Arden Park Post Acute

Based on interview and record review, the facility failed to report an allegation of abuse, for two of 35 sampled residents (Resident 77 and Resident 79), when an incident on 2/26/26 involving Resident 77 and Resident 79 was not reported to the Department.This failure had the potential to place Resident 77 at risk for continued abuse.Findings:A review of Resident 77's Progress Note (PN), dated 2/26/26, the PN indicated, Resident [Resident 77] had a verbal altercation with his roommate [Resident 79]. Per resident, his roommate threw water at him. Close contact of aggressive nature was alleged to have happened.During an interview on 3/17/26 at 8:31 a.m. with Resident 77, Resident 77 indicated that on 2/26/26, he was positioned in his wheelchair between his and Resident 79's bed. Resident 77 indicated he had asked Certified Nursing Assistant 7 (CNA 7) to open the curtains to the outside window and that is when Resident 79 became frustrated. Resident 77 then stated, He [Resident 79] threw a full water pitcher at me and yelled, 'Fxxx you. Goddamnit'.the water pitcher hit me on the right…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 an accurate medical record for one of 35 sampled residents (Resident 157) when PICC (peripherally inserted central catheter, a long thin flexible tube inserted through a vein in the upper arm and into a large vein just above the heart used to deliver medications directly into the bloodstream) dressing changes and an administration of IV (intravenous) medication were not recorded in the resident's medical record.These failures resulted in an inaccurate medical record and had the potential for miscommunication among healthcare professional which could lead to inadequate care for Resident 157.Findings:Resident 157 was admitted to the facility in early 2026 with diagnoses which included a serious lung infection caused by a specific type of staph bacteria that is resistant to many common antibiotics.During a review of Resident 157's Order Summary Report [OSR], dated 3/2/26, the OSR indicated an order for PICC dressing changes every seven days and as needed.During an observation on 3/16/26 at 10:26 a.m. 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 maintain three resident wheelchairs (Resident 80, Resident 130 and Resident 143) in a census of 152 in safe operating order when the armrests were damaged and unable to be sanitized.This failure placed the residents at risk for discomfort, skin tears, abrasions and infection.Findings: During observations on 3/16/26, three resident wheelchairs were found in disrepair when both armrests were found cracked, missing pieces of upholstery for Resident 80, Resident 130and Resident 143.During a concurrent observation and interview on 3/16/26 at 9:21 a.m. with Certified Nurses Assistant (CNA) 3, CNA 3 verified the wheelchair armrests used by Resident 130 was cracked and missing pieces of the upholstery and unable to be sanitized.During an observation and interview on 3/16/26 at 12:17 p.m. with the Director of Nurses (DON), the DON verified the wheelchair armrests of Residents 80 and Resident 143 were in disrepair, unable to be sanitized and said, Skin could get caught on the armrests when the cover is worn and the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure services were provided to meet professional standards of quality for one of three sampled residents (Resident 3) when Resident 3 had ongoing oxygen therapy without a physician's order. This failure had the potential to put Resident 1's health and safety at risk. Findings: A review of the admission Record indicated Resident 3 was admitted [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD, a chronic lung disease causing difficulty in breathing). A review of Resident 3's Brief Interview for Mental Status (BIMS, an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) dated 1/16/25 indicated Resident 3 was cognitively intact with a score of 13 out of 15. A concurrent observation and interview was conducted on 3/28/25 at 10:40 a.m. inside Resident 3's room. Resident 3 was lying in bed with ongoing oxygen via nasal cannula (a small plastic tube,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 proper infection control practice for two of seven sampled residents (Resident 1 and Resident 2), when Licensed Nurse 1 (LN 1) did not sanitize (to clean or disinfect) a shared glucometer (device used to measure blood sugar levels using a test strip and drop of blood) in between use. This failure had the potential to spread infection among residents. Findings: A review of an admission record indicated Resident 1 was admitted to the facility in February 2025 with a diagnosis of diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). A review of Resident 1 ' s Order Summary Report, dated 3/3/25, indicated to check Resident 1 ' s blood sugar (BS) as needed for DM management. A review of an admission record indicated Resident 2 was admitted to the facility in January 2024 with a diagnosis of DM. A review of Resident 2 ' s Order Summary Report, dated 3/3/25, indicated to check Resident 2 ' s BS as needed for DM management. During an observation on 3/3/25…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 four sampled residents (Resident 1), received treatment and care in accordance with professional standards of practice when the comprehensive centered care plan was not followed. This failure had the potential to result in Resident 1 ' s gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems) tube (G-tube) to be displaced during Activities of Daily Living ( (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). Findings: During a review of Resident 1's face sheet (a document containing patient information), the face sheet indicated, Resident 1 was admitted to the facility July 2023 with multiple diagnoses which included dementia (a progressive state of decline in mental abilities). During a review of Resident 1 ' s Minimum Data Set (MDS- an assessment tool), dated 1/8/25,…

