Sacramento Post-Acute

Based on observation, interview and record review, the facility failed to ensure the Mince and Moist level 5 (MM5) texture (the food texture is designed for residents who experience biting, chewing, or swallowing limitations. All food must be soft, moist and minced to size [no larger than 4 millimeters (mm) x 15 mm]. The food item size and texture must pass testing requirements, fork test and spoon tilt test) food items prepared properly for one of 23 sampled residents (Resident 9). This deficient practice had the potential to increase risk for Resident 9 with swallowing and chewing difficulties to choke and/or aspirate (a condition in which food, liquids, saliva, or vomit is breathed into the airway).Findings:According to Academy of Nutrition and Dietetics (AND, the organization of food and nutrition professionals, and is a leading source for credible, science-based information on nutrition and health), IDDSI (International Dysphagia Diet Standardization Initiative) diets was recognized to be the only texture-modified diet beginning in October 2021.According to IDDSI, MM5 texture…

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 appropriate, sufficient supervision to each resident to prevent an avoidable accident for one of two sampled residents (Resident 1) and failed to investigate an accident thoroughly when:Resident 1 fell to the floor while being transferred from her bed to a shower chair, and the facility failed to provide documentation of a fall investigation for Resident 1.These failures had the potential for Resident 1 to sustain a major injury, be exposed to physical pain, increased anxiety from her history of falls, and placed Resident 1 at risk for an unidentified injury from the failure to investigate.During a review of Resident 1's Hospital Discharge Summary dated 1/5/26, summary indicated, Resident 1 had hospital problems including but not limited to Closed pelvic ring fracture (serious injury, often from high-energy trauma like car accidents, causing severe pelvic/groin pain, bruising, and inability to bear weight) and a pubic ramus…

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

Based on observation, interview, and record review, the facility failed to ensure food was prepared and stored in a safe and sanitary manner for a census of 62 residents who received food prepared from the kitchen, when: 1. Expired food items were found on the kitchen shelf; 2. An unclean appliance attachment cap was on the steam table and an unclean oven top and mesh rack for storage of water pitchers were found in the kitchen; 3. Pans with hard black residue were available for use in the kitchen; 4. The dry storage room had no documented evidence of temperature monitoring; 5. The freezer section of the refrigerator used for storage of resident foods had no thermometer and no documented temperature monitoring evidence; and, 6. the ice dispensing mechanism of the ice maker had dark residue. These failures decreased the facility's potential to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Findings: 1. During a concurrent observation and interview on 10/15/24 commencing at 8:31 a.m. with the Registered Dietitian (RD) 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 maintain the reach-in meat freezer in safe operating condition when door seals were observed with tears/cracks, and the top of the freezer had ice buildup on the inside. This failure decreased the facility's potential to ensure food safety and quality for 62 residents who ate facility prepared meals. Findings: During a concurrent observation and interview on 10/18/24 at 10:37 a.m. with the Registered Dietitian (RD) in the kitchen, the reach-in meat freezer was observed with two cracks on door seals (under 1/2 inch in length) and ice build-up hung near the fan at the top of the freezer. The RD confirmed observations. A review of the facility provided freezer installation and operations manual, undated, indicated, The door gaskets should be cleaned in place with a mild soap solution to extend their life. A review of the United States Food and Drug (FDA) Food Code 2022 indicated, EQUIPMENT shall be maintained in a state of repair and condition that meets the requirements specified under Parts 4-1 and 4-2 EQUIPMENT components…

