Monterey Healthcare & Wellness Centre, LP

Based on observation, interview, and record review, the facility failed to assess and monitor one of three sample residents (Resident 9 ), diagnosed with hemolytic anemia (a blood disorder where the red blood cells [RBC] are destroyed faster than the bone marrow can replace them, leading to fatigue, jaundice [yellowing of skin], and dark urine) with symptoms of blood loss in accordance with the care plan and professional standards of practice by failing to: 1.Monitor and assess Resident 9 for any signs and symptoms of hemolytic anemia such as skin pallor, shortness of breath upon activity, sore tongue, chest pain, tinnitus (ringing in ears), palpitations, and changes in condition. 2.Follow up with Resident 9's Clinic 1 (Hematology Clinic) regarding the after visit care regarding the plan of care for resident's management of hemolytic anemia. These failures resulted in Resident 9 being transferred to the General Acute Care Hospital (GACH) 1 on 2/18/2026 with low blood pressure (BP, measure of the force of blood against artery walls; normal: 120/80 millimeters of mercury [mmHg]) 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 interventions to one of three sample residents (Resident 54) with increased verbal aggression towards other staffs or residents and increased episodes of delusion (misconceptions or beliefs that are firmly held, contrary to reality) to ensure safety to other residents by implementing interventions to prevent Resident 54 from aggression towards residents and staffs. As a result, Resident 54 hit Resident 25 on the right cheek without major injury. In addition, Resident 54 had the potential to emotionally and physically harm other residents and staff due to aggression and delusional thoughts.Findings: During a review of Resident 25's admission Record (AR), the facility admitted Resident 25 on 6/30/2021 and readmitted Resident 25 on 2/13/2026 with diagnoses that included paranoid schizophrenia (mental health disorder where a resident experiences intense, irrational suspicion, paranoia, and hallucinations [perceptual experiences in the…

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

Based on observation, interview, and record review, the facility failed to ensure the drugs and biologicals stored in Medication Cart A, for one of six sample residents (Resident 46) was properly labelled and reflected the correct dose and frequency as indicated on the active order's summary list. Resident 46's prescribed medication-Clozaril (Clozapine, an antipsychotic medication) Oral Tablet 25 milligrams (mg, unit of weight) medication label on the unit dose packaging (bubble pack or blister pack, an organization way to store and dispense pill medication). This failure had the potential to result in Resident 46 receiving the wrong dose and wrong frequency of Clozaril which may result in a medication error and compromise the safety of the resident. Findings: During a review of Resident 46's admission Record (AR), the facility admitted Resident 46 on 5/16/2024 and readmitted Resident 46 pm 9/8/2026 with diagnoses that include bipolar disorder (manic-depressive disorder; mood swings that range from lows of depression to elevated periods of emotional highs), schizophrenia (a mental…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to accurately document the administration of medication for one of one sampled resident (Resident 4.)This failure had the potential to cause severe hypoglycemia (low blood sugar), unconsciousness, and death to the resident.Findings: During a review of Resident 4's face sheet, the face sheet indicated Resident 4 was readmitted on [DATE] (original admission date 6/2/2008), with a diagnosis including but not limited to metabolic encephalopathy (a brain dysfunction caused by illness), schizophrenia (a mental disorder), diabetes mellitus (DM - a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 4's order summary report (OSR), dated 3/25/2026, the order summary report indicated on 11/24/2025 to start administering pioglitazone (medication used to treat DM) 45 milligrams (mg - metric unit of measurement, used for medication dosage and/or amount) give one tablet orally (by mouth) one time a day for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record review, the facility failed to notify the physician (MD) of an accident involving a resident for one of two sampled residents (Resident 1) after Resident 1 was observed by staff walking head first into a door that resulted in a cut near his right eye during the nightshift on 3/7/26 around 3 AM. The facility's staff did not notify Resident 1's physician (MD) of the injury during the morning shift, on 3/7/26 at 9 AM, six (6) hours after the accident, when Resident 1 was sent to a general acute care hospital (GACH) for medical evaluation and treatment. This failure to notify Resident 1's physician at the time of Resident 1's accident delayed the MD from placing orders to evaluate Resident 1 for severe injury that potentially required medical intervention and to monitor Resident 1 for any change in condition and had the potential for Resident 1 to decline from his head injury.Findings: During a review of Resident 1's admission Record, the record indicated Resident 1 was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure the licensed staff verified Resident 1 ' s admission orders from the facility, by reviewing Resident 1 ' s medical history and general acute care hospital (GACH 1) discharge orders upon readmission to the facility on 3/12/2025, for one of two sampled residents (Resident 1), when it failed to: As a result of this deficient practice, Resident 1 had the potential to not receive the care and services, and correct medications needed for the resident ' s diagnosis while in the facility. Findings: During a review of facility ' s admission Record indicated Resident 1 was initially admitted on [DATE] but readmitted back to the facility from GACH 1 on 3/12/2025, with diagnoses that included Schizophrenia (a disorder that affects a person ability to think, feel and behave clearly), Bipolar disorder (A disorder associated with episodes of mood swings ranging from depressive lows to manic highs). During a review of Resident 1 ' s History and Physical (H&P),…

