Capital Post Acute

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, and record review the facility failed to provide for two residents (Resident 138 and Resident 139) out of 32 sampled residents:Adequate supervision when Resident 138 eloped the facility without staff being aware of Resident 138's whereabouts; and,No smoking assessment completed for Resident 139.These failures placed residents at risk for serious injury, harm, or death related to elopement and fire hazards.Findings: 1.During a closed record review on 2/20/26, the admission Record (AR) indicated Resident 138 was admitted on [DATE] with diagnoses of Acute Pyelonephritis (a serious bacterial infection of the kidney, usually caused by a bladder infection that has spread upwards). Resident 138's medical record indicated, a history of Diabetes Type 1 (DM 1- a chronic autoimmune condition where the body's immune system mistakenly attacks and destroys insulin-producing cells in the pancreas), Bacteremia (the presence of bacteria in the blood stream), Bipolar Disorder (a chronic…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure safe storage of medication for one (Resident 139) out of 32 sampled residents.This failure resulted in the facility's inability to monitor Resident 139's medication administration, placing Resident 139 at risk for improper dosing and non-therapeutic medication levels.Findings:Review of Resident 139's admission Records, indicated that Resident 139 was admitted on [DATE] with diagnoses including anxiety disorder (a condition characterized by persistent worry and interferes with daily life), panic disorder (a condition that is characterized by unexpected panic attacks) and depression (a condition that causes persistent sadness that affects how a person feels, thinks and functions in daily life).Review of Resident 139's clinical record indicated no Interdisciplinary Team (IDT-a group of healthcare professionals who collaborate assess and plan a resident's care) notes, no order and no care plan indicating Resident 139 was able 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 resident's food preference was honored for one of 32 sampled residents (Resident 5) when Resident 5's request for a diet upgrade was not followed.This failure had the potential to negatively impact the residents' food intake and well-being.Findings:During a review of Resident 5's admission Record (AR), the AR indicated Resident 5 was re-admitted on [DATE] with diagnoses that included injury of cervical spinal cord (uppermost part of the spinal cord), type 2 diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) and adjustment disorder with depressed mood (persistent, intense, and long-lasting feeling of sadness or a loss of interest in activities).During a review of Resident 5's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 12/5/25, the MDS indicated, Resident 5 did not have any memory or cognitive impairment. The MDS also indicated Resident 5 did not have any…

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 necessary treatment and care services was provided for one (Resident 118) of 32 sampled residents in accordance with professional standards of practice when rehabilitation referral for restorative nursing (RNA) was not started right away for Resident 118.This failure had the potential to place Resident 118 at risk for decline in functional ability, including decreased mobility and muscle strength.Findings:During a review of Resident 118's admission Record (AR), the AR indicated Reisdent 118 was re-admitted on [DATE] with diagnoses that included multiple sclerosis (MS- a chronic, progressive disease involving damage to the nerve cells in the brain and spinal cord), paraplegia (loss of movement and/or sensation, to some degree, of the legs) and muscle wasting/atrophy (weakening, shrinking, and loss of muscle).During a review of Resident 118's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 12/22/25, 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.

Based on observation, interview, and record review the facility failed to ensure one resident's (Resident 105) out of 32 sampled residents, call light was accessible to call for staff assistance, when call light was out of reach. This failure had the potential to result in Resident 105's inability to notify staff if there was an emergency. Findings:A review of Resident 105's admission Record indicated he was admitted to the facility in March 2025 with diagnoses which included subarachnoid hemorrhage (where bleeding occurs between the brain and surrounding tissues) and dysarthria (difficulty speaking).A review of Resident 105's Care Plan (CP, a comprehensive, individualized plan of care) indicated the following concerns and interventions:1. The resident is at risk for alteration in musculoskeletal status: . Be sure call light is within reach and respond promptly to all requests for assistance, dated 4/8/25. 2. At risk for skin breakdown: Keep call light within reach and encourage resident to call for assistance, dated 3/29/25. 3. Resident is at risk for falls and/or injuries: Keep…

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 three sampled residents (Resident 1), when the facility failed to identify, implement and monitor new interventions to prevent falls after Resident 1 fell at the facility on 1/4/26 and fell twice more on 1/10/26.These failures could have contributed to a fall on 1/13/26 that resulted in a broken clavicle (a break in the outer end of the collarbone, often caused by a direct fall onto the shoulder causing intense pain), pain, and a four-day hospitalization for Resident 1. Findings:Resident 1 was admitted to the facility on [DATE] with multiple medical diagnoses which included dementia (a progressive state of decline in mental abilities), schizophrenia (a mental illness that is characterized by disturbances in thought), and seizures (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness).During 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.

Based on interview, and record review, the facility failed to protect one of five sampled residents from abuse (Resident 1) when a Certified Nursing Assistant (CNA) hit Resident 1 on the head and the CNA, along with Witness 1 and Witness 2, physically restrained Resident 1 during care.This failure resulted in violation of Resident 1's right to be free from abuse of any type and had the potential to result in physical and psychosocial harm.Findings:During a review of Resident 1's admission record, Resident 1 was admitted in February of 2025 with diagnoses of Traumatic Hemorrhage of Cerebrum (bleeding within the brain tissue), Dementia (disorder affecting memory, thinking, language, and problem-solving) and muscle weakness. Resident 1's Minimum Data Set (MDS, a federally mandated resident assessment tool) indicated Resident 1 had a Brief Interview for Mental Status (BIMS) score of 11 indicating moderate cognitive impairment (a score of 11 out of 15 suggests the individual has noticeable issues with memory and orientation, requiring more support for daily living tasks). During an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure one of six sampled residents (Resident 3) was free from abuse when facility staff witnessed Resident 4 hit Resident 3 with an object.This failure resulted in Resident 3 to feel unsafe in the facility and had the potential for Resident 3 to be harmed.Findings:During a review of Resident 3's clinical record, Resident 3 was admitted [DATE] with diagnosis that included bilateral below the knee amputation (surgical removal of the leg below the knee), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). During a review of Resident 3's Minimum Data Set (MDS- a federally mandated resident assessment tool), dated 8/26/24, Resident 3 had a Brief Interview for Mental Status (BIMS- a tool to assess cognition) score of 13 out of 15 which indicated Resident 3 had intact cognitive.During a review of Resident 4's clinical record, Resident 4 was admitted [DATE] with diagnosis that included…