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 nursing care provided met professional standards for three residents (Resident 63, Resident 36, and Resident 53) of 23 sampled residents when licensed nursing staff did not: 1. Perform Resident 63's suprapubic catheter (a tube that drains urine from the bladder through a small incision in the lower abdomen, just above the pubic bone) care and coccyx (also known as the tailbone which is the triangular bony structure found at the bottom of the spine) skin care as ordered; 2. Ensure Resident 36's medical record indicated the physician was notified as ordered; and, 3. Ensure Restorative Nurse Assistant (RNA, a program which provides exercise and a range of motion activities to the residents) services were provided to Resident 53 without active prescriber orders. These failures decreased the facility's potential to provide adequate and accurate care to residents. Findings:1. A review of an admission record indicated Resident 63 was admitted to the facility in Winter of 2023 with diagnoses which 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 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: 1. Resident 37's nephrostomy bag (a bag that collects urine from a nephrostomy tube, which is a thin, flexible tube placed into the kidney) was observed touching the floor and the antimicrobial bag used as a privacy bag was not labeled with a placement date; and, 2. The Continuous Air Mist (CAM) respiratory equipment was not labeled with placement dates for Resident 14 and Resident 59. These failures had the potential to result in infection among a facility census of 85 residents. Findings: 1. A review of Resident 37's admission record indicated admission to the facility in August 2024 with diagnoses which included pyelonephritis (a bacterial or viral infection that causes inflammation of the kidneys) and urinary tract infection (UTI- an infection in the bladder/urinary tract). A review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to report an incident of alleged abuse for one of three sampled residents (Resident 1), when Resident 1 verbalized he was treated roughly and handled like a rag doll. This failure had the potential to place the resident at risk for further harm. Findings: Review of an anonymous staff report received by the department on [DATE] indicated, During Afternoon shift, Resident [Resident 1] acquired an avulsion (degloving) [avulsion-a traumatic injury that occurs when the layers of skin and tissue are torn away from the underlying muscle, connective tissue, or bone] injury to RUE [right upper extremity] while brief change. Per resident CNA [certified nursing assistant] grabbed him by his arm and stated, she pulled me, and was so strong .she tore the last piece of skin I had. DON [director of nursing]/ administrator do not want to report and is insisting to Nursing staff to reword documentation, due to I can misinterpret to physical abuse. CNA was not written up.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to follow their policy and procedure (P&P) to investigate an allegation of abuse for one of three sampled residents (Resident 1), when on [DATE] Resident 1 was noted to have a degloving (avulsion-a traumatic injury that occurs when the top layers of skin and tissue are torn away from the underlying muscle, connective tissue, or bone) injury to right forearm and finger point areas to posterior right forearm and right wrist', and claimed it was from rough treatment from the Certified Nursing Assistant. This failure had the potential to place the resident at risk for further harm. Findings: Review of an anonymous staff report received by the department on [DATE] indicated, During Afternoon shift, Resident acquired an avulsion (degloving) [avulsion-a traumatic injury that occurs when the layers of skin and tissue are torn away from the underlying muscle, connective tissue, or bone] injury to RUE [right upper extremity] while brief change. Per resident CNA…

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

Based on interview and record review, the facility failed to notify the physician promptly or implement monitoring timely for one of four sampled residents (Resident 2) when Resident 2 was administered Norco (a narcotic mediation that contained hydrocodone and acetaminophen) when hydrocodone was listed as an allergy. This failure resulted in Resident 2 not being monitored for an allergic reaction for approximately 20 hours, which increased the risk for unmet health care needs. Findings: Resident 2 admitted early 2023 with diagnoses which included Multiple Sclerosis (a disease of the brain and spinal cord), stage four pressure ulcer (wound caused by pressure that extends to the muscle and bone), and paraplegia (paralysis that affect the legs). Resident 2 was listed as his own responsible party (RP). During a review of Resident 2's face sheet (a document that gives patient information at a quick glance), admission date 4/2023, the face sheet indicated, .Allergies: HYDROcodone (sic) . During a review of Resident 2's Order Summary Report (OSR), Active Orders As Of 6/12/24, the OSR…

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 person centered care plans were developed which included specific goals and interventions for one of four sampled residents (Resident 2) when Resident 2 was administered Norco (a narcotic mediation that contained hydrocodone and acetaminophen) when hydrocodone was listed as an allergy. This failure had the potential for Resident 2 to experience unmet care needs. Findings: Resident 2 admitted early 2023 with diagnoses which included Multiple Sclerosis (a disease of the brain and spinal cord), stage four pressure ulcer (wound caused by pressure that extends to the muscle and bone), and paraplegia (paralysis that affect the legs). Resident 2 is listed as his own responsible party (RP). During a review of Resident 2's face sheet (a document that gives patient information at a quick glance), admission date 4/2023, the face sheet indicated, .Allergies: HYDROcodone (sic) . During a review of Resident 2's Order Summary Report (OSR), Active Orders As Of 6/12/24, the OSR indicated, Allergies: HYDROcodone (sic) . Resident 2'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 ensure residents were free from unnecessary medications for one of four sampled residents (Resident 2) when Resident 2 was administered Norco (a narcotic mediation that contained hydrocodone and acetaminophen) when hydrocodone was listed as an allergy. This failure had the potential for adverse systemic effects and jeopardized Resident 2's health. Findings: Resident 2 admitted early 2023 with diagnoses which included Multiple Sclerosis (a disease of the brain and spinal cord), stage four pressure ulcer (wound caused by pressure that extends to the muscle and bone), and paraplegia (paralysis that affect the legs). Resident 2 is listed as his own responsible party (RP). During a review of Resident 2's face sheet (a document that gives patient information at a quick glance), admission date 4/2023, the face sheet indicated, .Allergies: HYDROcodone (sic) . During a review of Resident 2's Order Summary Report (OSR), Active Orders As Of 6/12/24, the OSR indicated, Allergies: HYDROcodone (sic) . Resident 2's OSR further 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 maintain the resident's communication within the facility for one of three sampled residents (Resident 1) when Resident 1's call light was not within reach. This failure had the potential to increase the residents' fear of not being able to get assistance from staff when needed. Findings: According to an admission Record, Resident 1 was admitted to the facility in 2023 with diagnoses including paralysis of the legs and lower body and post-traumatic stress disorder (PTSD; anxiety disorder from a traumatic event). A review of Resident 1's Minimum Data Set (MDS, an assessment tool), dated 5/7/24, indicated Resident 1 had no memory impairment. During a concurrent observation and interview on 4/18/24 at 10:06 a.m., inside Resident 1's room, Resident 1 stated he was not able to reach for the call light. The call light was observed hanging off the left side of the bed. During a concurrent observation and interview on 4/18/24 at 11:17 a.m. with Certified Nursing Assistant 1 (CNA 1), CNA 1 confirmed the call light 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 interviews, clinical record review, and facility documents review, the facility failed to readmit one of one resident (Resident 1) to return to the facility after hospitalization when Resident 1 was ready to be readmitted to the facility. This failure resulted in the denial of Resident 1's right to return to the facility and had the potential to negatively affect Resident 1's wellbeing. Findings: Resident 1 was admitted to the facility on [DATE], with diagnoses that included diabetes mellitus, acute respiratory failure with hypoxia (low level of oxygen) and atrial fibrillation (irregular heart rate). During a review of Resident 1's Progress Note, dated 12/22/23 at 2:25 a.m., indicated RP (responsible party) was notified about Resident 1's critical lab result. RP requested that Resident 1 be sent out to the hospital. PA (Physician Assistant) was notified and a new order was received to send Resident 1 to the ED (Emergency Department), for further eval (evaluation)/ blood transfusion. During a review of…

