Mission Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure proper maintenance of an intravenous (IV) site for 1 of 8 sampled residents (Resident 25). Resident 25 was observed with a double lumen midline catheter with an expired dressing and no Curos disinfecting cap in place. This deficient practice was inconsistent with the facility's Infection Control Policy - Intravenous Therapy, dated 12/2025, which required IV dressings to be dated and changed as scheduled and required cleansing or protection of the lumen port to prevent contamination. This failure had the potential to expose the IV site and lumen to contamination, increasing the risk for infection, including bloodstream infection and sepsis. Findings: During a review of Resident 25's admission Record (AR), it was noted the facility admitted the resident on [DATE] with diagnoses including sepsis, acute respiratory failure with hypoxia, and extended spectrum beta lactamase (ESBL) infection. During a review of Resident 25's Minimum Data…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record reviews, the facility failed to ensure oxygen therapy was provided in accordance with physician orders and infection control practices for 2 out of 8 sampled residents (Resident 40 and 62) when: The oxygen tubing for Residents 40 and 62 was not dated or was past the facility's required replacement interval. The oxygen therapy for Resident 40 was observed not in place as ordered by the physician. The facility staff failed to consistently monitor and verify oxygen placement for a resident known to remove the nasal cannula. These deficient practices had the potential to result in residents not receiving prescribed oxygen therapy and exposure to infection risk from outdated or improperly maintained oxygen equipment. Findings: 1. During a review of Resident 40's admission Record, the admission Record indicated the facility admitted the resident on [DATE] with diagnoses including acute respiratory failure with hypoxia, asthma, and atrial fibrillation. During a review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one out of two sampled residents (Resident 10) received correct dose of calcium carbonate (a dietary supplement that body needs to function and to treat indigestion or heart burn) as prescribed by the physician and in accordance with the facility's policy and procedure titled Medication Administration. This deficient practice placed Resident 10 at risk of ingesting more than the prescribed medication dosage or overdose which included symptoms such as constipation, nausea, vomiting, confusion and irregular heartbeat. Findings: During a review of Resident 10's admission Record (AR), the AR indicated that the resident was originally admitted on [DATE], and readmitted on [DATE], with diagnoses that included left arm fracture (a break in the bone), falls, and cellulitis (skin infection) of the left arm. During a review of Resident 10's History and Physical (H&P), dated 12/26/2025, the H&P did not indicate if the resident has the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to prevent unnecessary use of psychotropic medications (medications that affects mood and behavior) in accordance with the physician's order, and the facility's policy and procedure titled Chemical Restraints and Psychotropic Medication Management for two of the three sampled residents (Resident 6 and 61) by failing to ensure: 1.Resident 6 was monitored for the behavior indicated for the use of Abilify (antipsychotic medication given for psychosis [a severe mental condition in which thought, and emotions are so affected that contact is lost with reality] and other behavioral mental health conditions) for one of six sampled residents. 2. Resident 61 was monitored for the side effects (undesired effect) and effectiveness of quetiapine fumarate (a medication that may be used to treat insomnia [ a condition of having difficulty falling to sleep and/or remaining asleep) by documenting the presence of side effects if any and the resident's hours of sleep as…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 their policies and procedures (P&P) for the proper storage and disposal of medications for two of three Medication Carts (MC 1) by failing to ensure: 1.A used syringe (a medical instrument consisting of a small, hollow tube, a plunger, and usually a needle, designed to inject fluids into or withdraw fluids from the body) was not left on top of MC 1's waste container. 2. An unlabeled small white pill was not left on top of the medication cart This failure had the potential for the residents to take and ingest the medication and the potential to expose residents, visitors, and staff to the unsecured items in the MC. Findings: 1.During an observation on 3/18/2025 at 10:10 am, in the facility hallway, Licensed Vocational Nurse (LVN) 3 left the medication cart to enter a resident's room. There was an unlabeled small white pill on top of the medication cart. During an interview on 3/18/2025 at 10:10 am with LVN 3, LVN 3 stated she could not identify the white pill. LVN 3 stated if someone were to ingest the…