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

Based on interview and record review, the facility failed to provide appropriate competencies in skills and techniques necessary to care for one of one resident (Resident 11) reviewed for competent nursing staff to care for resident with a diagnosis of Post-Trauma Stress Syndrome (PTSD, a disorder in which a person has difficulty recovering after experiencing or witnessing a traumatic event) that was identified through the resident assessments. This failure resulted in Resident 11 not receiving the appropriate skills related to his trauma and PTSD as identified through his resident assessments. This failure resulted in the staff not receiving the appropriate competencies and skill set needed to care for residents with trauma or PTSD to ensure resident safety and to attain or maintain the highest practicable physical, mental, and psychosocial well-being of the resident. Findings: During a review of Resident 11 ' s admission Record, the facility admitted Resident 11 on 6/20/2023 and readmitted Resident 11 on 1/17/2025 with diagnoses which included schizoaffective disorder (a mental…

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

Based on observation, interview and record review, the facility failed to post nurse staffing information daily in a prominent location that was readily accessible to residents and visitors for viewing in accordance with the facility's policy and procedure titled Nursing Department - Staffing, Scheduling & Postings. This deficient practice resulted in inaccessibility of the accurate daily number of clinical staff giving direct care to the residents. Findings: During a concurrent observation and interview in the presence with the Assistant Director of Nurses (ADON) on 2/13/2025 at 9:50 AM, there was no visible daily nurse staffing information posted. The ADON stated, there should be Nurse Staffing Postings readily accessible and visible for the residents and visitors. The ADON stated, the Director of Staff Development (DSD) was responsible for posting the staff information daily at the beginning of the shift. During an interview on 2/13/2025 at 10 AM with the DSD, the DSD stated, she posted the nurse staffing information on the visiting window for only the visitors to view. The DSD…

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

Based on observation, interview and record review, the facility failed to follow the facility ' s proper sanitation and food handling practices by failing to ensure the Dietary Aide 1 (DA 1) adhere to properly securing hair with the hairnet without any hair exposed when assisting tray line ( process of preparing meals for the residents from the food preparation area to the meal trays) for 69 out of 69 residents residing in the facility. This deficient practice had the potential to result in foodborne illnesses (also called food poisoning caused by eating contaminated food (transfer of bacteria, viruses, toxins [poisons] from the environment to the food ingested). Findings: During a dining observation on 2/13/25 12:19 PM, the DA 1 had hair exposed outside and visible outside of the hairnet while assisting the cook with the preparation of the meal rays. In a concurrent interview DA 1 stated it was important to secure all hair within the hairnet to prevent contamination and the risks of infection or illness associated with exposed hair that could contaminate the food being prepared.…

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

Based on observation, interview, and record review, the facility failed to provide proper infection control practices for 69 of 69 sampled resident by failing to ensure the facility's Water Management Program followed the approved national, state, and local measures to prevent and monitor the growth of Legionella (water-borne opportunistic bacteria) These failures had the potential to contribute to poor infection control, improper cleaning and disinfection of the resident's clothing and linens, growth of Legionella within the facility's water system which can lead to Legionnaires' disease (a serious pneumonia [lung infection] that can be fatal) which would affect all the residents and staff within the facility, and potential to cause a facility fire by not tracking when lint screens were cleaned out from the clothes dryer. Findings: During an interview on 2/13/2025 at 10AM with the IP, the IP stated the facility does not test for Legionella unless there were 10 or more cases of pneumonia in the facility because testing for Legionella was very costly. The IP stated, there were five…