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Based on observation, interview, and record review, the facility failed to prepare, store, serve, and distribute food in accordance with professional standards of food service safety when: 1. The ice machine was not clean; 2. Several various kitchenware in the clean and ready-to-use storage areas: a. Were stacked and stored wet b. Had food debris; 3. Various size of cooking pans, readily available for use, had dry and heavy black substance buildup and deep scratches on the cooking surfaces; 4. Improper dating for the opened packages of food items in dry storage, walk-in refrigerator, and walk-in freezer; 5. Improper storage and handling for the opened package food items in the walk-in refrigerator and walk-in freezer; 6. Produce that were not fresh and not discarded found in walk-in refrigerator; 7. Issues found in resident's food refrigeration unit located in east station: 1. Improper and inconsistent labeling and dating of food items 2. Partially eaten food items stored in the refrigerator 3. Food items were expired and not discarded 4. Frozen foods stored in refrigerator 5. The…

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Based on observation, interview, and record review the facility did not maintain pharmacy services for a census of 154 when: 1. Expired glucagon [define] Emergency Medication [define] found in emergency supply kit (e-kit); 2. Twelve boxes of expired ear wax drops and 28 boxes of expired covid [define] test kits; 3. The medications for Random Resident (RR) was not discarded after discharge from the facility; and, 4. Narcotic medication [define] reconciliation did not match the electronic Medication Administration Record (eMAR) for Resident 81. This failure had the potential to cause inaccurate accountability of controlled medications and the potential to result in diversion of the residents' medication. 1. During medication storage observation and interview on 12/4/24 at 3:18 p.m. with Licensed Nurse 9 (LN 9) in Central Station Medication room, the LN 9 confirmed 1 Glucagon emergency kit with an expiration date of 4/30/2024. When LN 9 opened the e-kit, there were 3 glucagon 1 mg (milligrams, a unit of measurement) emergency medications with expired dates of 6/2024, 9/2024, and…

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Based on observation, interview, and record review, the facility failed to ensure the medication administration error rate was less than five percent (%) when five medication errors occurred out of 31 opportunities during medication administration for two residents (Resident 3 and Resident 28) of six selected residents during medication pass, when: 1. Resident 28 did not receive insulin (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication) per physician orders; 2. Resident 28 did not receive the correct bowel care medication and dose per physician's order; 3. Resident 28 did not receive respiratory medication per physician order; and, 4. Resident 3 did not receive Vitamin D supplement as ordered. These failures resulted in medications not being given in accordance with the physician's orders and had the potential to affect the residents' clinical conditions. Findings: 1. During an observation on 12/4/24 at 6:48 a.m., Licensed Nurse 14 (LN 14) was observed taking a blood glucose level for Resident 28. The blood sugar…

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

Based on observation, interview, and record review, the facility failed to ensure two residents (Resident 28 and Resident 56) were free of significant medication errors for a census of 154, when: 1. Insulin (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication) was not administered as ordered for Resident 28; and, 2. Resident 56 received five duplicate doses of Baclofen (a medication used to treat muscles spasms, cramping, and tightness in people with spinal cord injuries). These failures had the potential to compromise the health and safety of Resident 28 and Resident 56. Findings: 1. During an observation on 12/4/24 at 6:48 a.m., Licensed Nurse 14 (LN 14) was observed taking a blood glucose level for Resident 28. The blood sugar level was observed at 221. During a medication administration observation on 12/4/24 starting at 7:15 a.m. with LN 14, the LN 14 was observed administering 2 units of Humalog insulin (short-acting insulin). During a subsequent medication observation on 12/4/24 at 7:27 a.m., the LN 14 was…