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 reviews the facility failed to ensure Resident 1 was treated with respect and dignity for a census of 116. This failure had the potential for Resident 1 to not experience her highest practicable physical, mental, and psychosocial well-being. Findings: A review of Resident 1 ' s admission Record indicated Resident was admitted to the facility in February 2025 with diagnoses which included spinal cord disease (conditions that affect the spinal cord, causing damage or deterioration) and post-traumatic stress disorder (PTSD, an anxiety disorder caused by very stressful, frightening or distressing events). A review of Resident 1 ' s Brief Interview for Mental Status (BIMS, an assessment tool), dated 3/4/25, indicated Resident 1 was cognitively intact. A review of Resident 1 ' s Care Plan (CP, a document that outlines a person's specific care needs, medical history, and the interventions that will be used to address those needs), dated 3/5/25 indicated Resident 1 was dependent on facility staff for meeting her emotional, intellectual, physical and social…

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 infection prevention and control practices to help prevent the development and transmission of communicable diseases and infections when staff did not wear a gown when providing high contact care to three residents (Residents 1, 2, and 3) on Enhanced Barrier Precautions [EBP-set of infection control measures that use gowns and gloves to reduce the spread of multidrug-resistant organisms (MDRO)] for a census of 116 These failures could lead to increased risk of infection spreading among residents. Findings 1. Resident 1 was re-admitted to the facility in March 2025 with multiple medical diagnoses which included anemia (a condition where the body does not have enough healthy red blood cells). Resident 1 had a BIMS (Brief Interview for Mental Status-an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score of 15 out of 15 which indicated Resident 1 was cognitively intact. During an observation on 4/22/25 at 1:21 p.m. outside 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 report an allegation of abuse (the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish) to the State Survey Agency for one of nine sampled residents (Resident 4). This failure placed the residents at risk for continued exposure to potential abuse. Findings: Resident 4 was admitted to the facility on [DATE] with medical diagnoses which included acute and chronic respiratory failure with hypercapnia (the body's inability to efficiently remove carbon dioxide from the blood), anemia (a condition where the body does not have enough healthy red blood cells), and difficulty in walking. Resident 4 had a BIMS (Brief Interview for Mental Status-an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score of 15 out of 15 which indicated Resident 4 was cognitively intact. Resident 5 was admitted to 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 and interview, the facility failed to ensure medications were secure for a census of 118 when a medication/treatment cart was unlocked and unattended with prescription medications in it. This failure had the potential to expose residents, staff, and visitors to unauthorized access to medications resulting in possible injury or drug diversion. Findings: During an observation on 2/4/25 at 10:19 a.m. in the facility front lobby, the treatment cart was observed to be up against the wall, unattended and unlocked. During a concurrent observation and interview on 2/4/25 at 10:26 a.m. with the license Nurse (LN) 1, the LN 1 confirmed the treatment cart with prescription medications was unlocked. The LN stated, The cart should always be locked when not in use. During an interview on 2/4/25 at 12:15 p.m. with Director of Nursing (DON), the DON stated, I would expect all medication and treatment carts with prescribed medications to be locked when unattended for safety. During a review of the facility's Policy and Procedure (P&P) titled, Medication Storage dated 3/1/2023,…

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

Based on observation, interview, and record review, the facility failed to ensure proper storage, handling, labeling, and delivery of respiratory care and equipment consistent with the facility's policy and procedures (P&P) for three out of 25 sampled residents (Resident 105, Resident 23, and Resident 88) when: 1. Resident 105's nebulizer (machine that turns liquid medicine into a mist that can be easily inhaled) mask and tubing set was left on top of the bedside drawer, uncovered after use and was not changed after 72 hours; 2. Resident 23's nebulizer mask and tubing set was left on top of the bedside drawer, uncovered after use; and, 3. Resident 88's physician's order for oxygen therapy was not followed, and Resident 88'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) and humidifier bottle (a device prefilled with water that adds moisture to oxygen to make it more comfortable and effective to breathe) were not labeled with the date it was first used. These failures had the…

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

6. A review of Resident 63's clinical record indicated Resident 63 was admitted June of 2022 and had diagnoses that included hepatic failure (occurs when the liver is unable to perform its normal functions), chronic pain, diabetes mellitus (a chronic condition causing too much sugar in the blood that can affect nerves), and neuropathy (a nerve condition that can cause pain, numbness, tingling, or weakness in the body). A review of Resident 63's Minimum Data Set (MDS- an assessment tool used to guide care) Cognitive Patterns, dated 10/23/24, indicated Resident 63 had a Brief Interview for Mental Status (BIMS- a tool to assess cognition) score of 15 out of 15 which indicated Resident 63 had an intact cognition. A review of Resident 63's MDS Health Conditions, dated 10/23/24, indicated Resident 83 had experienced pain occasionally and had received scheduled and as needed pain medication regimen, and non-medication intervention for pain. A review of Resident 63's physician's order, dated 10/27/24, indicated, oxyCODONE HCl [a controlled pain medication] Oral Tablet 10 MG [milligrams-…

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 policy review, the facility failed to ensure dishes and utensils were cleaned in a sanitary condition for a census 112. This had the potential for foodborne illnesses. Findings: During an interview on 11/6/24 at 11:18 a.m. with the Dietary Manager (DM) she confirmed the facility had a low temperature dishwasher. During a concurrent kitchen observation and interview on 11/6/24 at 2:09 p.m. the facility's dishwasher had a yellow sign on it indicating it was Low Temperature Dishwasher. The Dietary Aide (DA) 1 was asked to check the dishwasher's sanitizing solution. DA 1 proceeded to take one of the chlorine test strips and dipped in the water of the final rinse cycle. The strip came back less than 10 parts per million (ppm). The DM re-checked chemical strip again less than 10 ppm. The DM confirmed the chemical strip was to be dark color in purple indicating 50 ppm. During a concurrent interview and record review on 11/6/24 at 2:14 p.m. with DA 1, the facility's document titled, Dish Machine Temperature Log (Low Temp Machine) for October and November…

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 and maintain an effective infection prevention and control program for a census of 112 when; 1. A shared glucometer (a device which measures blood sugar using blood from the fingertip) was not cleaned and sanitized properly after use and before storage; 2. A clean residents' personal items delivery cart was found with a thick layer of dust on its tray; 3. Shared glucometers (a device used to measure blood sugar) were not cleaned and sanitized based on manufacturer instruction when used for Resident 109 and Resident 315. 4. The facility did not follow safe infection prevention practices when care provided to Resident 82 with tube feeding and medication administration, in a room marked as Enhanced Barrier Precaution (or EBP, staff to use gown and gloves as protection to prevent spread of bugs or infections) These failures resulted in an increased risk for cross-contamination (movement or transfer of harmful bacteria from one person, object, or place to another), potential exposure of Resident 92,…