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

Based on observation, interview and record review, facility failed to maintain a clean and sanitary physical environment in one of one staff-use emergency safety areas observed, the laundry room eye wash station. This failure had potential to compromise staff safety during emergency use of the eyewash station (an emergency area used to flush the eyes readily available with clean and appropriate temperate water in case of facility staff getting exposure to hazardous chemicals or irritants). Findings: During an observation on 03/17/2026 at 9:16 am, in the facility's laundry area, the eye wash station was observed with green and black stains on the basin surface. During an interview on 03/17/2026 at 9:41 am, with the Housekeeping/Laundry Supervisor (HS), the HS stated that using a dirty eye wash station could lead to an eye infection in staff. During an interview on 03/18/2026 at 1:59 pm, with the Director of Nursing (DON), the DON stated if staff use an unclean eye wash station during an emergency, it could worsen an eye injury or irritation. During a review of facility's policy 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 implement the facility's infection control protocols by ensuring Certified Nursing Assistant (CNA) 1 and Treatment Nurse (TN ) 1 wore an isolation gown when providing direct contact care for one of one sampled residents (Resident 1) who was placed on Enhanced Barrier Precautions (EBP-an infection prevention and control intervention to reduce the spread multidrug resistant organisms [MDRO- disease causing organism resistant to medication used to treat infection]) due to the resident having a supra pubic stoma for intermittent catheterization (a small tube placed directly into the bladder through a tiny opening above the pubic bone, to drain urine) and a right heel and left ischium (back part of the hip bone) pressure injury (localized skin and tissue damage from constant pressure). This deficient practice had the potential to result in Resident 1 acquiring MDROs, contaminating other areas and/or spreading MDROs to other residents in the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of two sampled residents (Resident 1) who has pressure injuries (damaged skin and tissue from too much pressure) on the left ischium (bottom-rear section of pelvic bone) and right heel had a low air loss mattress ( LAL - designed to prevent and treat pressure injury) set at the setting according to residents weight as indicated in the manufacturer's guidelines to prevent and/or minimize skin pressure on the bony prominences of the body. This deficient practice had the potential to result in delay healing of Resident 1's pressure injuries and may result in new pressure injuries that may negatively affect Resident 1's quality of life.Findings: During a review of Resident 1's admission Record (AR), dated 12/10/2025, indicated Resident 1 was admitted [DATE], with diagnoses that included surgery on the genitourinary system (body parts responsible for both making and eliminating urine), retention of urine (a condition in which you…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 store food in accordance with professional standards for food service safety and facility ' s policy and procedure (P&P) by having an expired Traditional Cinnamon Roll Dough (expired 12/25/2024, 51 days after expiration date) in refrigerator number one and by not labeling: Two (2) bags of bell peppers with a use by date. Three (3) bags of carrots with a use by date. One (1) bag of tomatoes with a use by date. Five (5) lettuce heads with a use by date. Six (6) celery stalk with a use by date. Two bags of cucumbers with a use by date. One box of onions with a use by date. One box of oranges with a use by date. Four (4) cantaloupes with a use by date. Five pineapples with a use by date. These deficient practices had the potential to put 54 residents in the facility at risk for food borne illness (illness caused by food contaminated with bacteria, viruses, parasites, or toxins). Findings: During a concurrent observation and interview on 2/14/2025 at 5:08 PM with Dietary Supervisor (DS) observed two bags of bell…

