10:43 a.m., during an interview and review of Resident 83's Order Audit Report with the Infection Preventionist (IP), she stated, upon receipt of a physician order, the order should be transcribed into the resident medical record at the time…

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

Based on observation, interview, and record review, the facility failed to ensure the resident's call light was functioning at all times, for one of two residents reviewed for environment (Resident 67). This failure had the potential for Resident 67 to not be able to call for assistance when needed. Findings: On October 17, 2024, at 9:09 a.m., during a concurrent observation and interview of Resident 67 in his room, Resident 67 stated his call light was not working. Resident 67 pressed the call button, the light near the bed did not activate nor the dome light found outside the resident room. On October 17, 2024, at 9:10 a.m., during a concurrent observation and interview with Certified Nurse Assistant (CNA) 2. CNA 2 tested Resident 67's call light and stated the resident's call light was not working. CNA 2 stated Resident 67 used his call light to request for assistance and the call light should be fixed right away. During a review of facility policy and procedure titled Answering the Call Light, dated September 2022, indicated .Be sure that the call light is .functioning at all…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to notify the Resident Representative (a person assigned by the resident to make medical decisions in the event the resident is unable), when a new medication Lorazepam (a medication used to manage feelings of anxiety [feeling of worry, nervousness, or unease about something]) was added to the resident's medication regimen, for one of three sampled residents (Resident 1). This failure had the potential for the Resident 1's Representative to be unaware of Resident 1's care which could affect the resident's health and safety. Findings: On July 23, 2024, at 8:20 a.m., an unannounced visit was made to the facility to investigate a resident rights issue. On July 23, 2024, at 12:35 p.m., an interview was conducted with Resident 1's Representative (RR), who stated, the resident appeared drugged, when she visited him, and was concerned the resident was being over medicated. The RR further stated, at that time, she had not been notified by the facility 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.

Based on interview and record review, the facility failed to follow-up on a Letter of Agreement ({LOA}- an agreement of provided services between the facility and an uncontracted company), for hospice (End of life care) for one of three sampled residents (Resident 1). This failure resulted in the inability for Resident 1 to change hospice services, to a hospice of their choice. Findings: On July 23, 2024, at 8:20 a.m., an unannounced visit was made to the facility to investigate a resident rights issue. On July 23, 2024, at 12:35 p.m., an interview was conducted with Resident 1's Representative (RR - a person assigned to make medical decisions in the event the resident is unable), who stated, the resident was on hospice care at the facility. The RR stated the facility told them they could use any hospice of their choice. The RR stated, they found a new hospice and they wished to change Resident 1's care too. The RR stated, the new hospice had reached out to the facility for approval, and representative/new hospice had not received a response from the facility. The RR stated it had…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide care and services to maintain good personal hygiene when one of four sampled residents' (Resident 2) fingernails were not cleaned as part of daily grooming. The resident was observed to have dark brown debris under her fingernails on her right hand. This failure had the potential to negatively affect the resident's physical and psychosocial well-being. Findings: On January 16, 2024, at 10 a.m., an unannounced visit was conducted at the facility for the investigation of a quality-of-care complaint. On January 16, 2024, at 10:29 a.m., Resident 2 was observed lying in bed. Resident 2 was observed with dark brown debris under the fingernails on her right hand. Resident 2 stated, her fingernails were not clean. On January 16, 2024, at 10:48 a.m., an interview was conducted with Restorative Nursing Assistant (RNA- a certified nursing assistant that has been trained in range of motion and exercises) 1. RNA 1 stated, resident fingernails…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 clean and safe environment, as: 1) 3 out of 10 residents ' toilets were observed to be dirty with a black ring inside the toilet bowl at the water line. 2) The entrance/exit to nursing station1 was blocked with a trash can, and 20-gallon console, to prevent RN1 ' s puppy from exiting the nursing station. This failure had the potential to spread microorganisms and infections to the residents from the dirty toilets, and could result in a delay of care to the Residents if a staff member was unable to reach a Resident in a timely manner in the event of an emergency due to a blocked doorway at the nurses station. Findings: On October 05, 2023, at 8:40 a.m., an unannounced visit was made to the facility for a Quality-of-Care issue. On October 05, 2023, at 12:02 p.m., an interview was conducted with the Housekeeping Laundry Manager (HLM). HLM indicated, resident toilets Should be white and clean inside and out. 1) On October 5, 2023, at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide the following in accordance with the physician order: 1. For Resident B, the morning long-acting insulin; and 2. For Resident C the injectable Humira. These failures increased the risk of complication for Residents B and C's current medical condition. Findings: On June 27, 2023, at 11:00 a.m., an unannounced visit was conducted to investigate a facility reported incident. 1. A review of Resident B's medical record indicated, Resident B was admitted to the facility on [DATE], with diagnoses which included Type 1 Diabetes Mellitus (a condition where the pancreas produces little to no insulin). A review of Resident B's Order Summary Report, dated June 27, 2023, indicated the following: -Tresiba Flex Touch Insulin (used to regulate the body's energy supply) Solution, inject 22 units (a type of measurement) Subcutaneous (SQ- applied under the skin) in the morning; and -Dexcom G-6 (continuous glucose monitoring system), change site every 10 days. On…