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

Based on observation, interview, and record review, the facility failed to ensure food service personnel had skill sets to safely and effectively carry out the functions of the food and nutrition services when Dietary Aide (DA) 2 was unable to verbalize or demonstrate the procedure for cleaning and sanitizing food contact surfaces and was unable to verify the sanitizer concentration to ensure effective sanitation (cross refer to F812, #9). These failures had the potential to result in ineffective sanitation with potential to cause food borne illness in a high-risk population of 153 residents who consumed food from the facility kitchen. The census was 154. Findings: During an initial kitchen tour observation and concurrent interview on 12/3/24, at 9:23 a.m., DA 2 was observed using a rag from a red bucket (used as a standard of practice to contain sanitizer solution) to wipe a heavily soiled countertop with liquid and food particles on it. DA 2 verbalized the procedure for cleaning and sanitizing food contact surfaces, and DA 2 pointed to the red bucket and stated he used the rag…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 menu was followed for the therapeutic diet during lunch on 12/3/24 and 12/4/24 when: A. During a dining observation on 12/3/24: 1. Five residents (Resident 3, 13, 42, 114, and 126) with CCHO (consistent or controlled carbohydrate) diets (a diet for people who need to control their blood sugar or to manage diabetes) received one slice of bread instead of a 1/2 slice of bread. 2. Resident (RES) 42 with CCHO and Renal diet (diet to manage chronic kidney disease) received white rice instead of brown rice. B. During a meal service distribution on 12/4/24: 1. Four residents (Resident 82, 105, 129, and 142) with fortified diets (added calories and/or protein) did not get the fortified foods with their meals. 2. 21 residents (Resident 3, 13, 28, 29, 39, 49, 58, 67, 70, 87, 96, 103, 114, 115, 125, 126, 136, 150, 155, 311, and 360) with CCHO diets received one serving of dessert instead of a 1/2 serving of dessert. 3. Six residents (Resident 6, 37, 61, 67, 156, and 317) with mechanical soft texture diets (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 proper infection control was provided for eight residents (Resident 129, Resident 13, Resident 361, Resident 14, Resident 41, Resident 96, Resident 28, and Resident 16) for a census of 154 when: 1. Resident 129's nebulizer (a machine that delivers droplet medication into the lungs) mask and tubing were on the floor and the tubing was not labeled or dated; 2. Resident 13's nasal cannula (a medical device with two prongs that is connected to an oxygen source used to deliver supplemental oxygen directly into the nostrils) was undated and not properly stored when not in use; 3. Resident 361's BIPAP (bilevel positive airway pressure, a type of device that helps with breathing) machine was observed on the floor and BIPAP mask was not properly stored when not in use; 4. Resident 14's oxygen mask was undated and hanging on oxygen concentrator, and oxygen humidifier (a device that adds moisture to oxygen) was dated 6 months ago; 5. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that 45 resident rooms (104 to 109, 111, 203 to 210, 212, 214, 300 to 309, 400 to 409, 500, 503, 505, 507, 509, 511, 515, 517) met the required 80 square feet (sq ft) per resident. This failure had the potential to result in inadequate space for provision of care and a decrease in the quality of life for residents residing in these rooms. Findings: A review of the facility's Client Accommodation Analysis, dated 12/6/24 indicated: room [ROOM NUMBER] at 74.3 sq ft per resident room [ROOM NUMBER] at 74.3 sq ft per resident room [ROOM NUMBER] at 74.3 sq ft per resident room [ROOM NUMBER] at 74.3 sq ft per resident room [ROOM NUMBER] at 74.3 sq ft per resident room [ROOM NUMBER] at 74.3 sq ft per resident room [ROOM NUMBER] at 74.3 sq ft per resident room [ROOM NUMBER] at 74.3 sq ft per resident room [ROOM NUMBER] at 74.3 sq ft per resident room [ROOM NUMBER] at 74.3 sq ft per resident room [ROOM NUMBER] at 74.3 sq ft per resident room…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 residents were fully informed of the risks and benefits of medications for two of 33 sampled residents (Resident 147 and Resident 142) when: 1. The informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered) for Clozapine (medication used to treat Schizophrenia - a mental illness that is characterized by disturbances in thought) did not indicate the correct indication and target behavior for Resident 147; and, 2. There was no informed consent for the increase in the dose of Buspirone (medication used to treat anxiety) for Resident 142. These failures increased the potential for Resident 147 and Resident 142 to not be informed of the medications' risks and benefits and alternative options. Findings: 1. During a review of Resident 147's admission records, the records indicated Resident 147 was admitted in October 2024 with diagnoses that included Schizophrenia. Resident 147's Minimum Data Set (MDS, a federally mandated…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 homelike environment for two of 33 sampled residents (Resident 142 and Resident 109) when: 1. Resident 142's bathroom was in disrepair; and 2. Resident 109's bedside table was chipped and peeled on the sides. These failures increased the potential to negatively impact Resident 142 and Resident 109's psychosocial well-being. Findings: 1. A review of the clinical record indicated Resident 142 was admitted with diagnoses including depression (condition that causes constant feeling of sadness and loss of interest) and anxiety disorder (a condition that causes excessive worry and fear that interferes with daily life). A concurrent observation and interview was conducted on 12/3/24 at 12:50 p.m. inside Resident 142's room. Resident 142 stated there was mold in the bathroom and the bathroom had been like that since she had been there. Inside the bathroom, the baseboard was coming off/torn (near the toilet bowl) with blackish discoloration on the bottom of the baseboard. There was brownish to blackish…

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

Based on observation, interview, and record review, the facility failed to protect one of 33 sampled residents (Resident 311) from verbal abuse when Resident 312 expressed racial slurs to Resident 311. This failure resulted in Resident 311 feeling unsafe in his room and experiencing emotional distress. Findings: A review of Resident 311's admission Record indicated Resident 311 was admitted to the facility in November 2024 with multiple diagnoses including malignant neoplasm of prostate (prostate cancer), seizures, anxiety disorder (mental health disorder characterized by worry that interferes with daily life), and depression (mood disorder causing sadness and loss of interest in daily life). A review of Resident 311's Minimum Data Set (MDS- a federally mandated assessment tool), Cognitive Patterns, dated 12/2/24, indicated Resident 311 had a Brief Interview for Mental Status (BIMS- tool to assess cognition) score of 13 out of 15 that indicated Resident 311 was cognitively intact. A review of Resident 311's Progress Note, dated 12/3/24 at 6:42 a.m., indicated .Resident is requesting…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 person-centered care plans timely, specific to medical, nursing, physical, mental, and psychosocial needs for two of 33 sampled residents (Resident 147 and Resident 361) when: 1. Care plan for Resident 147's use of antipsychotic (medication used to treat psychosis - a severe mental condition in which thought, and emotions are so affected that contact is lost with reality) was not developed timely upon starting Clozapine (medication used to treat Schizophrenia - a mental illness that is characterized by disturbances in thought); and, 2. There was no care plan developed for Resident 361's hard of hearing and use of hearing aid (a device worn in or behind ear designed to amplify sound for individuals who have difficulty hearing). These failures had the potential to result in Resident 147 and Resident 361 not maintaining the highest practicable well-being and preventing avoidable decline. Findings: 1. During a review of Resident 147's admission records, the records indicated Resident 147 was admitted in October 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.