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

Based on interview and record review, the facility failed to implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime for one of four sampled residents (Resident 1), when Resident 1's allegation of mishandled care by Certified Nurse Assistant (CNA) 3 was not reported to the State Survey Agency/California Department of Public Health (CDPH) within 24 hours. This failure had placed Resident 1 and other residents in the facility at risk for further mishandled care, and possible serious physical and/or psychosocial harm. Findings: A review of Resident 1's clinical record indicated Resident 1 was admitted May of 2023 and had diagnoses that included encounter for other orthopedic aftercare (care provided after a surgery that involves bones, muscles, and joints) and muscle weakness. A review of Resident 1's Minimum Data Set (an assessment tool used to guide care) Cognitive Patterns, dated 6/2/23, indicated, Resident 1 had a Brief Interview for Mental Status (a tool to assess cognition) score of 15 out of 15, which indicated Resident 1 had intact…

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 of four sampled residents (Resident 1) when a report of suspected dependent adult/elder abuse was filed for Resident 1 who alleged Certified Nurse Assistant (CNA) 3 of not cleaning her well before putting on her new briefs (adult diaper). This failure had placed Resident 1 at risk of not receiving appropriate care and interventions and placed all residents in the facility at risk for mishandled care, and possible serious physical and/or psychosocial harm. Findings: A review of Resident 1's clinical record indicated Resident 1 was admitted May of 2023 and had diagnoses that included encounter for other orthopedic aftercare (a care provided after a surgery that involves bones, muscles, and joints) and muscle weakness. A review of Resident 1's Minimum Data Set (an assessment tool used to guide care) Cognitive Patterns, dated 6/2/23, indicated, Resident 1 had a Brief Interview for Mental Status (a tool to assess cognition) score of 15 out of 15 which…

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

Based on observations, interviews, and record review, the facility failed to ensure the medication administration error rate was less than 5 percent (%), when two medication errors occurred out of 25 opportunities during medication administration for two residents (Resident 46 and Resident 7) of 21 sampled residents. As a result of these failures, the facility's medication administration error rate was 8%. Findings: A review of an admission record indicated Resident 46 was admitted to the facility early 2018 with multiple diagnoses, which included anoxic brain damage (brain injury caused by a complete lack of oxygen to the brain). A review of Resident 46's physician's order, dated 5/10/23, indicated, [scopolamine (medication that prevents nausea and vomiting due to motion sickness, anesthesia, and surgery)] Patch .Apply 1 patch transdermally [on the skin] one time a day every 3 day(s) . A review of Resident 46's Medication Administration Record (MAR) dated 5/1/23 to 5/31/23, indicated the scopolamine patch was administered on 5/13/23 and 5/16/23. During a concurrent 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 interview and record review, the facility failed to ensure the Dietary Supervisor (DS) completed one of the seven pathways required to manage a skilled nursing facility in California. This failure had the potential for unsafe food handling and food borne illness in a highly susceptible population of 88 residents. Findings: During an interview on 5/16/23 at 8:01 a.m., the DS stated she had been employed at the facility for 10 years and had been in the position of Dietary Supervisor for approximately one year. The DS stated she had a ServeSafe Certificate (nationally accredited certificate in food safety that is required by law in many states) and did not have a Certified Dietary Manager certification nor was she currently participating in a Dietary Manager training program. During an interview on 5/16/23 at 1:37 p.m., the DS stated she conducted the training and monthly in-services for dietary staff and did the ordering of food and kitchen supplies. During an interview on 5/17/23 at 2:35 p.m., the Registered Dietician (RD) stated she was unaware of the pathway 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 proper infection control practices were performed for four residents (Resident 46, Resident 102, Resident 7, and Resident 86) of 21 sampled residents when: 1. The Licensed Nurse 1 (LN 1) and LN 3 did not perform hand hygiene between glove changes; 2. The LN 1 did not disinfect a stethoscope (an equipment used in listening to sounds produced within the body) prior to its use; 3. The LN 2 brought a container of glucometer strips (test strips used in a glucometer machine to check blood sugar level) and a glucometer to Resident 102's bedside without disinfecting them prior to use; 4. The LN 3 dropped a packet of powdered medication on the floor and continued to use the dropped medication to administer to Resident 7; and, 5. A Continuous Aerosol Misting (CAM, special tubing set-up used to provide moist air to the breathing tube) mask and tubing used for tracheostomy (surgically placed breathing tube in the front of the neck directly connected to the trachea) care did not indicate a date when the equipment…