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

Based on observation, interview, and record review, the facility failed to ensure an outbreak was reported on September 6, 2023, when a staff and a resident was reported with symptoms and had tested positive for COVID-19 infection (an infectious disease caused by SARS-CoV-2 Virus). The facility failure had delayed early intervention to monitor and prevent virus spread and proliferation as reporting was intended to facilitate timely intervention. Findings: On September 15, 2023, at 1:25 p.m., an unannounced visit was conducted to investigate allegation of COVID-19 Outbreak. On September 15, 2023, the facility record was reviewed. The LTC (Long Term Care) Respiratory Surveillance Line List , for residents had a total 13 residents that turned positive for COVID-19 on September 6, 2023 through September 15, 2023, and the staff had 11 that contacted COVID-19 on September 6, 2023 through September 13, 2023. On September 15, 2023, at 2:53 p.m., the Director of Nursing (DON) was interviewed. The DON stated they had notified the county of the COVID-19 Outbreak but had not reported it 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 the call lights (devices that emit a tone and light up indicating the location of the call, used by the residents to signal a need for assistance from facility staff), were answered timely, when four out of four residents (Residents 1, 2, 3, and 4), who required assistance from staff with activities of daily living (ADLs), verbalized their concerns of facility staff not answering their call lights and/or attending to their needs in a timely manner. This failure had the potential for delayed medical management and unmet care needs. Findings: On August 21, 2023, at 9:20 a.m., an unannounced visit was conducted at the facility for a staffing complaint. On August 21, 2023, at 11:48 a.m., Resident 1 was observed lying in bed. During a concurrent interview, Resident 1 stated he had been at the facility since July 2023. Resident 1 stated call light response was sometimes over 30 minutes. Resident 1 stated night shift seemed to be the slowest 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 observation, interview, and record review, the facility failed to ensure safe and sanitary food preparation and storage practices in the kitchen when: 1. The ice machine was dirty. 2. The two compartment prep sink did not have an air gap. 3. Dust found on the following areas: a) Silver storage shelves stored clean kitchen wares in juice area. b) Door stopper in juice area. c) Walk in refrigerator: [NAME] color food storage shelves; wall, above door; copper pipe behind ventilator, black pipe behind ventilator. d) Silver storage shelves stored clean kitchen wares next to stove. e) Cart stored clean kitchen wares. f) Under steam table where stored clean serving pans. g) Cabinet under steam table which stored clean pot and pans. h) Three ventilator funs inside Reach in refrigerator. 4. The kitchen's cutting boards surface was heavily marred. 5. Walk in refrigerator two green food storage shelves had chipped paint. 6. The ventilator above stove had peeling and chipped paint. 7. Both ovens had black grime. 8.…