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 resident's right to privacy and confidentiality of personal and medical records for one resident out of a census of 112 residents when a computer screen that showed a resident's photo and confidential personal and medical information was left unsecured and unattended. These failures had the potential to result in unauthorized access of residents' personal and medical information. Findings: During an observation on 11/4/24 at 1:50 p.m. near nurse's station 1, 2, & 3, next to the facility lobby, a computer on top of a treatment cart had a screen showing a resident's photo, complete name, medical record number, current room and bed number, gender, date of birth , age, attending physician, and other pertinent personal and medical information. It was left unattended facing the facility lobby. Four residents and three facility staff were observed passing by the treatment cart. Multiple staff were in the facility lobby. During a concurrent observation and interview on 11/4/24 at 1:50 p.m. near nurse'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 maintain a safe, comfortable, and homelike environment for one of 25 sampled residents (Resident 70) when a hole was observed in the wall of Resident 70's room. This failure created a non-homelike environment for Resident 70. Findings: Resident 70 was admitted to the facility in 2024 with diagnoses that included a stroke (damage to the brain from an interruption of its blood supply), hemiplegia (the inability to move one side of the body), and aphasia (a condition affecting the ability to express language). A review of Resident 70's Minimum Data Set (MDS - an assessment tool used to guide care) Cognitive (having full understanding) Patterns, dated 9/27/24, indicated Resident 70 had a Brief Interview for Mental Status (a tool to assess a persons' full understanding) score of 14 out of 15 which indicated Resident 70 was cognitively intact. During an observation on 11/4/24 at 10:17 a.m., Resident 70's room had a six inch by 12 inch hole in the drywall with exposed plumbing approximately two feet above the floor…

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 staff interview, record review and policy review, the facility failed to ensure an assessment accurately reflected the resident's status for one of 25 sampled residents (Resident 112). This deficient practice had the potential for inaccurate care. Findings: Resident 112 was admitted to the facility on [DATE] with diagnoses that included encounter for surgical aftercare following surgery on the digestive system and chronic obstructive pulmonary disease (COPD-lung disease). Review of Resident 112's MDS (Minimum Data Set-an assessment tool), dated 9/7/24 under section A0310 Type of Assessment-Continued indicated unplanned discharge. Under section A2105 Discharge Status indicated Resident 112 went to 04. Short-Term General Hospital (acute hospital .). During a review of Resident 112's Progress Note dated 9/7/24 at 10:54 a.m., indicated Res (resident) decided that he wanted to go home against medical advice (AMA) today. Risk and benefits explained to the res but still doesn't want to stay and verbalized i…

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 for one out of 25 sampled residents (Resident 105) when Resident 105's respiratory care and nebulizer (machine that turns liquid medicine into a mist that can be easily inhaled) treatment care plan was not developed. This failure placed Resident 105 at risk to not meet his medical needs and to not achieve the highest practicable well-being. Findings: A review of Resident 105's clinical record indicated Resident 105 was admitted October of 2024 and had diagnoses that included parkinsonism (a clinical syndrome characterized by tremor, slowed movement, rigidity, and postural instability), asthma (a condition in which a person's airways become inflamed, narrow, and swell, and produce extra mucus, which makes it difficult to breathe), dementia (impairment of the ability to remember, think, or make decisions that interferes with everyday activities), and schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly). 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.

Based on observation, interview, and record review the facility failed to ensure safe Quality Control (or QC, proactive testing and calibration for accuracy of devices) and resident care practices with resident census of 112 based on standards of practice and facility's policy when: 1. The facility did not perform Quality Control (testing and calibration for accuracy) for glucometer (a machine that measures the blood sugar level) devices consistently based on facility's policy and the manufacturer recommendations. 2. Nursing care did not follow orders for checking feeding tube (surgically inserted tube into the stomach for feeding or medication administration when oral route not available) residuals (practice of checking volume of residue in the tube connected to stomach; this helped with reduced risk of aspiration [when stomach contents get into lung]) and keeping head elevated when medication was given to Resident 82 via feeding tube. These failed practices could contribute to unsafe care of diabetes resident with blood sugar monitoring and risk of complications from tube feeding.…

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 an observation, interview and record review, the facility failed to ensure one out of 25 sampled residents (Resident 29) received treatment and care in accordance with professional standards of practice, and facility's policy and procedure (P&P) when Resident 29's physician's order for G-Tube Insertion Site (Gastronomy tube-a tube used to provide nutrition and medications) treatment was not followed. This failure had the potential for Resident 29's G-tube insertion site to become infected and for Resident 29 to not achieve their highest practicable well-being. Findings: Resident 29 was admitted to the facility on [DATE] with diagnoses that included dysphagia (difficulty swallowing) and as having a G-Tube. During a review a Resident 29's physician orders contained an order dated 5/10/24 for Enteral - Cleanse G Tube Insertion Site QD (every day) with NSS (normal sterile saline), pat dry, cover with gauze or abdominal pad. Monitor and report to MD if s.s. (signs & symptoms) of worsening. every day shift.…

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 pressure injury/ulcer (PI/PU, injury to skin and underlying tissue resulting from prolonged pressure) care and treatment consistent with professional standards of practice and facility's policy and procedures (P&P) for one of 25 sampled residents (Resident 89) when Resident 89's newly applied pressure ulcer dressing was not initialed and dated. This failure has the potential for Resident 89's stage 4 PU (full-thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage, or bone) to not get ordered care and treatment, to get worse, and/or develop complications, and for Resident 89 to not achieve the highest practicable well-being. Findings: A review of Resident 89's clinical record indicated Resident 89 was admitted March of 2023 and had diagnoses that included stage 4 PU of sacral region (lower back near the crease of the buttocks), severe malnutrition, muscle weakness, and need for assistance with personal care. A review of Resident 89's admission Minimum Data Set (MDS- an…