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 develop a comprehensive person-centered care plan for one resident (Resident 51) of 21 sampled residents upon re-admission to the facility. This failure reduced the facility's potential to meet Resident 51's care needs for a urinary catheter (a tube used to drain urine from the bladder to a collection bag). Findings: A review of an admission record indicated Resident 51 was re-admitted to the facility on [DATE], with multiple diagnoses which included stroke, hemiplegia, or hemiparesis (paralysis of one side of the body), aphasia (loss of ability to express speech caused by brain damage), and neurogenic bladder (lack of bladder control due to injury or disease of the nervous system). A review of Resident 1's Minimum Data Set (MDS, an assessment tool), dated 4/13/23, indicated a permanently present indwelling urinary catheter. During an observation on 5/16/23 at 9:30 a.m., Resident 51 was lying in bed, looked alert, well-groomed, with no…

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 update care plans for two residents (Resident 24 and Resident 65) of 21 sampled residents when: 1. A care plan was not created on the precautions and safe usage for Resident 24's new medication enoxaparin (an injected medication that prevents blood clots); and, 2. A care plan was not created for the Resident 65's new diagnosis of septicemia (sepsis, an infection in the blood). These failures decreased the facility's potential to meet residents' needs upon a change in their care. Findings: 1. A review of Resident 24's admission record indicated admission to the facility on 1/4/22, with diagnoses of dissection of precerebral arteries (a tear in the carotid or vertebral arteries of the head and neck which transmit blood to the brain), traumatic subdural hemorrhage (a head injury causing bleeding into the brain), and respirator dependence. A review of Resident 24's clinical record indicated a physician's order, dated 5/6/23, for enoxaparin 40…

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 services provided met professional standards for one resident (Resident 65) of 21 sampled residents when: 1. Staff did not immediately notify the physician of Resident 65's change in condition; and, 2. Staff carried out an intervention for Resident 65 but did not evaluate the effectiveness of the intervention per protocol. These failures reduced the facility's potential to provide safe and effective care to Resident 65. Findings: A review of Resident 65's admission record indicated re-admission on [DATE], with multiple diagnoses which included type 2 diabetes (the body's inability to efficiently process sugar). A review of Resident 65's medical record on 5/18/23, indicated the following: A physician's order, dated 4/20/23, indicated, .if Blood Sugar [BS] less than 70, Initiate Hypoglycemic [low blood sugar] protocol .Notify MD [physician] . A weights and vitals summary, dated 5/1/23 at 9:34 p.m. and 5/1/23 at 10:31 p.m., indicated Resident 65…

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 maintain an acceptable parameter of nutritional status when one resident (Resident 62) of four sampled residents lost 9.9% of his body weight over a 12-day period. This failure placed Resident 62 at risk for potential muscle loss increasing his susceptibility to infection and delayed wound healing for a census of 88. Findings: A review of Resident 62's admission record indicated admission to the facility in April 2023 with multiple diagnoses which included dysphagia (difficulty swallowing) and stage four pressure ulcer (a deep wound that extends to the muscle, tendons, ligaments, or bone). A review of Resident 62's Weights and Vitals Summary, between 4/14/23 and 5/19/2023, indicated, Resident 62 weighed 242 pounds (a measure of weight) on 4/15/23 and 218 pounds on 4/27/23. This loss of 24 pounds was 9.9% of his body weight was classified as severe weight loss over a 12-day timespan. A review of Resident 62's undated Order Listing Report indicated, Resident 62 required enteral feeding (liquid formula given through a tube…

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