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

Based on observation, interview, and record review, the facility failed to provide a safe, functional, and sanitary environment for 69 or 69 residents, staff and the public by failing to: 1. Ensure the facility's washing machine Lint Cleaning Log for 2/12/2025 and 2/13/2025 were completely filled out to indicate the facility's lint screens (lint trap, a device that catches lint and debris from laundry) were cleaned from the clothes dryer. These failures had the potential to cause a facility fire by not tracking when lint screens were cleaned out from the clothes dryer. Findings: During a concurrent interview and record review on 2/13/2025 at 8:50AM with Laundry Services (LS), the facility's Lint Cleaning Log for 2/10/2025 to 2/12/2025 was reviewed. The Lint Cleaning Log indicated on 2/12/2025 at 4:00PM there was no documented evidence the lint screens were cleaned for two of three dryer machines. The LS stated, on 2/13/2025 at 8:30AM, there was no documented evidence the lint screens were cleaned for three of three dryer machines. The LS stated the lint screens were cleaned every 2…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 respect and dignity to one of one resident reviewed for dignity (Resident 19) who was observed with jeans tied with elastic gloves on the belt loop and was falling off, exposing his buttocks and groin area. This deficient practice has the potential to affect the resident's self image, sense of self-worth/ self-esteem and negatively affect the psychosocial being of the resident. Findings: During a review of Resident 19's admission Record indicated the facility initially admitted Resident 19 on 6/2/2008 and readmitted her on 5/24/2022 with diagnoses that included paranoid schizophrenia (a mental disorder characterized by disruptions in thought processes, perceptions, emotional responsiveness, and social interactions) and hyperlipidemia (a condition in which there are abnormally high levels of fats in the blood). During a review of Resident 19's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 1/31/2025, indicated Resident 19 had intact cognition (ability to think 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 be fully informed by the physician or other professional in a language that he can understand for one of three residents reviewed for resident's rights (Resident 56) who signed a consent to receive psychotropic medications ( medications that affects mood and behavior) when: 1.The Health & Physical (H&P) assessment by physician indicated Resident 56 does not have the mental capacity to make medical decisions. 2. Psychiatric notes indicated Resident 56 had cognitive impairments such as loose associations (a thought disorder characterized by a lack of logical connection between ideas or thoughts) and distractibility (the tendency to be easily distracted by external or internal stimuli). The facility allowed the Resident 56 to making medical decision and signed informed consent without a surrogate decision-maker (a person that advocate for the resident) or an interdisciplinary team (IDT) meeting was not conducted to assist the resident 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 accommodate the needs of one of three residents reviewed for resident's rights, (Resident 119) in accordance with the facility ' s policy and procedure by failing to ensure the call light (a device used by residents to signal his or her needs for assistance) was within reach of the resident in Shower room [ROOM NUMBER] in the west wing. This deficient practice had the potential for residents who shared Shower room [ROOM NUMBER] in the west wing not able to call the facility staff to ask for help or assistance specially during emergency. Findings: During a review of Resident 119 ' s admission Record indicated the facility admitted Resident 119 on 9/11/2024 and readmitted him on 2/5/2025 with diagnoses that included schizophrenia (a mental disorder characterized by disruptions in thought processes, perceptions, emotional responsiveness, and social interactions) and hypertension (high blood pressure). During a review of Resident 119's MDS,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure two of two residents reviewed for right to privacy (Resident 41 and 119) were provided with privacy when using the common restroom and common shower room by failing to ensure: The window in Shower room [ROOM NUMBER] in the [NAME] Wing had stained-glass window film peeling off which let other people in the patio look thorough the window and see the residents when in the shower room. The window in Restroom [ROOM NUMBER] in the East Wing ' s had stained-glass window film that were peeling off which let other residents, staffs and visitors from the patio see the residents when using the restroom. This failure violated the resident ' s rights for privacy and the potential to result in Resident 41 not wanting to shower because she was feeling unsafe and exposed when showering, and Resident 119 feeling uncomfortable using the restroom. This practice also had the potential for other residents ' privacy to be violated. Findings: 1. During a…