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 a physician's order for care of a feeding tube (a tube placed in the gastrointestinal (GI) tract to deliver nutrition and calories (enteral nutrition) to your body if you can't safely chew or swallow), when a water flush (water given to hydrate patients via enteral feeding tube) volume and frequency received by Resident 107 was not consistent with the physician's order for one (Resident 107) of 25 sampled residents. This deficient practice placed Resident 107 in danger of receiving incorrect amounts of water flushes and may have resulted in depleted nutrition. Findings: A review of Resident 107's admission Record, indicated, Resident 107 was admitted in the facility in October 2024 and had diagnoses that included Type 2 Diabetes (high blood sugar), Dysphagia (difficulty swallowing), and the need for assistance with personal care. A review of Resident 107's Brief Interview for Mental Status, Section C, (BIMS, cognitive screening test), indicated, Resident 107 was unable to complete the interview. During…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure Resident 94's medically related social services needs were met when, Social Services Assistants (SSA) did not clarify his surgery with his primary physician for one of 25 sampled residents, Resident 94. This failure had the potential to cause delay in Resident 94's healing and recovery. Findings: During a review of Resident 94's admission Record (AR), the AR indicated Resident 94 was admitted to the facility in March 2024 with diagnoses that included cerebral infarction (disrupted blood flow to the brain), and dysphagia (difficulty of swallowing) following cerebral infarction and depression. During a review of Resident 94's summary score for Brief Interview for Mental Status (BIMS, cognitive screening test) was 12 out of 15 which indicated Resident 94 had moderately impaired cognitive function. During an interview with Resident 94 on 11/4/24 at 10:30 a.m., Resident 94 stated, together with her husband, she had an appointment 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.

Based on observation, interview, and record review the facility failed to ensure safe medication administration practices when medication error rate was more than 5% (% or percentage- number or ratio that expressed as a fraction of 100) with Resident census of 112. Medication administration observations were conducted over multiple days, at varied times, in random locations throughout the facility. The facility had a total of three errors out of 37 opportunities which resulted in a facility wide medication error rate of 8.11 % in two out of 10 residents (Resident 69 and Resident 105) observed for medication administration. These failures may result in unsafe medication use, medication error, and use of spoiled or ineffective drugs. Findings: During a medication administration observation, in facility's Units 1-2, accompanied by Licensed Nurse 3 (LN 3), on 11/4/24, at 9:38 a.m., LN 3 administered a total of seven medications to Resident 105. LN 3 pulled a unit of liquid inhalation medication called DuoNeb (a combination product with albuterol-ipratropium used to treat shortness 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 safe medication storage practices were maintained in the medication room and medication carts with the census of 112 when: 1. The Back Station medication room stored expired, unlabeled, and undated medications. 2. Medication Cart #2 found a pill in the pill cutter, and Pro-Stat AWC had yellow/orange streaks running down the bottle. 3. Hazardous medications (drugs that can cause harm to the body when handled unsafely) were stored in medication Carts # 1 and Cart #4 with no warning label on how to be handled by nursing staff. 4. Inhalation products called Ipratropium Bromide and Albuterol Sulfate (or DuoNeb, a breathing treatment) stored in medication Cart #1 and Cart #4 were not dated, and/or the beyond use date was not followed. These failures had the potential to negatively impact the residents' well-being and the use of spoiled or expired medications. Findings: 1. During a concurrent observation and inspection on, 11/4/24 at 10:27 a.m., at the Back Station medication room, accompanied by Licensed…

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 accurate documentation of Resident 100's diagnosis in the medical records in one out of five residents. This failure of inaccurate documentation of resident's diagnosis may contribute to unsafe care and treatment by the facility and subsequent care providers. Findings: During a concurrent interview with Assistant Director of Nursing (ADON), on 11/7/24, at 11:31 AM, and record review of Resident 100's medical record, titled Discharge Summary, dated 9/30/24, the record indicated Resident 100 had history of dementia (loss of memory) along with other medical diagnoses for heart disease and bedsore infection. The record indicated Resident 100 was ordered olanzapine (or Zyprexa, a mind-altering drug) 2.5 mg (mg is milligram, a unit of measure) at bedtime on discharge from hospital which was a reduced from 7.5 mg previous dosage. ADON acknowledged the indication for use of olanzapine was dementia related behavior. During a concurrent interview with Assistant Director of Nursing (ADON), on 11/7/24, at 11:31 AM, and record…

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 two residents (Resident 1 and Resident 2) of two sampled residents' right to be free from verbal and physical abuse when Resident 1 yelled racial slurs and Resident 2 slapped Resident 1 in the face. This deficient practice resulted in both residents feeling either discontent, pain, and concerns about safety. Findings: The following documents were reviewed in Resident 1's medical record: - An admission record, printed on 10/10/24, indicated Resident 1 was re-admitted to the facility in summer of 2024 with diagnoses which included schizophrenia (a mental illness that is characterized by disturbances in thought) and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). The admission record also indicated Resident 1 was under conservatorship (had an appointed conservator to make personal decisions). - A Minimum Data Set (MDS, an assessment tool) dated 9/20/24, indicated a Brief Interview for…

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

Based on observation, interview, and record review, the facility failed to ensure medications were stored locked for a census of 119 when two bags of medications were left unlocked and unattended on top of a cabinet. These failures had the potential for medication misuse and drug diversion. Findings: During an observation on 8/6/24 at 9:58 a.m. in the Director of Nursing's (DON) office, there were two bags with approximately 30-40 bottles and boxes of medications on top of the black cabinet that was left unlocked. The door was open and unlocked. The DON was not in the room, and there was a female staff entering the DON's office. There were other staff members walking outside of the hallway. There was a resident's room that consisted of three residents positioned in front of the DON's office. During an interview on 8/6/24 at 10:14 a.m. with the DON, the DON confirmed expecting the medications to be locked in a locked compartment or a locked room without resident access. The DON stated residents or staff could have taken and ingested the expired medications. A review of the facility'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 meet the professional standards of practice for Resident 1 when the nasal cannula (a device used to deliver oxygen to the nose) was not labeled with an open date (start of use) and the nasal cannula replacement order was scheduled for a longer interval than indicated on the facility's policy. These failures decreased the facility's potential to prevent the spread of infection. Findings: Resident 1 was most recently admitted to the facility in 2022 with diagnoses which included cirrhosis of the liver (a chronic liver damage from a variety of causes leading to scarring and liver failure), diabetes (a long-term condition in which the body has trouble controlling blood sugar and using it for energy), and chronic respiratory failure (a condition when blood has too much carbon dioxide or not enough oxygen). A review of Resident 1's Medication Administration Record (MAR), dated April 2024, indicated the following orders: Order initiated on 6/6/23 indicated, Change Oxygen tubing monthly every night shift every 28…