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

Based on observation, interview, and record review, the facility failed to post a designated No Smoking sign in the patio used by the residents to smoke and have a fireproof blanket available for use in care of fire per the facility ' s policy and procedure (P&P). These deficient practices had the potential to place the residents at risk for burns and the facility at risk for fire hazards. Findings: During an observation of the designated Smoking Patio on 2/15/2025 at 3:28 PM, the Smoking Patio had one (1) ash receptacle (place to put cigarette ashes and butts), one metal container for cigarettes, one apron, and a sign for Fire Extinguisher Inside posted on a window. The Smoking Patio did not have a sign indicating the area was a designated Smoking Patio. The Smoking Patio did not have a sign indicating No Oxygen to be used or permitted in the designated Smoking Patio. The Smoking Patio did not have a fire blanket as indicated in the facility ' s policy and procedure (P&P). During an interview on 2/16/2025 at 10:30 AM, the Activities Assistant (AA) stated there should have been a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure one of one sampled resident ' s (Resident 37) Advance Directive (living will, legal document in which a person specifies what actions should be taken for their health if they are no longer able to make decisions for themselves because of illness or incapacity) was obtained and readily available in the resident ' s records (medical chart). This deficient practice had the potential to result in misinformation of medical care and treatment and not honoring resident ' s wishes in cases where the resident and/or responsible party was unable to participate in making healthcare decisions. Findings: During a review of Resident 37 ' s admission Record (AR), the AR indicated the resident was admitted on [DATE] with diagnoses that included urinary tract infection (UTI- an infection in the bladder/urinary tract), difficulty walking, and hypertension (high blood pressure). During a review of Resident 37 ' s History and Physical (H&P), dated 1/8/2025, the H&P…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of three Certified Nurse Assistants (CNA 1) was checked for background screening and criminal history prior to employment at the facility in accordance with the facility ' s policy and procedure (P&P) titled, Pre employment Investigation. This failure increased the risk of applicants and employees with possible criminal convictions to have direct access to all patients in the facility and the potential not to be protected from abuse and place the residents at risk of abuse and feelings of intimidation. Findings: A review of CNA 1 ' s Offer of Employment indicated CNA 1 ' s offer of employment dated as of 11/4/2024. The form indicated the offer described above is contingent upon the results of your reference checks, criminal background check and the completion of a drug screening with negative results. A review of Facility provided document titled Memo indicated the document was from Operations Manager with facility…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of 3 sampled residents (Resident 150) received oxygen therapy (treatment that provides supplemental, or extra, oxygen) as ordered by the attending physician. This deficient practice has the potential for Resident 150 not to receive enough oxygen to meet the body ' s demand and place the resident at risk for shortness of breath and/or hypoxia (low levels of oxygen in the body tissues) which can lead into serious injury or death. Findings: A review of Resident 150 ' s Face Sheet (front page of the chart that contains a summary of basic information about the resident) indicated the resident was admitted to the facility on [DATE] with diagnoses that included Hemiplegia and hemiparesis (muscle weakness or partial paralysis on one side of the body following a cerebral infraction (a condition where blood flow to the brain is interrupted) , Chronic kidney disease(a gradual loss of kidney function) During a review of Resident 150 ' 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 prevent unnecessary medication by ensuring one (1) of three (3) residents (Resident 42) was administered Timolol Maleate Ophthalmic Solution (a medication used to treat high pressure in the eyes) to the left eye only as ordered by the physician reviewed for pharmacy services. This deficient practice had the potential for Resident 42 to have high pressure in the eyes that could lead to blindness. Findings: A review of Resident 42 ' s Face Sheet (admission record) indicated the resident was admitted to the facility on [DATE], with diagnoses including metabolic encephalopathy (a problem in the brain caused by a chemical imbalance in the blood), primary open-angle glaucoma (an eye disease that causes slow symptomless vision loss) bilateral, stage unspecified. A review of Resident 42 ' s undated History & Physical (H&P) dated 1/26/2025, indicated the resident has limited decision-making capabilities. A review of Resident 42 ' s record, titled…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 (2) medications were in accordance with prescription label in two out of three Medication Carts at the facility. 1. In Medication Cart #1, no open date label found for an opened package of Albuterol (medication used to prevent and treat wheezing, difficulty breathing, chest tightness, and coughing caused by lung diseases) for Resident 203. 2. In Medication Cart #2, an open package of Albuterol with open date of 2/4/2025, was not discarded. This deficient practice had the potential for residents not to receive full strength of the medications and receive ineffective medication dosages. Findings: 1. During a review of the facility ' s admission Record (AR), the AR indicated Resident 15 was admitted on [DATE] with diagnoses that included urinary tract infection (UTI- an infection in the bladder/urinary tract), dysphagia (difficulty swallowing), and Chronic Obstructive Pulmonary Disease (COPD). During a review of Resident 15 '…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 document a resident ' s discharge disposition on the resident ' s discharge summary for one of one sampled resident (Resident 47). This deficient practice resulted in inaccurate documentation of Resident 47 ' s discharge disposition/location for accurate and appropriate tracking purposes of all residents discharged or transferred out of the facility. Findings: During a review of Resident 47 ' s admission Record (AR), the AR indicated the resident was admitted on [DATE] with diagnoses that included fracture of nasal bones, abnormalities of gait and mobility, and type 2 diabetes mellitus (condition when the body cannot use insulin [hormone that turns food into energy] correctly and sugar builds up in the blood). During a review of Resident 47 ' s History and Physical (H&P), dated 10/18/2024, the H&P indicated the resident had decision making capacities. During a review of Resident 47 ' s Order Summary dated 11/13/2024, the Order Summary…