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

Based on interview and record review, the facility failed to develop and implement a comprehensive resident specific care plan for two of twelve residents reviewed (Resident 68 and 11) by failing to ensure: 1. Resident 68's care plan was developed to address discharge planning before discharged from the facility on 12/2/2024. These deficient practices had the potential to result in confusion of Resident 68 ' s care and discharge process and negatively affect the resident's psychosocial wellbeing. 2. Resident 11's care plan was developed to address management and triggers for the Post-Traumatic Stress Syndrome (PTSD, a disorder in which a person has difficulty recovering after experiencing or witnessing a traumatic event). As a result of this deficient practice the resident did not received interventions to prevent and aggressive behaviors towards staffs and residents that could result in futher decline in psychosocial wellbeing. Findings: 1. During a review of Resident 68's Record of admission indicated the facility originally admitted Resident 68 on 10/10/2024 with diagnoses that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide one of four residents that was reviewed for trauma informed care, (Resident 11) who was diagnosed with Post-Traumatic Stress Syndrome (PTSD, a disorder in which a person has difficulty recovering after experiencing or witnessing a traumatic event) with culturally competent (cultural competence involves valuing diversity, conducting self-assessments, avoiding stereotypes, managing the dynamics of difference, acquiring and institutionalizing cultural knowledge, and adapting to diversity and cultural contexts in communities), trauma-informed care (an approach to delivering care that involves understanding, recognizing and responding to the effects of all types of trauma) according to professional standards of practice and accounting for the resident ' s experience and preferences to eliminate or mitigate triggers that may cause the resident ' s re-traumatization. This failure resulted in Resident 11 experiencing re-traumatization and…

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

Based on observation, interview, and record review, the facility failed to provide the necessary behavioral health care and services for one of four residents reviewed (Resident 11) to attain or maintain the highest practicable physical, mental, and psychosocial well-being which encompassed the resident's whole emotional and mental well-being. This failure resulted in Resident 11's, who was diagnosed with Post-Traumatic Stress Syndrome (PTSD, a disorder in which a person has difficulty recovering after experiencing or witnessing a traumatic event), continued behavior of agitation, yelling, and attempts to hit staff members. Cross reference with F699 and F726 Findings: During a review of Resident 11 ' s admission Record, the facility admitted Resident 11 on 6/20/2023 and readmitted Resident 11 on 1/17/2025 with diagnoses which included schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), schizophrenia (a mental illness that was characterized by disturbances in thought), bipolar disorder (sometimes called manic-depressive disorder; mood swings 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 observation, interview and record review, the facility failed to ensure one of three residents (Resident 28) does not receive Bactrim (Sulfamethoxazole-Trimethoprim an antibiotics or medication used to treat infection) unnecessarily by indicating in the physician's order how long the medication should be administered. This deficient practice had the potential for Resident 28 to develop antibiotic resistance (medication not effective to treat infection) and results in adverse reaction (undesirable effect) health outcomes. Findings: During a review of Resident 28 ' s admission Record (Face Sheet), the facility admitted Resident 28 on 5/30/2024 with diagnoses that included heart failure (failure of the heart to meet the body ' s demand), asthma (a chronic lung condition that causes inflammation and narrowing of the airways, making it difficult to breathe), schizophrenia (is a serious mental health condition that affects how people think, feel and behave) and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). 