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 report an incident of allegation of abuse for one of four sampled residents (Resident 1) as required by the regulations. This failure resulted in a delay in the abuse investigation process and decreased the facility's potential to protect residents from physical and psychosocial harm. Findings: A review of Resident 1's admission Record, dated 4/4/24 indicated, Resident 1 was admitted to the facility over two years ago with multiple diagnoses which included hemiplegia ( paralysis of half of the body) following cerebral infarction (disrupted blood flow to the brain due to problems with the blood vessels that supply it). The admission record also indicated Resident 1 was non-English speaking. The Minimum Data Set (MDS, an assessment tool) dated 3/14/24, indicated the resident had severe cognitive impairment. During a review of Resident 1's change in condition (CIC) notes, dated 3/16/24, the notes indicated, On 3/16/2024 at around 8:00 AM, resident reported to RNA [Restorative Nursing Assistant] that he was hit…

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, record review and policy review, the facility failed to provide supervision and monitoring for one of three sampled residents (Resident 1) when Resident 1, after several attempts, eloped from the facility. This failure had the potential to result in serious injury or death for Resident 1. Findings: Resident 1 was admitted to the facility on [DATE] with diagnoses that included cerebral infarction (stroke) affecting right dominant side, intracranial injury (brain injury) without loss of consciousness, mild cognitive impairment, right knee pain, and cognitive communication deficit. Resident 1's admission MDS (Minimum Data Set-an assessment tool), dated 6/4/13 documented Resident 1 as having unclear speech, usually able to understand others, usually able to make self-understood and his Brief Interview for Mental Status (BIMS) summary score as an 8 (moderate impairment). The MDS described Resident 1 as having no delirium or behavioral symptoms. The MDS also described Resident 1 as needing limited…

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 three sampled residents (Resident 1's) representative obtained a copy of Resident 1's record or any portions thereof upon request and of two working days advance notice to the facility. This failure resulted in the impingement of Resident 1's representative rights. Findings: Resident 1 was originally admitted to the facility on [DATE] with diagnoses that included metabolic encephalopathy (neurological disorders) and acute respiratory failure with hypoxia (low levels of oxygen in the body). During an interview on 3/22/24 at 9:11 a.m., with the Administrator, he confirmed he received the request for Resident 1's medical records, from the complainant, on 3/14/24 and sent the request to legal on 3/14/24. The Administrator confirmed Medical Records had all requested documents copied and ready to go on 3/14/24. The Administrator stated he received an email from legal, on 3/15/24, not to send anything until further notice. The Administrator…

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 observe professional standards of practice to meet the needs of one of three sampled residents (Resident 1), when the facility failed to carry out physician's order for management of shortness of breath as ordered upon discharge from a General Acute Care Hospital (GACH). This failure resulted in worsening of Resident 1's shortness of breath and subsequent need to be transferred to a hospital. Findings: A review of Resident 1's admission Record indicated the facility originally admitted the resident in 2021 with multiple diagnoses including diabetes mellitus (a chronic condition that affects the way the body processes blood sugar). Resident 1's medical history indicated that he had multiple hospitalizations while living in the facility. A review of Resident 1's Physician's Order dated 6/29/2021 indicated the resident had the capacity to understand and make decisions. A review of Resident 1's most recent Minimum Data Set (MDS, an assessment tool) dated 3/1/24 indicated the resident was cognitively intact and had no memory…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow their policy and procedure (P&P) on notification of changes for one of six sampled residents (Resident 1) when Resident 1's family member was not notified of Resident 1's change of condition and transfer to the hospital. This failure resulted in Resident 1's family member to be unaware and not involved with Resident 1's current medical status and transfer to the hospital. Findings: A review of Resident 1's clinical record indicated Resident 1 was admitted [DATE], and had diagnoses that included cerebral palsy (a group of conditions that affect movement and posture), convulsions (an involuntary action of jerking and contractions), 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 right dominant side. A review of Resident 1's Minimum Data Set (MDS- an assessment tool…

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 a written notice of bed-hold was provided for 2 of 3 sampled residents (Resident 1 and Resident 3) or their representatives. These failures caused residents or their representatives to not be fully informed of bed-hold options and rights. Findings: A review of the clinical record indicated Resident 1 was admitted with diagnoses including acute and chronic respiratory failure with hypoxia (a serious condition that makes it difficult to breath), tracheostomy status (an opening created into the windpipe from outside the neck to help air and oxygen reach the lungs), and unspecified dementia (decline in cognitive ability). Resident 1's Brief Interview for Mental Status (BIMS, a cognitive screening) dated 11/27/23 indicated Resident 1 had moderate cognitive impairment with a score of 9. Further review of Resident 1's clinical record indicated a 'Transfer Form' dated 1/8/2024. Resident 1's reason for transfer was due to respiratory arrest (respiratory failure). A review of the clinical record indicated Resident 3 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 one of three sampled residents (Resident 1) received treatment and care in accordance with professional standards of practice when there was no care plan, no wound assessment, and no monitoring for Resident 1's left middle toe wound. These failures contributed to Resident 1 being admitted to the hospital with osteomyelitis (serious infection of the bone from injuries that cause damage to deep tissues) and gangrene (tissue death often caused by lack of blood flow or infection) on his left second and third toes and, as a result; both toes were amputated. Findings: A review of the admission Record indicated Resident 1 was originally admitted in 2023 with multiple diagnoses that included Type 2 Diabetes (body's inability to regulate blood sugar) and peripheral vascular disease (a common condition in which narrowed arteries reduce blood flow to the arms or legs). A review of Resident 1's Minimum Data Set (MDS, an assessment tool) dated 11/17/23 indicated, Resident 1 was cognitively intact. His skin…