Based on observation, interview, and record review, the facility failed to ensure services were provided to meet professional standards of quality for two residents (Resident 28 and Resident 116), for a census of 154, when: 1. Resident 28's insulin (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication) order was marked as given prior to administration; 2. The licensed staff did not dispose used lancets (small sharp objects used to take blood samples for blood sugar) in biohazard sharps containers; and 3. Resident 116's medication was left at bedside. These failures had the potential to put residents' health and safety at risk. Findings: 1. During observation on 12/4/24 at 6:48 a.m., Licensed Nurse 14 (LN 14) was observed taking a blood glucose level for Resident 28. The blood sugar level was observed at 221. During a medication administration observation on 12/4/24 starting at 7:15 a.m. with LN 14. LN 14 was observed administering 2 units of insulin to (Resident 28). During a subsequent medication observation on 12/4/24…

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

Based on interview and record review, the facility failed to ensure one of 33 sampled residents (Resident 107) received vision services as ordered in a timely manner. This failure increased the potential for Resident 107 to experience further loss of vision. Findings: A review of the clinical record indicated Resident 107 was admitted with diagnoses including type 2 diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing). A Minimum Data Set (MDS- a federally mandated resident assessment tool) dated 11/10/24 indicated Resident 107 had vision impairment and he was cognitively intact. Further review of Resident 107's clinical records indicated the following physician orders: - an order dated 3/12/24 for Latanoprost ophthalmic solution 0.005% to instill 1 drop to left eye once a day for glaucoma (a condition where fluid builds up inside the eye causing increased pressure); - an order dated 5/20/24 for Brimonidine tartrate ophthalmic solution 0.2% to instill 1 drop to left eye three times a day for glaucoma; - an order dated 6/3/24 for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide care for pressure injuries (injury to skin and underlying tissue resulting from prolonged pressure on the skin) consistent with facility policy and professional standards for two of thirty-three sampled residents (Resident 311 and Resident 318), when: 1. Resident 311 developed pressure injury to sacrum (base of the spine) after admission to the facility; and 2. Resident 318 did not have an accurate skin assessment upon admission to the facility. These failures placed Resident 311 and 318 at increased risk for infection and health status decline. Findings: 1. A review of Resident 311's admission Record indicated Resident 311 was admitted to the facility in November 2024 with multiple diagnoses including malignant neoplasm of prostate (prostate cancer), malignant neoplasm of the bone (cancer in the bone), seizures, diabetes (too much sugar in the blood), and cord compression (compression of the spinal cord causing neurological…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 33 sampled residents (Resident 27) received services to maintain mobility of fingers and prevent further contracture (a stiffening/shortening at any joint, that reduces the joint's range of motion). This failure increased the potential for Resident 27 to experience total loss of mobility on fingers and to negatively impact psychosocial well-being. Findings: A review of the clinical record indicated Resident 27 was admitted with diagnoses including unspecified osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage). A Minimum Data Set (MDS- a federally mandated resident assessment tool) dated 10/29/24 indicated Resident 27 had moderate cognitive impairment and had functional limitation in range of motion (ROM) on her upper extremity. A review of Resident 27's care plan revised 8/5/24 indicated, Resident 27 had self-care performance deficit related to left side weakness, cognitive and physical function deficits, contractures to right hand, need extensive to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to ensure two of 33 sampled residents (Resident 147 and Resident 30) was free from unnecessary psychotropic medications (drugs that affect brain activities associated with mental processes and behaviors) when: 1. Resident 147's Clozapine (medication used to treat Schizophrenia - a mental illness that is characterized by disturbances in thought) was given without appropriate target behavior and side effects monitoring; and, 2. Resident 30 did not have adequate indication for the use of antipsychotic medication. These failures decreased the facility's potential to monitor Resident 147 for appropriate target behaviors and had the potential to result in increased risk and exposure to side effects associated with psychotropic medications for Resident 147 and Resident 30. Findings: 1. During a review of Resident 147's admission records, the records indicated Resident 147 was admitted in October 2024 with diagnosis that included Schizophrenia. Resident 147'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 ensure services furnished by outside resources had written agreements when two out of 33 sampled residents' (Resident 41 and Resident 50) dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidneys have failed) services were provided without existing agreements with dialysis clinics. This failure had the potential to result in the lack of responsibility and accountability in the dialysis services received by Resident 41 and 50. Findings: 1a. During a review of Resident 41's admission records, the records indicated Resident 41 was admitted in May 2024 and readmitted in October 2024 with diagnoses that included chronic kidney disease and dependence on dialysis. Resident 41's Minimum Data Set (MDS, a federally mandated resident assessment tool) indicated Resident 41 had intact cognition. During a review of Resident 41's MDS Section O, dated 11/17/24, the MDS indicated Resident 41 was receiving dialysis while a resident in the facility. 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 develop and implement an effective discharge planning process when Resident 1 was discharged home without proper arrangements for home health services to manage the wound and therapy services. This failure resulted in Resident 1 ' s not having wound care for over 8 days which had the risk potential for the wound to get infected and deteriorate in functional status due to therapy services not provided. Findings: A review of the admission record indicated the facility admitted Resident 1 in the fall of 2024 with multiple diagnoses which included aftercare for surgical wound that got separated and caused a life-threatening infection due to ruptured appendix (lower end of intestine). Resident 1 ' s medical history indicated that the resident had a recent colostomy (a surgical opening in which a piece of colon was removed and a new opening was created and a small pouch was attached to collect and remove waste material). A review of Resident 1 ' s clinical…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) services, consistent with professional standards of practice, to meet the needs of one of three sampled residents (Resident 1), when: 1. Resident 1 missed scheduled dialysis appointments due to transportation issues, and 2. Resident 1's responsible party (RP) and physician were not informed about missed dialysis appointments. These failures increased Resident 1's risk of developing medical complications, including hospitalization and death. Findings: A review of an admission record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including end stage renal disease (ESRD-irreversible kidney failure) and dependence on renal dialysis. Resident 1 was discharged on 7/6/24 due to death. A review of Resident 1's Minimum Data Set (MDS; an assessment tool), dated 6/30/24, indicated Brief Interview…