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 interview and record review, the facility failed to implement its policy and procedure on resident safety by failing to provide supervision to one of two sampled residents (Resident 1) who were at high risk for falls. This deficient practice resulted to Resident 1 having an acute subdural hematoma (a blood clot that forms between the brain's surface and its tough outer covering) after he had a fall when he attempted to stand up from a sitting position at the facility's patio without staff supervision. Findings: During a review of the facility ' s investigation summary report, dated 1/7/2025, indicated that on the evening of 1/2/2025, a staff who was in the patio observed Resident 1 sitting on the patio ' s brick seating area. At around 9 PM, Resident 1 stood up using his front-wheeled walker and fell on his right side. The staff who immediately responded to the fall assessed Resident 1 and found a bump and a cut on the resident ' s right forehead. The facility called 911 (a universal emergency number)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop a care plan for one of two sampled Residents (Resident 1) that included specific interventions to monitor resident's behaviors who goes out on pass and with had a history of drug abuse. This deficient practice had the potential for residents to not receive appropriate care, treatment, and/or services. Findings: A review of Resident 1's admission Record indicated a readmission to the facility on 5/16/2024 with diagnoses that included encephalopathy (group of conditions that cause brain dysfunction), schizoaffective disorder (mental health condition that is marked by a mix of schizophrenia [mental health condition that affects how people think, feel, and behave] symptoms such as hallucinations [false perception of objects or event involving the senses], delusions [belief or altered reality], and mood disorder symptoms such a depression [mental health disorder characterized by persistently depressed mood or loss of interest in activities], mania…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 investigate and attempt to locate one of two sampled residents, (Resident 1) who was assessed at risk for elopement, had a history of suicidal ideations, and had fluctuating capacity to understand and make decisions, upon receiving information on 7/13/2024, that Resident 1 was not admitted to the General Acute Care Hospital (GACH 2) on 7/11/2024. As a result, Resident 1 had not been located and currently still missing, after eloping from the ambulance transportation on the way to GACH 2 emergency room (ER). This deficient practice had the potential to result in Resident 1 ' s physical injuries and change in condition that may lead to hospitalization or death. Findings: During a review of General Acute Care Hospital (GACH 1) records indicated Resident 1 was admitted on [DATE] with a diagnosis of Psychosis (mental disorder characterized by a disconnection from reality) and was discharged to Facility on 7/1/2024. During a review of GACH 1…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to monitor and supervise one of three sampled residents (Resident 1), who was identified and assessed at risk for elopement. As a result, Resident 1 eloped from the facility on 4/30/2024, and remained missing until 5/1/2024, when resident was found at a nearby school football field, next to the facility. This failure had the potential for Resident 1 to sustain injuries from being outside the facility with no access to scheduled medications and shelter needed for his condition which could lead to serious injury, serious harm, serious impairment and/or death. Findings: A review of Resident 1 ' s admission Record indicated the resident was initially admitted to the facility on [DATE], with the diagnosis of unspecified psychosis (a person ' s thoughts are disrupted and have difficulty recognizing what is real and what is not real), major depressive disorder (mood disorder that causes a persistent feeling of sadness and loss of interest), and…