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 necessary treatment and services were provided to promote healing and prevent further progression of wounds for 2 residents (Resident 1 and Resident 2), for a census of 116, when: 1. Resident 1's open area on the coccyx (tailbone) and surgical wound on the posterior spine (backbone) were not assessed weekly; and 2. Resident 2 was not provided with a low air loss mattress (LAL, designed to distribute the body weight and help prevent skin breakdown) and heel suspension boots (removes pressure from the heel). These failures increased the risk for Resident 1 and Resident 2 to develop new pressure ulcers and the deterioration of existing wounds. Findings: 1. A review of the clinical record indicated Resident 1 was admitted with diagnoses including fusion (connects two or more bones) of the spine, thoracolumbar region (parts of the spine supporting the chest and lower back, and the nerves which receives and sends messages between 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 implement acceptable standards of practice in the use of controlled medications when Resident 1's unused narcotic was taped back into the peeled blister pack and Resident 2's discontinued narcotics were stored in the medication cart for available for use and, had a reconciliation discrepancy. These failures increased the potential for controlled medication diversion, loss, and medication errors for a census of 119. Findings: Resident 1 was a long term resident in the facility with diagnoses that included unspecified pain. During a controlled medication reconciliation conducted on 1/11/24 at 11:29 a.m. with Licensed Nurse (LN 1) , LN 1 verified Resident 1's Norco 5/325 mg (a narcotic pain medication, Hydrocodone 5 milligram per 325 mg of Acetaminophen) blister pack was torn open in the back and resealed with clear plastic tape with a pill in it. LN 1 indicated when the narcotic was taken from the blister pack and unused, LNs were to discard the unused narcotic in the presence of another LN instead of taping…

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 its policy and protocols on abuse for one of six sampled residents (Resident 1), when: 1. The facility failed to provide a nursing assessment immediately after Resident 1 alleged he had been physically abused by a staff member, and 2. The facility failed to immediately place a staff member, who was accused of physically abusing a resident, on leave. These failures resulted in Resident 1 not receiving an immediate assessment and interventions to ensure safety. Findings: 1. In an interview on 1/9/24 at 11:27 a.m., the Administrator in Training (AIT) acknowledged during the nocturnal shift (NOC shift, the overnight shift) on 1/1/24, Resident 1 was allegedly physically abused by a staff member and had alleged skin redness to one shoulder as a result of the physical abuse. In an interview on 1/9/24 at 12:47 p.m., Resident 3 stated he was Resident 1's roommate on 1/1/24, when Resident 1 alleged a nurse had pushed him. Resident 3 stated he observed a red mark on Resident 1's right arm. In an interview on 1/9/24 at 2:19…

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 report an allegation of abuse involving one of six sampled residents (Resident 1) to the California Department of Public Health (CDPH) within two hours after facility staff were made aware of the allegation of abuse. This failure decreased the facility's potential to protect vulnerable residents and provide a safe environment. Findings: In an interview on 1/9/24 at 11:27 a.m., the Administrator in Training (AIT) stated on 1/1/24 at approximately 6:30 a.m., he received a phone call from Licensed Nurse 4 (LN 4) informing him Resident 1 had called the police earlier in the morning. The AIT stated he arrived at the facility, spoke to LN 4 before she left her shift around 7 a.m., and then spoke to Resident 1. AIT stated Resident 1 alleged LN 4 had pushed him during a verbal altercation which occurred earlier that morning. The AIT acknowleged he reported the allegation of physical abuse to CDPH via phone after the interview with Resident 1. In an interview on 1/10/24 at 7:26 a.m., LN 4 stated at approximately 2:40 a.m. on 1/1/24…

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 observation, interview and record review, the facility failed to follow infection control practices for a census of 121 residents when a Certified Nursing Assistant (CNA) did not perform hand hygiene when entering and exiting multiple resident rooms before providing care to a resident during lunch. This failure decreased the facility's potential to prevent the spread of infection among the residents. Findings: In an observation on 1/9/24 at 12:30 p.m. during lunch time, CNA 1 entered room [ROOM NUMBER] and exited the room with a lunch tray with used dishes, used utensils, and partially eaten food. CNA 1 put the used lunch tray on a tray cart and did not perform hand hygiene after holding the used lunch tray. CNA 1 immediately proceeded to enter and exit rooms [ROOM NUMBERS] without performing hand hygiene. CNA 1 then entered room [ROOM NUMBER], did not perform hand hygiene, and then began wiping food from Resident 6's face. In an interview on 1/9/24 at 12:36 p.m., CNA 1 stated in order to reduce risk of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1) received respiratory care in accordance with professional standards of practice when: 1. Resident 1's Bilevel Positive Airway Pressure (BiPAP, a machine that pushes pressurized air into the lungs to help with breathing) treatment was not signed as given for 63 days, and 2. Resident 1's nasal cannula (used to deliver oxygen to patients who need supplemental oxygen) and humidifier (adds moisture to the oxygen) were not dated, her BiPAP mask and tubing were found uncovered on top of the oxygen concentrator (a machine that delivers oxygen) ; and a used nasal cannula was found on the bedside table. These failures had the potential to result in Resident 1 developing hypoxia (low oxygen) and infections. Findings: A review of Resident 1's admission records indicated, Resident 1 was admitted to the facility in mid-2023 with multiple diagnoses that included Chronic Obstructive Pulmonary Disease…

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, record review, and facility policy review, Licensed Nurse 1 (LN 1) failed to ensure the correct type and dose of insulin (a medication used to control blood sugar levels) was administered to one of three sampled residents (Resident 1). This failure had the potential to result in hypoglycemia (low blood sugar) for Resident 1. Findings: A review of the Skilled Nursing admission Record indicated, Resident 1 was admitted to the facility on [DATE], with diagnoses that included, Type 1 Diabetes Mellitus (a disease involving inappropriately elevated blood glucose levels). During an interview with the Director of Nursing (DON) on 11/22/23 at 10 a.m., the DON stated on 10/6/23 at approximately 7:45 p.m., LN 1 administered 50 units of Lispro (a rapid acting insulin used to control blood sugar) instead of 50 units of Lantus (a long-acting insulin used to control blood sugar). LN 1 had discovered the error approximately 30 minutes later and notified the Physician. LN 1 was then instructed to monitor…

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 policy review, the facility failed to ensure one of 3 sampled residents (Resident 1) was treated with respect and dignity when the staff did not provide privacy during care. This failure decreased the potential to ensure Resident 1's right to privacy was maintained. Findings: A review of the clinical record indicated Resident 1 was admitted to the facility with diagnoses including chronic respiratory failure with hypoxia (a serious condition that makes it difficult to breathe) and tracheostomy status (a surgical procedure to create an opening into the trachea [windpipe] from outside the neck to help oxygen reach the lungs). During an observation on 11/14/23 starting at 10:30 a.m., Resident 1 was suctioned (removal of secretions to keep the windpipe clear) by the Respiratory Therapist (RT) through her tracheostomy with the privacy curtain open. In an interview on 11/14/23 at 10:35 a.m., the RT confirmed she did not close the privacy curtain prior to suctioning Resident 1. In an interview on 11/14/23 at 12:28 p.m., the Director of Nursing (DON)…