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

Based on observation, interview, and record review, the facility failed to maintain the walk-in freezer in good operating condition as indicated in the facility's policy and procedures by failing to: Document temperature readings of the freezers both in the morning and evening as indicated on the facility ' s P&P Procedure for Freezer Storage indicating freezer temperatures should have been recorded twice daily. The walk-in freezer ' s plastic curtain had water dripping down the curtain and had condensation (the process where water vapor becomes liquid) with visible water droplets on the ceiling. These deficient practices had the potential to affect 54 residents in the facility to be at risk for food borne illness (illness caused by food contaminated with bacteria, viruses, parasites, or toxins) or contamination (process of making something dirty or poisonous, or the state of containing unwanted or dangerous substances). Findings: During a review of the Refrigerator and Freezer Temperatures Log dated January and February 2025, the Refrigerator and Freezer Temperatures Log provided…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 implement its policy and procedure, and the local public health department's recommendation on infection prevention and control by failing to: 1. Screen visitors for symptoms of Covid19 (a highly contagious respiratory disease caused by the SARS-CoV-2 virus with symptoms of cough, fever, headache, chill, diarrhea etc.) before entering the facility. 2. Conduct biweekly (twice a week) mass PCR testing (a polymerase chain reaction (PCR) laboratory test used to detect if a person is infected with Covid-19) for all residents and staff. 3. Allow only 1-2 residents with face mask and distanced residents in the rehabilitation room (a room used by the staffs when providing exercises to the residents). 4. Ensure the breakrooms do not have extra chairs, has a maximum occupancy of two (2) people sitting across from each other, have a signage reminding staff to change their masks after eating, have an air purifier (a device that removes pollutants and contaminants from the air in a room), facemasks, hand sanitizers, 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 interview and record review, the facility failed to ensure that a wheelchair sensor pad alarm (a weight-sensitive sensor pad that is connected to a monitor unit and activates an alarm if a patient leaves the chair or the bed) was placed on the wheelchair (a mobility device that helps a person with mobility impairment to move around) of one of three sampled residents (Resident 1). This deficient practice had the potential to result in multiple falls with injuries for Resident 1 who was assessed as high riskfor falls. Findings: During areview of Resident 1 ' s admission Record, the admission Record indicated that the facility admitted the resident on 07/01/2019 and readmitted the resident on 09/19/2024 with diagnoses that included difficulty in walking, hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body), and hemiparesis (a condition that causes weakness or an inability to move on one side of the body). During areview of Resident 1 ' s Minimum Data Set (MDS – a resident assessment tool), dated 09/25/2024, indicated that the resident ' s…