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

Based on interviews and record review, the facility failed to ensure professional standards of quality were followed for one of three sampled residents (Resident 1), when the fluid restriction physician order was not followed. This failure had the potential to increase Resident 1's difficulties in breathing resulting in hospitalization. Findings: A review of the admission record indicated the facility admitted Resident 1 in 2022 with multiple diagnoses including chronic lung disorders. A review of Resident 1's clinical records contained a chest x-ray result dated 6/27/24 which indicated that the resident had pulmonary edema (a condition caused by too much fluid in the lungs making it difficult to breathe). A review of Resident 1's Order Summary Report, dated 6/28/24, indicated a physician order for fluid restriction of 1500 milliliters (ml, unit of measurement) a day. The physician directed nurses to total all fluids that the resident received every shift and added, Should not exceed 1500 total 24 hr [hour] fluid restriction. A review of the physician's progress notes, dated 7/2/24,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to protect the five out of eight sampled residents' (Resident 1, Resident 3, Resident 4, Resident 5, and Resident 7) right to be free from mental and physical abuse by a resident (Resident 2) when: 1. The facility failed to reasonably investigate residents' complaints regarding Resident 2 to ensure their well-being and safety; and, 2. Resident 2 (with known history of wandering) went inside Resident 1 and Resident 4's room on 7/2/24, unsupervised, masturbated, and pooped on the floor. These failures resulted in Resident 1, Resident 3, Resident 5, and Resident 7 being scared, feeling unsafe, fearful, and experiencing emotional distress, and had the potential for Resident 1, Resident 3, Resident 4, Resident 5, and Resident 7 and all residents in the facility to experience physical and/or psychosocial harm. Findings: 1. A review of Resident 1's clinical record indicated Resident 1 was admitted November of 2018 and had diagnoses that included bipolar disorder…

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

Based on interview and record review, the facility failed to implement policies and procedures for ensuring the reporting of a reasonable suspicion of abuse in accordance with section 1150B of the Act for one of eight sampled residents (Resident 1) when: 1. Resident 1 reported to nursing staff that she was slapped by Resident 2 on 4/9/24; and, 2. Resident 1 reported to the Assistant Director of Nursing (ADON) that Resident 2 (with known history of wandering) went inside Resident 1's room on 7/2/24, unsupervised, masturbated, and pooped on the floor. This failure had placed Resident 1 and other residents in the facility at risk for further abuse, and possible serious physical and/or psychosocial harm. Findings: 1. A review of Resident 1's clinical record indicated Resident 1 was admitted November of 2018 and had diagnoses that included bipolar disorder (a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration), major depressive disorder (persistently depressed mood or loss of interest in activities, causing significant impairment in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement its Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating policy for four of seven sampled residents (Resident 1, Resident 3, Resident 5, and Resident 7) when the facility failed to ensure one of Resident 1's allegation of abuse and mistreatment was timely and thoroughly investigated. This failure to protect, investigate, and provide a safe environment caused Resident 1, Resident 3, Resident 5 and Resident 7 to feel emotionally unsafe, violated, and helpless. Not investigating and interviewing these other residents allowed the perpetrator (Resident 2) to have access to Resident 1, Resident 3, Resident 5 and Resident 7 and other vulnerable residents and allowed further abuse. Findings: A review of Resident 1's clinical record indicated Resident 1 was admitted November of 2018 and had diagnoses that included bipolar disorder (a mental illness that causes unusual shifts in a person's mood, energy, activity levels, 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 reasonable access to a telephone for one resident (Resident 1). This failure prevented Resident 1 from calling her significant other and from being contacted by the State Agency. Findings: A review of Resident 1's admission record indicated, Resident 1 was admitted in the summer of 2023 with diagnoses that included multiple sclerosis (a degenerative disease affecting the nervous system), paraplegia (inability to move the lower part of the body), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness). During a concurrent observation and interview on 6/11/24 at 12:43 p.m. with Resident 1 in the resident's room, Resident 1 was observed without the facility's phone in the room and without a personal phone. Resident 1 confirmed not having a phone, and she expressed desire to call her significant other. Resident 1 agreed for the surveyor to place a test call to the facility and use the facility's cordless phone for her personal needs after it will be brought to her by…