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 pharmacy services timely for three of three sampled residents (Resident 1, Resident 2, and Resident 3) when prescription medications were not available for administration. This failure resulted in Resident 1, Resident 2, and Resident 3 to not receive their routine medications as prescribed and placed the residents at risk for adverse consequences. Findings: 1. Resident 1 was admitted to the facility with diagnoses that included atrial fibrillation (an irregular and often rapid heart rate which could lead to blood clots), lung problems and high blood pressure. Review of Resident 1's clinical record included physician orders, dated 9/2/23, for apixaban (a blood thinner to prevent forming blood clots), to administer 5 mg (milligram) twice a day for the irregular heart rate and for bumetanide (a diuretic, a water pill to treat fluid retention and high blood pressure) to administer 1 mg once a day for heart problems. 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.

Based on observation, interview, and record review, the facility failed to ensure two of three sampled residents (Resident 1 and Resident 2) attained the highest mental and psychosocial well-being when the residents were concerned about their medication supplies after they missed their routine medications due to medication delivery delays. This failure resulted in Resident 1 to start keeping her own medication administration log to remind staff to reorder her medications timely and Resident 2 was more depressed and experienced uncontrolled pain, high stress, and anxiety. Findings: 1. Resident 1 was admitted to the facility with diagnoses that included atrial fibrillation (an irregular and often rapid heart rate that could lead to blood clots), lung problems and high blood pressure. In a concurrent observation and interview on 10/5/23 at 11:15 a.m., Resident 1 was in the bed in her three shared bedroom. Resident 1 reported she did not receive her blood thinner and heart medications because the facility ran out of the medications. The resident stated she worried about the medication…

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 resident's right to privacy of personal and medical records when residents' meal tickets were discarded in the facility kitchen garbage bin for the 98 residents who ate facility prepared meals. This failure had the potential for unauthorized access of residents' personal and medical records. Findings: During a concurrent observation and interview on 9/11/23 at 9:40 a.m. with Dietary Aide (DA) 1 in the dishwashing area, DA 1 was observed throwing uneaten food, used napkins, and residents' meal tickets left on the meal trays into the garbage bin. DA 1 confirmed the observation. During a concurrent observation and interview on 9/11/23 at 9:42 a.m. with the Dietary Services Supervisor (DSS) in the dishwashing area, the DSS confirmed that DA 1 threw the residents' meal tickets into the garbage bin. The DSS also confirmed that multiple residents' meal tickets were returned with their meal trays to the kitchen. During an observation on 9/12/23 at 9:22 a.m. with DA 3 in the dishwashing area, DA 3 was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure expired biological supplies found in Station 1 and 2 Medication Rooms (MR) were not available for use, and failed to ensure proper labeling of drug when, 1. Resident 47's oxycodone (an opioid, controlled medication used to treat moderate to severe pain) had no change in order label on the bubble pack; and 2. Expired medical supplies in the medication rooms were not removed and discarded, for a census of 111 residents. These failures placed Resident 47 at risk for receiving more than the prescribed dose of the opioid medication and had the potential for the expired biological supplies to be used for residents, compromising the accurate findings of their laboratory results, and may have subsequently led to misdiagnosis or prescribing wrong medications and treatments. Findings: 1. A review of the clinical record indicated Resident 47 had diagnoses that included chronic pain and long-term use of opiate analgesic. Further 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.

Based on observation, interview, and record review, the facility failed to serve residents' therapeutic diet (a diet ordered as part of treatment for a disease or clinical condition, or to eliminate, decrease, increase, or provide specific nutrients in the diet) as prescribed by the physician when the prescribed controlled carbohydrate diet (CCHO- a diet focused on having the same amount of carbohydrates; fiber, starches and sugars, every day) for 14 out of 32 residents (Resident 81, Resident 78, Resident 33, Resident 52, Resident 10, Resident 121, Resident 171, Resident 114, Resident 97, Resident 107, Resident 570, Resident 122, Resident 44, and Resident 76) were not followed. This failure has the potential for Resident 81, Resident 78, Resident 33, Resident 52, Resident 10, Resident 121, Resident 171, Resident 114, Resident 97, Resident 107, Resident 570, Resident 122, Resident 44, and Resident 76 to experience fluctuating and/or uncontrolled blood sugar levels which may lead to serious medical complications. Findings: A review of Resident 81, Resident 78, Resident 33, 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 provide food storage and preparation, as well as maintain kitchen equipment and food contact surfaces in accordance with professional standards for food safety for the 98 residents who ate facility prepared meals when: 1. A package of ground sausage with ice crystals built-up was found open and exposed to air in the freezer; 2. Two out of two dry storage logs were not filled in four out of 11 entries; 3. A food preparation sink lacked an air gap (a backflow prevention device that prevents contaminated water from re-entering the sink); 4. Five large steam table pans, three medium steam table pans, one small steam table pan (with food particles), two water pitchers and covers, and two medium measuring containers were all found stored wet; 5. One baking soda container was found open to the air and past the used-by date, one spice was found with an unreadable use-by label, and two gravy mixes, a box of corn starch, and a seasoning salt were found opened and exposed to air; 6. A metal pipe was found chipped 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.