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

Based on observation, interview, and record review, the facility failed to ensure the facility was free from a medication error rate of 5% or greater when two medication errors were observed out of 34 opportunities. The Licensed Vocational Nurse (LVN) administered Ipratropium-Albuterol inhalation solution (medication that help control the symptoms [wheezing and shortness of breath] caused by a lung disease) instead of budesonide inhalation suspension (steroid - help prevent the symptoms and decrease the number and severity of asthma [lung disease] attacks) for one of five residents reviewed during medication administration (Resident 500). This failure resulted in medication error rate of 5.88%. Findings: On July 11, 2023, at 9 a.m., during a medication administration observation with Licensed Vocational Nurse (LVN) 2, in Resident 500's room, LVN 2 administered the ipratropium-albuterol inhalation solution to Resident 500. LVN 2 did not administer budesonide inhalation suspension to Resident 500. During a review of Resident 500's Order Summary Report, for the month of July 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 observation, interview and record review, the facility failed to ensure that Dietary staff safely and effectively carried out the functions of food and nutrition services when: 1. Two Dietary Aide did not know the proper procedures using 2 compartment sinks to clean kitchen wares. 2. One Diet Aide did not know the right location to test sanitizer of dish machine and unable to accurately test the concentration of dish machine chlorine. These failures had the potential to cause foodborne illness (stomach illness acquired from ingesting contaminated food), negatively impact the residents' nutritional status and further in a medically compromised 94 out of 101 sample residents who received foods from the kitchen. 1. During a concurrent observation, interview, and record review on 7/9/23, at 11:30 a.m., with the Dietary Aide (DA) 1, in front of 2 compartment sinks (sinks used for manual washing kitchen ware. 1st (first) sink is for wash, 2nd (second) sink is for rinse and reused 2nd sink again for sanitizer), DA 1 was observed washed the kitchen wares with the 1st sink without…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 dietary observation, interview and record review, the facility failed to follow its policy on Menus to served planned menu for four of 101 sampled residents (Resident 11, 21, 56, 84). This failure had the potential to negatively impact the residents' nutritional status and further compromising resident's medical status. Findings: During a concurrent noon meal plating observation and interview on 7/09/23, at 12:00 p.m., with [NAME] 1 in front of steam table. Baked chicken, rice and carrot were observed place on steam table. [NAME] 1 stated, he served the baked chicken, rice, and carrot as lunch for residents. During a concurrent observation, interview, and record review on 7/09/23, at 12:35 p.m., with Resident 56 and Dietary supervisor (CDM) in dining room. Resident 56 meal ticket was reviewed. Resident 56 meal tray ticket indicated, Roast Beef. Resident 56 was served chicken and he did not touch the chicken at all. Resident 56 stated, I do not like chicken. CDM confirmed Resident 56 received chicken and meal ticket indicated Roast Beef. CDM offered Resident 56 Hamburger.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 its policy on Serving Foods and Dining Service to provide appetizing food at appropriate temperatures according to residents' preferences for Nine of 101 sampled residents (Resident 5, 11, 33, 51, 53, 67, 83, 93, 500). This failure had the potential risk to decrease nutritional intake and affect the residents' nutritional status and further compromising residents' medical status. Findings: During an interview on 7/9/23, at 10:25 a.m., with Resident 83. Resident 83 stated, Scramble egg is runny and cold. During an interview on 7/9/23, at 10:46 a.m., with Resident 500. Resident 500 stated, Provided foods sucks and nasty. During an interview on 7/9/23, at 10:48 a.m., with Resident 33. Resident 33 stated, Food is nasty and cold. During an interview on 7/9/23, at 10:54 a.m., with Resident 51. Resident 51 stated, Food does not taste good. During an interview on 7/9/23, at 10:58 a.m., with Resident 93. Resident 93 stated, Food is horrendous like dog food. No fresh veggies and fruits 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 promote dignity and independence while dining, for one of one resident reviewed for dignity (Resident 21), when the resident was provided a disposable plastic spoon. This failure had the