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

Based on observation, interview, and record review, the facility failed to provide accurate documentation of Activities of Daily Living (ADL) services provided for one of three sampled residents (Resident 1), when Resident 1's clinical record did not reflect Resident 1 was offered bathing services according to facility's protocol. This failure had the potential for Resident 1 to not receive bathing services per facility protocol resulting in missed skin change evaluations and loss of dignity. Findings: A review of Resident 1's admission Record indicated she was admitted to the facility in January 2022 with multiple diagnoses including diabetes (too much sugar in the blood), post traumatic stress disorder (mental health condition triggered by a traumatic event), and schizoaffective disorder, bipolar type (mental health condition combining symptoms of schizophrenia and mood disorder). A review of Resident 1's Minimum Data Set (MDS- an assessment tool), Section C, dated 3/29/24, indicated Resident 1 had a Brief Interview for Mental Status (BIMS- tool to assess cognition) score of 12…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 resident (Resident 1) was treated with respect and dignity when facility staff was on the phone while providing care, for a census of 145. This failure had the potential for Resident 1 not to receive care based on her needs and preferences. Findings: A review of the clinical record indicated Resident 1 was admitted end of March 2024 with diagnoses including aftercare following joint replacement surgery. The Minimum Data Set (MDS, an assessment tool), dated 4/3/24, indicated Resident 1 was cognitively intact, required partial or moderate assistance with toileting hygiene and frequently incontinent of urine and stool. Further review of Resident 1's care plan dated 3/28/24 indicated, .[Resident 1] has actual for ADL[activities of daily living, tasks related to personal care and includes toilet use]/mobility decline and requires assistance related to recent hospitalization, recent surgery . The inteventions included, Encourage to use call light…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 effective pain management was provided for one of three sampled residents (Resident 1) who was admitted to Hospice (specialized care that provides physical comfort, and quality of life for patients with a terminal illness and approaching the end of life) when the facility's licensed staff did not administer the right dose of pain medication as ordered by the physician. This failure had the potential for Resident 1 to endure pain and suffering as a result of poor pain management. Findings: A review of Resident 1's clinical record indicated, she was readmitted to the facility late 2023 with multiple diagnoses that included cerebral infarction due to unspecified occlusion or stenosis of unspecified cerebral artery (blood vessel in the brain is blocked or narrowed, causing lack of blood flow to a part of the brain). A review of Resident 1's care plan initiated 11/15/23, indicated, admitted to Hospice under [Name of hospice] Hospice with DX[Diagnosis] CVA [Cerebral Vascular Accident] .Interventions .Monitor for c/o…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 Minimum Data Set (MDS, an assessment tool used to guide care) for one of three sampled residents (Resident 1) accurately reflected Resident 1's Physician's Order for Life Sustaining Treatment (POLST) when her MDS Section S RESIDENT ASSESSMENT AND CARE SCREENING was not accurately documented. This failure had the potential to result in Resident 1 receiving interventions that were contrary to her own choices. Findings: A review of Resident 1's clinical record indicated, she was readmitted to the facility late 2023 with multiple diagnoses that included cerebral infarction due to unspecified occlusion or stenosis of unspecified cerebral artery (blood vessel in the brain is blocked or narrowed, causing lack of blood flow to a part of the brain). A review of Resident 1's POLST dated, [DATE] indicated the following: Section A Cardiopulmonary Resuscitation Section (CPR, emergency procedure that combines chest compressions and artificial ventilation)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, person-centered care plan (a detailed approach outlining resident's concerns and needs) for one of three sampled residents (Resident 1), when she fell, and no actual fall care plan was developed or prior care plans revised to include new interventions to prevent further falls. This failure increased the risks for Resident 1 to have recurrent falls and injuries when preventative interventions were not revised. Findings: A review of the 'admission Record ' indicated Resident 1 was admitted to the facility in 2023 with multiple diagnoses which included generalized muscle weakness, unsteadiness on feet, and lack of coordination. A review of Resident 1's 'Fall Risk Assessment,' dated 1/18/23, listed resident's risk factors and indicated that the resident was at high risk for falls. A review of Resident 1's clinical records indicated the resident had an 'At risk for falls' or injury care plan initiated on 4/13/23. The care plan interventions were not revised or updated since 4/13/23. 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.

The facility failed to ensure the resident's right to personal privacy and confidentiality of his or her personal medical information when meal tray tickets were thrown into the general trash and dumpsters. This had the potential of compromising resident privacy for the 150 residents eating facility prepared meals. Findings: During the initial kitchen tour on 1/22/24 at 10:22 a.m., a Dietary Aide (DA) demonstrated dish washing. As he removed the used trays from the meal carts, he threw the tray tickets into the garbage can. The Dietary Manager (DM) confirmed the tray tickets in the trash can. During a concurrent review of the tray tickets, they were observed to contain information such as the resident's name, date, room number, diet order (which may correlate to medical diagnosis), special orders such as adaptive equipment, food likes/dislikes, and food allergies. Review of facility provided policy titled Confidentiality of Information and Personal Privacy (Med-Pass Inc., 2001) indicated that Our facility will protect and safeguard resident confidentiality and personal privacy.…