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

Based on observation, interview and record review, the facility failed to ensure foods were handled, prepared, and stored in a manner that prevented foodborne illness (food poisoning) for 63 of 63 residents receiving food from the kitchen, by failing to ensure: a. Expired products were removed from kitchen pantry. b. Food items were dated, labeled, and sealed after opening in the food preparation area, walk in freezer and dry storage area. c. [NAME] 1 wore hair restraint to cover beard and mustache while in kitchen and food storage areas. These failures had the potential to result in harmful bacteria growth and cross contamination (transfer of harmful bacteria from one place to another) that could lead to food borne illness for 63 of 63 medically compromised residents who received food from the kitchen. Findings: a. During concurrent observation and interview on 03/12/2024 at 08:43 AM with the Dietary Services Supervisor (DSS), observed the following in the walk-in refrigerator: - Teriyaki marinade and sauce had labeled that indicated opened date 12/14/2024, use by date (the last…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide a sanitary environment and implement the facility ' s policy and procedure for infection control by ensuring resident ' s clothing and two clean linen carts were stored in the clean designed areas. These deficient practices had the potential to result in the spread of diseases and infection to the residents, the facility staffs, and visitors. Findings: During a concurrent observation and interview on 3/12/24 at 1:28 p.m. with the Infection Control Nurse (IPN) in Shower room [ROOM NUMBER] East Wing (EW), eleven (11) hangers with clothes were observed hanging on the shower curtain pole with the shower curtain covering the shower stall. The IPN stated, she did not know if the clothes were clean or dirty, or with whom the clothes belong to, why and how long the clothes were placed in the common shower room that all other residents have access to. The IPN stated, the clothes should not be hanging in the common shower room because 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 interview and record review, the facility failed to keep the copy of an Advance Directive (known as living will, personal directive, advance directive, medical directive or advance decision, is a 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.) in the medical record for one of five sample residents (Resident 44). This deficient practice had the potential to cause harm and conflict in carrying out the resident 44's wishes for medical treatment and health care decisions leading to irreversible outcomes. Findings: A review of the admission record indicated Resident 44 was admitted on [DATE], with diagnoses that included dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life) and insomnia (sleep disorder). A review of the History and Physical Examination (H&P) dated 5/28/23, indicated Resident 44…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, and interview, the facility failed to ensure one of one resident sample (Resident 20) was provided with privacy when showering in the common shower rooms. 1. Shower 1 (East Wing [EW]) did not have a privacy curtain in the shower room. 2. Shower 2 EW and Shower 3 EW and Shower 1 [NAME] Wing (WW) had no curtain in the shower room to provide privacy to the residents when dressing after shower. 3. Shower 2 WW had a large window without cover that could see through the shower room and the dressing area. This failure resulted in Resident 20 ' s not feeling safe, feeling exposed when showering or dressing after shower, and resident ' s refusal for shower for fear of somebody looking at him while he was naked. This deficient practice also had the potential for other residents ' privacy to be violated. Findings: A review of Resident 20 ' s admission Record, dated 3/14/24, indicated Resident 20 was admitted to the facility on [DATE], and readmitted on [DATE] with diagnoses that included schizophrenia…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide a safe, clean, and homelike environment by ensuring the two restrooms had no foul odor for one of three sampled residents (Resident 47) that uses both restrooms. This failure resulted in Resident 47's reported not feeling to be in a homelike environment and had to wear mask when going to the restrooms because he could not breath due to terrible smell of the restroom. Findings: A review of Resident 47's admission Record, dated 3/14/24, indicated Resident 47 was admitted to the facility on [DATE] with diagnoses that included schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves), anxiety disorder (a condition in which a person has excessive worry and feelings of fear, dread, and uneasiness), and osteoarthritis (inflammation or swelling of one or more joints). A review of Resident 47's Minimum Data Set (MDS- a comprehensive assessment and screening tool) dated 9/21/23, the MDS indicated,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2. A review of Resident 22 ' s admission Record indicated the resident was admitted to the facility on [DATE], with diagnoses that included DM2 and schizophrenia (a chronic and severe mental disorder that affects how a person thinks, feels, and behaves). A review of Resident 22 ' s history and physical, dated 2/23/2023, indicated the resident does not have the capacity to understand and make decisions. A review of Resident 22 ' s Minimum Data Set (MDS, a comprehensive standardized assessment and screening tool), dated 3/1/2024, indicated the resident has intact cognition. Resident 22 ' s MDS also indicated the resident is independent in doing activities of daily living (ADL ' s), including eating, toileting, bathing, dressing, and walking. A review of Resident 22 ' s Order Summary Report, dated 3/13/2024, indicated Resident 22 is prescribed medications for DM2: 1. Glipizide (medication used to decrease blood sugar level) 10mg one tablet by mouth two times a day, ordered on 11/6/2023. 2. Metformin 1000mg…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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, facility failed to meet the professional standards of quality care for one of four sample residents (Resident 5) by failing to clarify with the physician and review the pharmaceutical recommendation whether to administer Ziprasidone (a medication that affects mood and behavior) with food. This deficient practice has the potential to decrease bioavailability (drug become completely available to the body to produce a therapeutic effect) of the Ziprasidone and result in Resident 5 increased mood and behavioral concerns. Findings: A review of Resident 5 ' s admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses of schizophrenia (a serious mental health condition that affects the way a person thinks and communicates with outside world). A review of the History and Physical Examination dated 3/11/24, indicated Resident 5 is able to make decisions for activities of daily living. A review of Resident 5 ' s Minimum Data Set (MDS, a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to ensure one of one sampled resident (Resident 20), maintains the ability to perform ADL (Activities of Daily Living) by failing to assess the reason for the refusal to take a shower and/or provide alternative measures to receive ADL assistance for a total of 47 days from 1/21/24 to 2/23/24 and 2/29/24 to 3/14/24. This failure had a potential to result in Resident 20 ' s decline to perform ADL, risk for body odor that could negatively affect the resident's self-image, skin break down, skin infections (occurs when germs enter the body and multiply, causing illnesses) and rashes. Findings: A review of Resident 20 ' s admission Record, dated 3/14/24, indicated Resident 20 was admitted to the facility on [DATE], and readmitted to the facility on [DATE] with diagnoses that included schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves), anxiety disorder (a condition in which a person has excessive worry and feelings of…