potential to affect Resident 21's self-esteem and psychosocial wellbeing. Findings: On July 9, 2023, at 9:45 a.m., Resident 21 was interviewed. Resident 21 stated, this morning, at breakfast, he was provided a plastic spoon. Resident 21 stated he informed the staff. On July 9, 2023, at 12:59 p.m., during a concurrent observation and interview with Resident 21, during lunchtime, in the resident's room, Resident 21 was served with disposable plastic spoon. Resident 21 stated, the staff served him again with a plastic spoon. Resident 21 stated, he used the silverware spoon to cut meat to small pieces. Resident 21 stated, he could not cut the meat with disposable spoon compared to silverware spoon. During a review of Resident 21's meal ticket (undated), 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 the call light button was within reach of the resident, for one of two residents reviewed for accommodation of needs (Resident 25). This failure placed Resident 25 at risk for not being able to contact staff for assistance when needed. Findings: On July 9, 2023, at 11:09 a.m., during a concurrent observation and interview with Resident 25, Resident 25 stated he needed a diaper change. Resident 25 was observed looking for his call light button and could not find it. Resident 25's call light was observed at the head of the bed, tied to the bed frame. Resident 25's call light was observed not within Resident 25's reach. On July 11, 2023, at 11:11 a.m., during a concurrent observation and interview with Licensed Vocational Nurse (LVN) 1 in Resident 25's room, LVN 1 stated, the call light button should be in front of Resident 25. LVN 1 stated, Resident 25's call light should be within the resident's reach. A review of Resident 25'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 for two of 24 residents reviewed for quality of care (Residents 48 and 72) to ensure Residents 48 and 72s' medications at bedside had a physician's order. This failure had the potential for Residents 48 and 72 to receive medications without appropriate monitoring for side effects. Findings: 1a. On July 9, 2023, at 09:53 a.m., during a concurrent observation and interview with Resident 48, Resident 48 was observed lying in bed. On Resident 48's bedside table, a bottle of Bio-[NAME] Stem Cell Nutrition (a dietary supplement) was observed. Resident 48 stated, a family member brought in the medications from home. Resident 48 stated, he was taking the dietary supplement twice a day while in the facility. On July 11, 2023, Resident 48's medical records were reviewed. Resident 48 was admitted to the facility on [DATE], with diagnoses which included diabetes mellitus (abnormal blood sugar levels). During a review of Resident 48's Minimum Data Set…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide the activity that met the interest for one of two residents reviewed for activities (Resident 62), when resident was not offered his preferred activity of music. This failure had the potential to result in a decline in the physical, and emotional well-being of Resident 62. Findings: Resident 62 was observed to be lying in bed and was not observed listening to music on the following dates and times: a. On July 9, 2023, at 10:35 a.m.; b. On July 10, 2023, at 11:18 a.m.; and c. On July 11, 2023 at 1:15 p.m. A review of Resident 62's record indicated, Resident 62 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses which included paraplegia (The inability to have movement of the legs and lower body, typically caused by spinal injury or disease). During a review of Resident 62's History and Physical (H&P), dated July 6, 2023, the H&P indicated Resident 62 is competent to make medical judgements. During a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents were assessed before and after administering pain medications for two of six residents reviewed for pain (Residents 3 and 151). This failure had the potential for Residents 3 and 151's pain not adequately managed leading to adverse physical, mental, and psychosocial outcome. Findings: 1.On July 11, 2023, at 9:50 a.m., during observation of medication administration, Resident 3 was complaining of pain on her right hand and right leg. Resident 3 stated, the pain scale (PS- an assessment tool to determine the level of pain-0-no pain ; 10- worst pain) was 6-7. On July 11, 2023, at 10 a.m., the Licensed Vocational Nurse (LVN) 5 gave one tablet of Norco (hydrocodone / acetaminophen is a combination opioid [are powerful pain-reducing medications that include oxycodone, hydrocodone, and morphine], medication used to manage pain). Gabapentin (medication taken for nerve pain [condition that can happen after an injury]) was not…