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

Based on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for two out of 33 sampled residents (Resident 96 and Resident 52) when: 1. Resident 96's Activities of Daily Living (ADLs- normal daily functions required to meet basic needs) care plan was not developed; and, 2. Resident 52's care plan intervention did not accurately reflect Resident 52's physician's order for oxygen therapy. These failures placed Resident 96 and Resident 52 at risk to not meet their medical, physical, and psychosocial needs. Findings: 1. A review of Resident 96's clinical record indicated Resident 96 was originally admitted August of 2023 and had diagnoses that included need for assistance with personal care, and hemiplegia (complete loss of the ability to move one side of the body) and hemiparesis (partial weakness of one side of the body) following nontraumatic intracerebral hemorrhage (a condition where a pool of blood is formed within the brain causing structural, biochemical or electrical abnormalities in the brain, spinal…

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

Based on observation, interview and record review, the facility failed to provide respiratory care consistent with the facility policy and procedure for three of 33 sampled residents when: 1. Resident 14 received oxygen therapy without humidifier and the resident's BiPAP (a device supplies pressurized air into the lungs through a mask or nasal plugs) was placed on the bedside table unbagged and undated, and 2. Resident 52 and Resident 107's physician's orders for oxygen therapy were not followed. These failures placed Resident 14 at risk for respiratory infection and increased potential for ineffective respiratory therapy for Resident 52 and Resident 107. Findings: 1. Resident 14 was a long-term resident at the facility with diagnoses that included lung disease and sleep disorder. During the Initial Tour on 1/22/24 starting at 9:30 a.m., Resident 14 was sitting on her bed receiving supplemental oxygen via nasal cannula (a plastic tubing that delivers the oxygen from the concentrator to the nostrils). The oxygen concentrator was in operation with the oxygen flow rate set at 4 liters…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 meet food storage and service practices that meet professional standards for food service safety when: 1) Kitchen staff did not consistently use hair and beard guards while in the kitchen, 2) Dry storage did not have a thermometer and temperature monitoring system, 3) Dry storage floors found with black markings, rust stains and holes in the linoleum, 4) Food not consistently closed and covered after opening, 5) Ice build-up found on freezer ceiling and floor as well as thick condensation making visibility poor, 6) Wet pans and bowls in ready to use area, 7) Equipment not replaced when no longer meeting safe standards, 8) Food particles and debris found on kitchen equipment, 9) Dumpsters found with lids left open, overflowing, and trash around base, 10) Resident refrigerator without freezer log system for monitoring temperature and food safety. These issues had the potential of leading to food borne illness for the 149 out of 150 residents eating facility prepared foods. Findings: 1) During the initial…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow and maintain an effective infection prevention and control program for a census of 151 residents when: 1. Two facility staff entered a droplet isolation precaution room (an isolation precaution implemented when a patient infected with a pathogen which is transmittable through air droplets by coughing, sneezing, talking, and close contact with an infected patient's breathing) without using all the required personal protective equipment (PPE); 2. Resident 3's incentive spirometer (a hand-held exercise equipment for the lungs that helps people to take slow, deep breath) was left on top of Resident 3's bedside drawer with no cover, and was not labeled with a resident identifier and the date it was initially used; 3. Resident 52's incentive spirometer was not stored properly; 4. Resident 17's urinal (a hand-held bottle for urination) was not labeled with a resident identifier and the date it was initially used; and, 5. Resident 107'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 and interview, the facility failed to ensure that 44 resident rooms (104-109, 111, 203-210, 212, 214, 300-309, 400-409, 500, 503, 505, 507, 509, 511, 515, and 517) met the required 80 square feet (sq ft) per resident when the following rooms were measured as: room [ROOM NUMBER] at 70.5 sq ft per resident room [ROOM NUMBER] at 73 sq ft per resident room [ROOM NUMBER] at 71.9 sq ft per resident room [ROOM NUMBER] at 73.5 sq ft per resident room [ROOM NUMBER] at 74.1 sq ft per resident room [ROOM NUMBER] at 73.5 sq ft per resident room [ROOM NUMBER] at 73.5 sq ft per resident room [ROOM NUMBER] at 73.4 sq ft per resident room [ROOM NUMBER] at 73.2 sq ft per resident room [ROOM NUMBER] at 73.2 sq ft per resident room [ROOM NUMBER] at 73.2 sq ft per resident room [ROOM NUMBER] at 72.8 sq ft per resident room [ROOM NUMBER] at 70 sq ft per resident room [ROOM NUMBER] at 73.2 sq ft per resident room [ROOM NUMBER] at 70.2 sq ft per resident room [ROOM NUMBER] at 69.4 sq ft per resident room [ROOM…

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

Based on observation, interview and record review, the facility failed to protect one of 33 sampled residents (Resident 121's) dignity when the resident's urinary catheter drainage bag with an indwelling urinary catheter was not covered with a privacy bag. This failure resulted in Resident 121's urinary bag to be exposed and visible from the hallway and placed the resident at risk for feeling an involuntary loss of his dignity. Findings: Resident 121 was admitted to the facility in the Summer of 2023 with diagnoses that included prostate cancer and history of urinary tract infection. During the Initial Tour on 1/22/24 starting at 9:12 a.m., Resident 121 was lying in bed in a shared bedroom. The door to the room was wide open from the hallway and Resident 121 was noted to have the urinary catheter drainage bag attached to the right side of his bed facing towards the hall. The urinary drainage bag did not have a privacy cover and was visible from the hallway. Upon a closer observation, there was about 200 ml of bright red bloody urine collected in the drainage bag. 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.