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

Based on observation, interview and record review, the facility failed to ensure staffing information was posted and updated on a daily basis. to ensure sufficient staffs were maintained at the facility to provide care. As a result, the total number of staff and the actual hours worked by the staff was not readily accessible to residents and visitors to ensure the residents receives the care they needed. Findings: During an observation, on 3/13/24 at 10:48 a.m., the staffing information posted in reception station, indicated the date of 3/12/24, and a resident census of 64. On 3/13/24 at 12:13 p.m., the staffing information posted in reception station, was not updated or changed. During an observation and interview on 3/13/24 at 12:13 p.m., with the Director of Staff Development (DSD), the DSD stated that the facility staffing information posted in Reception Station was still not updated or changed. The DSD stated she was the one updating and posting the staffing information. The DSD stated she posted the updated staffing information every day by 9 a.m. The DSD stated the staffing…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 pharmaceutical services indicated in the facility policy by failing to ensure the Change of Shift Narcotics (drug that relief pain, cause state of stupor or sleep, and physical dependence) Reconciliation Records verified by two of wo Licensed Nurses. This deficient practice could lead to inaccurate record of narcotic medication use, loss or misuse of narcotic medication. Findings: On 2/21/2024, the night shift (11 PM to 7 PM shift) licensed nurses did not, count and sign off the Controlled Drugs Count Record (CDCR) at the end of shift with up coming licensed nurse as required in the facility's policy. On 3/3/2024, the day shift (7AM to 3 PM shift) licensed nurses did not perform narcotic count and sign off the CDCR at the end of the shift with up coming licensed nurse as required in the policy. During a concurrent record review of the CDCR and an interview with the Licensed Vocational Nurse (LVN) 1 on 3/13/24 at 1:05 p.m., the LVN 1 stated CDCR were missing signatures from licensed nurses on 2/21/2024…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to label drugs and medical device used in the facility that were stored in one of the two med carts and one of two medication room storage, in accordance with currently accepted professional principles by failing to: 1. Label a multi-dose Valproic Acid (a medication used to treat seizure disorder [a sudden, uncontrolled burst of electrical activity in the brain]) bottle without an opened date, stored in Medication Carts (Med Cart 1). 2. Remove three expired foley catheter insertion trays (medical device that helps drain urine from the bladder) stored in Medication Storage Room. This deficient practice had the potential to result in the loss of efficacy of the Valproic Acid and can increased risk of seizures and a potential to result in the use of ineffective medical device for the residents. Findings: 1. During an observation and Medi Cart inspection in the [NAME] Wing Station on [DATE], at 9:49 a.m., in the presence of 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure accurately document in the Medication Administration Record (MAR) that insulin was given for one of five sampled residents (Resident 22) that indicated two doses of regular insulin (a medication prescribed to control blood sugar level) were not administered. This deficient practice had the potential for Resident 22 not to receive care and intervention in management of DM2 and lead to complications related to DM2 such as having high or low blood sugar. Findings: A review of Resident 22 ' s admission Record indicated the resident was admitted to the facility on [DATE], with diagnoses that included DM2 and schizophrenia (a chronic and severe mental disorder that affects how a person thinks, feels, and behaves). A review of Resident 22 ' s history and physical, dated 2/23/2023, indicated the resident does not have the capacity to understand and make decisions. A review of Resident 22 ' s Minimum Data Set (MDS, a comprehensive standardized assessment…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure three of three sampled residents (Residents 10, 55, and 44) who had no mental capacity to understand the terms of the facility ' s binding arbitration agreement (an agreement that allows parties to resolve disputes and lawsuits privately rather than going to the court) does not sign the arbitration agreement. This failure had the potential for Resident 10, 55 and 44 to not understand their rights for a binding arbitration agreement. Findings: 1. A review of Resident 10 ' s admission Record indicated the facility admitted Resident 10 on 6/15/2023, with diagnoses that included schizophrenia (a serious mental disorder in which people interpret reality abnormally) and dementia (the loss of cognitive functioning, thinking, remembering, and reasoning to such an extent that it interferes with a person's daily life and activities. The admission Record indicated Resident 10 was self-responsible. A review of Resident 10's Minimum Data Set ([MDS] a…