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

Based on observation, interview and record review, the facility failed to dispose of garbage and refuse properly when trashes were found surrounding the dumpsters. This failure had the potential to attract pests and rodents. Findings: During a concurrent observation and interview on 7/9/23, at 9:36 a.m. with Maintenance Director (MD), outside facility back parking lot area, there was 2 dumpsters. Trashes were observe surrounding both dumpsters. MD confirmed there was trashes surrounding both dumpsters. MD stated, surrounding dumpsters not supposed to have trashes. MD claimed, it should keep surrounding dumspters area clean to prevent attract pests. During an interview on 7/9/23, at 10:07 a.m., with Dietary Supervisor (CDM). CDM stated, it supposed to be no trash around dumpsters, otherwise trash was going to attract pest. During a review of the facility's policy and procedure (P&P) titled, Food Handling Practices, Revised January 2013, the P&P indicated, Purpose: Food service employees .use proper food handling techniques to prevent the occurrence of food borne illness.12. Follow…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 physician's orders were written in accordance with professional standards of practice, for one of three residents (Resident 11), when a wound care order was transcribed incorrectly for the wrong wound site. This failure had the potential to negatively impact Resident 11's care and delay in wound healing. Findings: On July 10, 2023, Resident 11's record was reviewed. Resident 11 was admitted to the facility on [DATE], with diagnoses which included paraplegia (paralysis of the legs and lower body). A Review of Resident 11's physician order summary for the month of July 2023, indicated: - Order dated July 10, 2023, .TREATMENT FOR REOPENING STAGE 3 COCCYX (a sore that has gone through all layers of skin into the fat tissue): CLEANSE WITH NS (normal saline - mixture osodium chloride and water), PAT DRY, APPLY COLLAGEN/ZINC OXIDE (medications used to treat bedsore) 20%, COVER WITH DD (dry dressing) every shift for 14 days . - Order dated July 11,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 infection control practices were implemented for two of 24 residents reviewed (Residents 72 and 300) when: 1. Resident 72's nebulizer mask (device used to administer breathing medications) was undated and not stored in a bag; and, 2. Resident 300's peripheral intravenous line (IV- device used to give medication and or fluids to a person through their veins) dressing was not changed according to facility's policy and procedure. These failures had the potential to increase the risk of infection, and affect the overall health and wellbeing for Residents 72 and 300 . Findings: 1a. On July 9, 2023, at 09:58 a.m., during an observation and interview with Resident 72, Resident 72 was observed lying in bed. Resident 72 was observed to have a nebulizer machine (device that turns liquid breathing medication into mist that will be inhaled through a mask) at her bedside table with an undated nebulizer mask that was on top of food and trash.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 bedroom (room [ROOM NUMBER]) did not accommodate more than four residents. This failure had the potential to affect the health and safety of the residents residing in this room. Findings: On July 9, 2023, at 9:30 a.m., during the initial tour of the facility, room [ROOM NUMBER] was observed to have five residents (41, 43, 44, 47, 251) assigned to the room. A record of the facility's room size was reviewed and indicated room [ROOM NUMBER] measured 440.94 square feet (sq ft) (length-in feet X width-in feet), 20 feet, 9 inches X 21 feet, 2 inches. The square footage allows 88.18 sq ft per resident. During the facility survey from July 9, 2023, to July 12, 2023, no adverse effects that would affect the quality of life of the residents were observed. Residents in room [ROOM NUMBER], who were interviewable, stated they were comfortable in the room and no desire to change rooms. A continuation of room waiver is recommended.