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

Based on observation, interview, and record review, the facility failed to promote and treat residents with respect, privacy and dignity for three of three sampled residents (Resident 40, 26 and 83) by failing: 1. To ensure Resident 40 ' s lower part of body was not and visible from outside of room. 2.To provide privacy to Resident 26 by leaving the resident ' s post-operative surgical suction drain uncovered. 3. To provide dignity to residents during dining. Licensed Vocational Nurse 1 (LVN 1) was observed drinking coffee during the resident's mealtime. These deficient practices had the potential to cause a psychosocial (mental and emotional well-being) decline, resident ' s individuality, self-esteem, and self-worth. Findings: 1. During a review of Resident 40 ' s admission Record, indicated the facility admitted Resident 40 on 11/24/2023 with diagnoses that included atherosclerotic heart disease (general term for the progressive narrowing and hardening of coronary arteries due to atheroma [degeneration of the walls of the arteries caused by accumulated fatty deposits and scar…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to develop and implement individualized person-centered plans of care with measurable objectives, timeframes, and interventions to meet the residents ' needs for six (6) of 6 sampled residents (Residents 1, 16, 27, 26, 31, and 30). 1. For Resident 26, the facility failed to develop a care plan to indicate interventions to manage Resident 26 ' s peripheral intravenous catheter (IV, a thin plastic tube inserted into a vein using a needle allowing for the administration of medications, fluids and/or blood products). 2. For Resident 27, the facility failed to develop an individualized, person- centered care plan to indicate interventions to manage Resident 27's diagnosis of atrial fibrillation (when the atria or the upper chambers of the heart contract at an excessively high rate and in an irregular way) while receiving Xarelto (blood thinner - a medication that thins the blood and could cause bruising or bleeding) medication. 3. For Resident 31, develop 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 two of three sampled residents (Resident 16 and 26) follow the facility ' s policy and procedure on Intravenous Therapy by failing to: 1. Label and date intravenous catheter (IV, a thin plastic tube inserted into a vein using a needle allowing for the administration of medications, fluids and/or blood products) for Resident 26. 2. Obtain a physician order for IV catheter insertion for Resident 16. These deficient practices had the potential to put the residents at risk for intravenous complications without appropriate intervention or preventive measures. Findings: 1. A review of Resident 26 ' s admission Record, indicated the facility admitted Resident 26 on 1/22/2024, with diagnoses that included sepsis (life-threatening condition that arises when the body's response to infection injures its own tissues and organs), unidentified organism and psoas muscle (helps to bring the leg toward the torso [hip flexion] or vice versa) abscess…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 resident safety in administering oxygen for four (4) of 4 sampled residents (Residents 40, 154, 205, and 30) who were receiving oxygen therapy, in accordance with the facility ' s policy and procedure: 1. For Resident 40, that facility failed to ensure the resident ' s nasal cannula tubing (flexible plastic tubing used to deliver oxygen through nostrils and the tubing is fitted over the patient's ears) was not touching the floor when in use. 2. For Resident 154, the facility failed to ensure the Yankaeur suction tip (an oral suctioning tool) was not on the floor and post Oxygen/no smoking signage for Resident 154. 3. For Resident 30, the facility failed to have the resident ' s room post a signage indicating Oxygen in use and No Smoking Sign, as per facility policy. 4. For Resident 205, the facility failed to ensure the resident ' s oxygen equipment was labeled or dated, a storage bag should be at bedside, and to post a signage…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 proper sanitation and safe food handling based on the facilities policy and procedure by failing to ensure: 1.Kitchen staff wear hair covering while in the kitchen to prevent hair from falling on food surface areas that can lead to contamination 2.Label used or opened food items with an open or use by date in the kitchen refrigerator, kitchen freezer, food preparation area and dry goods storage area to indicate when foods are no longer safe to eat. These deficient practices had the potential to put residents at risk for foodborne illnesses (illness caused by food contaminated with bacteria, viruses, parasites, or toxins). Findings: During the initial observation of the kitchen on 2/18/2024 at 6:50 PM, Kitchen assistant 1(KA 1) was observed entering the kitchen, not wearing a hair net then proceed to go into kitchen refrigerator and dry storage area with no hair net. During an observation in the kitchen on 2/18/2024 at 7:11 PM 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 maintain a safe, sanitary environment to help prevent the spread of transmission of infections to residents, staff members, visitors in accordance with the facility ' s policy and procedure on infection control by failing to: Ensure an open plastic container of sliced fruits for staff was not at the nursing station. Ensure Community Liaison (CL) wore personal protective equipment (PPE) that included an isolation gown (gown used to protect clothing from contaminants or contacting disease causing organism) and gloves while in the room of Resident 18, who was under contact isolation (containing one in an area prevent transmission of infectious agents which are spread by direct or indirect contact with the resident or resident ' s environment) precautions. These deficient practices had the potential to increase the risk of the spread of infection to the residents, staff, and other visitors in the facility. Findings: During an observation 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 reasonable accommodation of need for one of one sampled resident (Resident 157) who was at risk for fall, by failing to ensure the resident's call light was within reach as indicated in the facility's policy and procedure and resident's care plan. This deficient practice had the potential for Resident 157 not to receive or received delayed care to meet necessary care and services that could result in fall and accident. Findings: A review of Resident 157 ' s admission Record indicated an admission on [DATE] with diagnoses of multiple fractures (partial or complete break in the bone) of ribs (right side), disorientation (altered mental state), and Parkinson ' s Disease (age-related degenerative brain condition, causes parts of the brain to deteriorate) without dyskinesia (involuntary, erratic, writing movements of the face, arms, legs or trunk). A review of Resident 157 ' s History and Physical assessment dated [DATE], indicated…