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

Based on observation, interview, and record review the facility failed to provide a call light (device used to alert facility staff assistance as needed by residents) for one out of 11 sampled residents (Resident 10). This deficient practice had the potential for the resident facility ' s failure to provide resident 10 with a call light is a serious issue that has the potential to delay care, endanger their safety, and impact their overall well -being. Findings: A review of Resident 10's admission Record indicated the facility admitted the resident on 6/15/2023, with diagnoses including but not limited to schizophrenia (lifelong brain disorder that causes people to interpret reality abnormally), dementia (Impaired thinking, remembering, or reasoning), unsteadiness on feet, and localized edema (swelling caused by excess fluid in body tissues). A review of Resident 10's History and Physical dated 6/15/2023, indicated resident 10 lacks capacity to make medical decisions. History and Physical of Resident 10 indicated Resident 10 has poor coordination and abnormal gait (when a person…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 physician for one out of four sampled residents (Resident 1) when Resident 1 refused to take Olanzapine and Divalproex, psychotropic medications (medications that affect brain activities associated with mental processes and behavior) on 2/19/2024. This deficient practice placed the resident and other residents at risk of harm when Resident 1 had a physical altercation with Resident 2 the following day. Findings: A review of Resident 1 ' s admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses that included restlessness and agitation, bipolar disorder (a mental health illness that causes extreme mood swings), and schizophrenia (mental disorder that affects how a person thinks, feels, and behaves). A review of Resident 1 ' s History and Physical (H&P), dated 1/31/2024, indicated Resident 1 does not have capacity to make medical decisions. A review of Resident 1 ' s…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to prevent misappropriation of property (the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money) by failing to provide the trust fund (a legal arrangement that allows an individual to place assets in a special account to benefit another person or entity) to the resident or resident representative upon discharge from the facility, in accordance with the facility ' s policy and procedure on Discharge and Transfer of Residents for one of three sampled residents (Resident 1). These deficient practices resulted in Resident 1 ' s missing $5,091.46 Trust Fund from the date the resident was discharged from the facility on 5/2/23 up until 5/11/23 which caused an increased in Resident 1 ' s sadness and anxiety. Findings: During a review of Resident 1 ' s admission Record, dated 11/3/23, the admission Record indicated, Resident 1 was admitted on [DATE] with diagnoses that included but not limited 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 protect Resident 2 from physical abuse by one of three sampled residents (Resident 1), who had a known history of physical aggression toward staff and other residents by failing to: 1. Supervise Resident 1 to prevent Resident 1 from hitting Resident 2 on 8/27/2023, during the 3 PM to 11 PM shift, after Resident 1 had change of condition manifested by increased verbal/physical aggression and striking out during the 7 AM to 3 PM shift. 2. Ensure that a care plan was initiated when Resident 1 had a change of condition manifested by increased in verbal and physical aggression on 8/27/2023. 3. Follow the facility's policy and procedure (P&P) titled, Abuse Prevention, Screening, & Training Program, that indicated the facility identifies, corrects, and intervenes in situations in which abuse, neglect, exploitation, misappropriation of resident property and/or mistreatment is more likely to occur. These failures resulted in Resident 1 striking out by hitting…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide adequate supervision for one of two sampled residents (Resident 1) by failing to identify Resident 1's risk of elopement (an incident in which a person with cognitive (thought process) loss wanders out of a safe area, such as a home or nursing facility) by locating the resident's whereabouts when the resident was not found in his room by Certified Nursing Assistant (CNA) 1 on 8/12/23 during the night (11 PM to 7 AM) shift. CNA 1 did not look for Resident 1 and did not notify the charge nurse (Licensed Vocational Nurse 1) that Resident 1 was not in bed on 8/12/23, during the start of the night shift. In addition, the facility failed to conduct reevaluation of Resident 1's elopement risks, after Resident 1 verbalized frustrations with wanting to go home during psychological consultations on 6/27/23, 7/14/23, and 8/11/23 (one day before Resident 1 eloped from the facility on 8/12/23), in accordance with the facility's policy on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the facility's licensed nurses and certified nurse assistants had the competencies and skills sets to provide care and services needed in the facility to work effectively with residents who had mental health disorders and other behavioral health needs, in accordance with the Facility Assessment on the facility's general resident population and the facility's policy on Staff Competency Assessment. As a result, one of two sampled residents (Resident 1), who had behavioral health needs due to diagnosis of sever psychosis and auditory hallucinations eloped from the facility on 8/12/2023. The facility's Certified Nursing Assistant (CNA) 1 failed to ensure monitoring and supervision was provided to Resident 1 by locating the resident's whereabouts when the resident was not found in his room on 8/12/23 during the night (11 PM to 7 AM) shift. CNA 1 did not look for Resident 1 and did not notify the charge nurse (Licensed Vocational Nurse 1) 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.