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 resident needs and preferences for one of 33 sampled residents (Resident 30) when Resident 30's bed and bedside drawer was re-arranged without Resident 30's permission. This failure resulted in Resident 30 experiencing emotional distress, irritation, and hindered Resident 30's ability to transfer from his wheelchair to his bed. Findings: A review of Resident 30's clinical record indicated Resident 30 was originally admitted September of 2021 and had diagnoses that included hemiplegia (complete loss of the ability to move one side of the body) and hemiparesis (partial weakness of one side of the body) following cerebral infarction (damage to a part in the brain due to a disrupted blood flow) affecting left non-dominant side, muscle weakness, and major depressive disorder (persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). 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.

Based on observation, interview, and record review, the facility failed to ensure two out of 33 sampled residents (Resident 96 and Resident 52) were assisted with nail care as part of their Activities of Daily Living (ADLs- normal daily functions required to meet basic needs) when Resident 96 and Resident 52 had fingernails that were long and with blackish substance underneath the fingernails. These failures had the potential for Resident 96 and Resident 52 to sustain injury and/or for the residents to acquire an infection. Findings: 1a. A review of Resident 96's clinical record indicated Resident 96 was originally admitted August of 2023 and had diagnoses that included the need for assistance with personal care, and hemiplegia (complete loss of the ability to move one side of the body) and hemiparesis (partial weakness of one side of the body) following nontraumatic intracerebral hemorrhage (a condition where a pool of blood is formed within the brain causing structural, biochemical or electrical abnormalities in the brain, spinal cord, or other nerves) affecting right dominant…

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

Based on observation, interview and record review, the facility failed to ensure two of 33 sampled residents (Resident 80 and Resident 103) received enteral feeding (tube feeding) consistent with the facility's policy and procedure and the resident's care plan when: 1. Resident 80's medical record had no documented evidence for enteral tube feeding assessments prior to nutrition formula and/or medication administration, and 2. Resident 103 had no I&O (Intake & Output) summary and evaluation in the medical records. These failures placed Resident 80 at risk for complications related to tube feeding such as aspiration pneumonia and increased the potential for Resident 103's fluid imbalance to go unnoted. 1. Resident 80 was admitted to the facility in the Summer of 2023 with diagnoses that included cognitive impairment and had PEG tube (percutaneous endoscopic gastronomy tube; G-tube, surgically inserted feeding tube through the abdominal wall into the stomach) for administration of food, fluids, and medication. Review of Resident 80's MDS (Minimum Data Set, an assessment tool) in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to maintain accurately documented clinical records for one out of 33 sampled residents (Resident 96) when Resident 96's clinical record did not accurately reflect Resident 96's advance directive (legal documents that provide instructions for medical care, recognized under State law, relating to the provision of health care when the individual is incapacitated or in the event of a medical emergency). This failure placed Resident 96's advance medical related wishes and directives at risk to not be followed in an emergency. Findings: A review of Resident 96's clinical record indicated Resident 96 was originally admitted August of 2023 and had diagnoses that included need for assistance with personal care, and hemiplegia (complete loss of the ability to move one side of the body) and hemiparesis (partial weakness of one side of the body) following nontraumatic intracerebral hemorrhage (a condition where a pool of blood is formed within the brain causing…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to ensure one of three sampled residents (Resident 1) received treatment and care in accordance with professional standards of practice when Resident 1's temperature and blood glucose level were not assessed upon Resident 1's change in condition. This failure had the potential to delay interventions for Resident 1's life-threatening symptoms when the Resident was hypoglycemic (low blood glucose) and hypothermic (low temperature) upon arrival to the Emergency Department (ED). Findings: Resident 1 was admitted to the facility on [DATE], with diagnoses that included sepsis (life threatening complication of an infection as it moves throughout the body), diabetes mellitus (high blood sugar) and chronic obstructive pulmonary disease (COPD-lung disease that block airflow and make difficulty to breathe). A review of Resident 1's Minimum Data Set (MDS-an assessment tool) dated 11/20/23, described Resident 1 as having clear speech, able to make herself understood…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 policies and procedures for ensuring the reporting of an allegation of abuse for one of four sampled residents (Resident 1) when Resident 1's allegation of mishandled bowel care by Licensed Nurse (LN) 4 was not reported to the State Survey Agency/California Department of Public Health (CDPH), to the State Ombudsman, and to the law enforcement officials within two hours. This failure placed Resident 1 and other residents in the facility at risk for further mishandled bowel care, and possible serious physical and/or psychosocial harm. Findings: A review of Resident 1's clinical record indicated Resident 1 was admitted on [DATE], and had diagnoses that included encounter for other orthopedic aftercare (a care provided after a surgery that involves bones, muscles, and joints) and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest that can interfere with daily life). A review of Resident 1's progress…

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