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

Based on interview and record review, the facility failed to follow the facility's policy on Notice Requirements Before Transfer or Discharge for one (1) of three (3) sampled residents (Resident 53), by failing to: 1. Ensure the Notice of Proposed Transfer and Discharge was provided to the resident's responsible party. 2. Provide documentation to show that the State Long Term Care Ombudsman (public advocate) was notified of Resident 53 ' s transfer to the General Acute Hospital (GACH) on 11/26/2024. This deficient practice had the potential for Resident 53's rights to ensure for an appropriate discharge/transfer from the facility. Findings: A review of Resident 53 ' s admission Record indicated the facility admitted Resident 53 on 11/17/2023, with diagnoses that included disorders of the brain. During a review of Resident 53's Order Summary Report (Physicians Order) dated 11/26/2024, indicated to transfer Resident 53 to the GACH emergency room (ER) due to altered mental status, increased sleepiness. During a concurrent interview and record review of Resident 53 ' s Notice 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 establish a system of surveillance designed to prevent the spread of communicable diseases that included Coronavirus -19 (COVID 19 – a highly contagious disease caused by a virus) for one of 24 sampled residents (Resident 1), who had a positive test result and symptomatic for the COVID 19 virus. In addition, the facility failed to report the COVID 19 positive resident as a potential disease outbreak, to the local health officer and the California Department of Public Health (CDPH). This deficient practice had the potential for the virus to spread among residents, staff, and visitors which can negatively affect the resident ' s health and quality of life. Findings: A review of Resident 1 ' s admission Record dated 2/2/2024, the indicated Resident 1 was admitted to the facility on [DATE], with diagnoses including Corneal transplant (to remove all or part of a damaged cornea and replace it with healthy cornea tissue from a donor), asthma (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 interview and record review, the facility failed to implement its policy on HIPAA Privacy and Security Operational Policy and Procedure to protect the residents private and confidential information when two of two sampled residents' (Residents 1 and 2) discharge records were sent out to different residents on 8/28/2023. LVN 1 gave Resident 1's medical records to Resident 2's family member (Family 1) during Resident 2's discharge to home on 8/28/2023. LVN 2 gave Resident 2's medical records to the 911 emergency services during transfer of Resident 1 to the acute hospital on 8/28/2023. A written notification from the facility was provided to the resident's families on 9/14/2023. The California Department of Public Health (CDPH) was notified by the facility in writing via certified mail on 10/13/23 (29 days). This deficient practice had the potential to negatively impact Resident 1 and 2's rights to privacy and unauthorized access of others to resident's confidential records. Findings: A review of Resident…

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