Based on observation, interview, and record review, the facility failed to maintain an effective pest control program for the facility when two cockroaches were observed in the facility kitchen. This failure has the potential for contamination of resident's food, soilage of kitchen utensils and surfaces, and possible spread of disease or infection. Findings: During a concurrent observation and interview on 9/11/23 at 9:01 a.m. with the Dietary Services Supervisor (DSS) in the kitchen, a 3/4 sized dead cockroach was found upside down in the food preparation sink. The DSS confirmed the observation. During a concurrent observation and interview on 9/11/23 at 9:15 a.m. with the DSS in the kitchen, a 1/2 sized cockroach was seen running on the floor from the southern wall of the kitchen going under the steam table and kitchen counter holding hot water, coffee dispenser and cutting boards. The DSS confirmed the observation and stepped on the cockroach to kill it. During an interview on 9/14/23 at 10:25 a.m. with the DSS, the DSS stated It's not good to have them [cockroaches] 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 interview and record review, the facility failed to ensure smoking safety for one of 24 sampled residents (Resident 97) when the initial smoking assessment was delayed and the smoking care plan was inconsistent with the assessment. This failure placed the resident at risk for injuries related to smoking and had the potential for non-smoking residents to be exposed to smoking hazards. Findings: Review of Resident 97's medical records, admission Record, indicated the resident was admitted to the facility early 2023 with diagnoses that included mental issues and lung problems. Review of Resident 97's smoking assessment, Smoking Safety, completed on 6/20/23, indicated it was the initial smoking assessment since the resident's admission in January 2023. The assessment identified the resident was an independent smoker and recommended, Resident may smoke independently. Review of Resident 97's care plan for smoking, initiated on 6/20/23, indicated the resident's smoking goal was The resident will not smoke without supervision . as opposed to the smoking assessment specified the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure professional standards were met when two of 24 sampled residents (Resident 170 and Resident 173) received medications without identifying irregularities of the indications for use. This failure had the increased potential for medication errors and placed the residents at risk for erroneous diagnoses and inaccurate medications. Findings: a. Review of Resident 170's admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses that included lung problems and infection. The resident's admission Record indicated the resident had neither depression nor anxiety disorder in the DIAGNOSIS INFORMATION section. Review of Resident 170's Order Listing Report included a physician order, dated 9/7/23, for an anti-depressant medication, Fluoxetine 20 mg (milligram, a unit of measurement) 1 tablet by mouth once a day. The physician order prescribed the indication for use of Fluoxetine was for Anxiety M/B [manifested 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to; 1. Identify signs and symptoms of opioid (a controlled medication used to treat moderate to severe pain) overdose (a life-threatening condition characterized by lessened alertness and small pupils) and to develop a care plan to accurately assess and monitor one of three sampled residents (Resident 47), and 2. failed to ensure Licensed Nurses (LN) provided quality of care in accordance with professional standards of practice for Resident 171 when: a. No comprehensive person-centered care plan with interventions that reflected his Peripherally Inserted Central Catheter, PICC (a thin, soft, long catheter inserted into the arm, neck, or leg's vein); b. No physician order about routine care and maintenance of PICC line; and c. LN 7 did not verify blood return (withdraw blood into the syringe) prior to use to confirm the location within the vein. These failures had the potential to affect the health and safety of Resident 171 and resulted 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 document review, Resident 44 failed to maintain his usual body weight, losing 38 pounds (lbs.) and 18% of his body weight since admission. This had the potential of leading to decreased independence due to muscle loss, as well as reduced ability to fight off infections. Findings: During the lunch meal rounds on 9/11/23 at approximately 1 p.m., Resident 44 was visited. While discussing his dislike of facility prepared meals, he reported that he had lost weight during his 2 years at the facility. He expressed anger and frustration by the continued weight loss. During a chart review of Resident 44 on 9/13/23 at 11:52 a.m., he was noted to have a diagnosis including failure to thrive, malnutrition, anemia, and a vitamin deficiency. His diet order included a controlled carbohydrate diet (used to control blood sugar levels) with a shake twice a day. Abbreviated Weight History as follows: 8/17/23=171lbs. (a loss of 38 lbs. or 18.2% of his body weight since admission). 7/23=not available…

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 respiratory care was provided consistent with the facility policy for one of 24 sampled residents (Resident 12) when oxygen tubing, oxygen mask for nebulizer (to administer liquid medicine into a mist through a mask to inhale the medication) treatment and the Bi-pap (the machine supplies pressurized air into the lungs) bag were outdated or not dated at all. These failures increased potential for respiratory infection for Resident 12 who already had compromised lung function. Findings: Resident 12 was admitted to the facility in the Spring of 2023 with diagnoses that included lung disease and mental issues. In an observation on 9/11/23 at 8:45 a.m., Resident 12 was out of her room in a 4-bed shared room. Next to the resident's bed which was close to the door, the oxygen concentrator was observed in operation with the oxygen flow rate set at 4 liters/minute. The nasal cannula (a plastic tubing that delivers the oxygen from the concentrator to the nostrils) was connected to the concentrator and placed on…

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

Based on observation, interview, and record review, the facility failed to provide the necessary care for one of three sampled residents (Resident 1) and failed to notify the physician immediately of Resident 1's change of condition (COC), when the resident complained of chest pain. In addition, the facility failed to assess Resident 1 and monitor him for his complaint of chest pain. These failures resulted in Resident 1's calling 911 due to the delay for needed medical attention and placed the resident at risk for harm when his condition was not evaluated. Findings: A review of Resident 1's admission record indicated the facility admitted the resident in 2022 with multiple diagnoses, including quadriplegia (loss of movement and sensation affecting resident's torso, upper and lower extremities and making him unable to move in a bed), heart failure (a condition when the heart is unable to pump enough blood for body's needs), and high blood pressure. A review of Resident 1's care plan titled, Resident has quadriplegia, dated 3/25/22, indicated resident's goal to remain free 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 protect one of three sampled residents (Resident 1) from neglect when Resident 1 did not receive incontinence care, was not turned and not repositioned for over five hours. This failure resulted in Resident 1's feeling uncomfortable, itching and had the potential to worsen his skin rash. Findings: A review of Resident 1's admission record indicated the facility admitted the resident in 2022 with multiple diagnoses, including quadriplegia (loss of movement and sensation affecting resident's torso, upper and lower extremities and making him unable to move in a bed), heart failure (a condition when the heart is unable to pump enough blood for body's needs), and high blood pressure. A review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 3/28/23, indicated the resident was cognitively intact. The MDS indicated Resident 1 was incontinent for bladder and bowel and was completely dependent on facility staff for ADLs, including bed mobility, toileting, personal…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain sufficient staff to provide nursing and related services to meet the residents needs for census of 116, when Resident 2 had to wait for over an hour to be assisted with cleaning, multiple residents complained of extended wait time for assistance with their needs, and the facility failed to meet State staffing requirements for Certified Nursing Assistants (CNAs) for 10 of 10 sampled days. These failures resulted in inadequate availability of CNAs to attend to Residents 2 and other residents requiring assistance needs, had the potential to place residents at risk for skin breakdown, and negatively affect residents' physical and psychosocial well-being. Findings: A review of Resident 2's admission record indicated the facility admitted the resident in the beginning of this year with multiple diagnoses which included after stroke care, aphasia (difficulty with communication), muscle weakness, and lack of coordination. 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.