Golden San Andreas Care Center

Based on interview and record review the facility failed to carry out physician orders on two (Resident 1 and Resident 3) out of five residents reviewed for unnecessary drugs.These failures could have contributed to unsafe care and not following the physician orders for the treatment of medical problems. Findings: 1. A review of Resident 1's electronic medical record, titled admission Record; Diagnosis Information indicated Resident 1 had diagnosis of anemia (blood condition where body lacks enough healthy red blood cells to carry adequate oxygen to your tissues), low thyroid level, depression, high blood pressure and fracture of thighbone among others.A review of Resident 1's medical record under laboratory work, titled Complete Blood Count . (blood test for anemia and immune system), dated 3/10/26, the paper record indicated low level of hemoglobin (Hemoglobin, an iron-rich protein in red blood cells that carries oxygen to the rest of the body) in addition to abnormal level of other markers for anemia. The paper record had three handwritten orders for Iron pill (a supplement that…

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

Based on observation, interview, and record review, the facility failed to maintain accurate and complete medical records for 1 of 26 sampled residents (Resident 17) when Resident 17's Documentation Survey Report (form used by Certified Nurse Assistants (CNA) to document patient care and report observations as a proof that required care was provided) did not reflect activities were provided on daily basis from 5/1/26 through 5/31/26.This failure had the potential to not provide sufficient information that reflected Resident 17's activity participation on a daily basis.Findings: During a review of Resident 17's admission RECORD indicated Resident 17 was admitted to the facility with diagnoses including parkinsonism (neurological disorders that cause slowed movement, rigidity, and tremors), difficulty walking, and muscle weakness. During a review of Resident 17's Minimum Data Set (MDS, an assessment tool), dated 5/27/26, the MDS revealed a BIMS (Brief Interview for Mental Status) score of 9 out of 15 indicating a moderate problem with thinking, learning, and memory. 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 report the facilities investigation findings to the appropriate parties for an allegation of abuse for two of four sampled residents (Resident 1 and Resident 2), when the results of the investigation for the alleged allegation of abuse that occurred on 4/1/26 was not reported to the Department.This failure had the potential to compromise the facility's ability to ensure that appropriate corrective action was taken as the result of the investigation and could have compromised Resident 1 and Resident 2's safety. Findings:A review of Resident 1's admission RECORD, indicated that Resident 1 was admitted to the facility with diagnoses including depression (a serious mood disorder that causes persistent feelings of sadness, emptiness, and a loss of interest in activities).A review of Resident 2's admission RECORD, indicated that Resident 2 was admitted to the facility with diagnoses including Alzheimer's disease (the most common form of dementia, a progressive and irreversible brain disorder that slowly destroys memory, thinking…

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 document the administration of controlled drugs (medications that are tightly controlled by the government because they may be abused or cause addiction) for one of five (5) sampled Residents (Resident 5) when, Resident 5's controlled medication count sheet indicated three doses of hydrocodone/APAP (a controlled medication prescribed for pain management) had been signed out (taken out of the medication container) by a licensed nurse but had not been documented as administered to the resident on the medication administration record (MAR). These failures had the potential to cause medication errors and for Resident 5 to be inadvertently overmedicated.Findings: A review of Resident 5's admission RECORD, indicated Resident 5 had been admitted to the facility with diagnoses which included low back pain. During a concurrent interview and record review on 5/29/26 at 11:44 AM with Licensed Nurse (LN) 2, Resident 5's clinical document titled, ANTIBIOTIC OR CONTROLLED DRUG RECORD, dated 5/1/26 through 5/31/26, was compared 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 interview, and record review, the facility failed to ensure treatment and care was provided in accordance with professional standards of practice for two of three sampled residents (Resident 1 and Resident 2) when:1. Resident 1's low pulse rate (PR) readings of 46 on 3/19/25 were not rechecked and not reported to the medical doctor (MD) in a timely manner; and,2. Resident 2's left knee x-ray result was received and not reported to the MD.These failures had the potential for the facility not to recognize Resident 1 and Resident 2's potential change in conditions which could result in delays in their care and physical harm.Findings:1. A review of Resident 1's admission RECORD, indicated Resident 1 was admitted to the facility in 2025 with diagnoses which included hypertension (a condition with high blood pressure [BP]), type 2 diabetes mellitus (disorder characterized by difficulty in blood sugar control and poor wound healing), presence of a pacemaker (a small device that helps maintain a healthy heart beat using electrical impulses) and cardiomyopathy (a disease of 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 maintain a complete and accurate medical record for one of three sampled residents (Resident 1) when, Resident 1's Activity of Daily Living (ADL - refer to the basic self-care tasks essential for independent living, like bathing, dressing, eating and toileting) charting tasks for July of 2024 had multiple shifts that lacked Certified Nursing Assistant (CNA) entries. This failure had the potential to provide insufficient information regarding the condition, care, and services provided to Resident 1. Findings: 1. A review of Resident 1's clinical document titled Documentation Survey Report v2, a report that lists all the ADL areas that CNAs are to chart on each shift had missing documentation for the following care areas and dates: Behavior:10 PM-6 AM shift for July 2,3,7,8,17,20,24,26,30,31; 2 PM-10 PM shift for July 4,9,11,17,18,19; and 6 AM-2 PM shift for July 4,11,13,15,17,18,19 Bladder Continence:10 PM-6 AM shift for July 2,3,7,8,17,23,24,26,30,31; 2 PM-10 PM shift for July 4,9,11,17,18,19; and 6 AM-2 PM shift for July…

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 that nursing staff followed established protocols for the initiation and discontinuation of Cardio-Pulmonary Resuscitation (CPR – an emergency lifesaving procedure performed when the heart stops beating) for one out of three sampled residents (Resident 5) when, nursing staff discontinued CPR prior to the arrival of Emergency Medical Services (EMS - a system that provides emergency medical care) and without a physician's order or confirmation of death. This failure resulted in a lack of adherence to professional standards of practice and the facility's policies regarding life-saving interventions. Findings: During a review of Resident 5's clinical record titled, admission RECORD, indicated Resident 5's diagnoses included Orthopedic Aftercare (follow-up care and rehabilitation services provided to Resident 5 after surgery) and Hypertension (high blood pressure). A review of Resident 5's Physician Orders for Life Sustaining Treatment, (POLST, a…

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

Based on interview and record review, the facility failed to ensure that adequate supervision and safety interventions were implemented for one out of three residents (Resident 3) when Resident 2 grabbed Resident 3 ' s right wrist and shirt and attempted to strike her. This incident occurred 3 days after Resident 2 had been involved in a separate incident with another resident (Resident 4). This failure had the potential to negatively affect Resident 3 ' s physical and psychosocial well-being. Findings: During a review of Resident 2 ' s clinical record titled admission RECORD, the record indicated Resident 2's diagnoses included Dementia (a condition that caused a progressive decline in mental abilities), Paranoid Schizophrenia (a serious mental health condition that included symptoms of altered thinking, feeling and behavior), and Alzheimer ' s Disease (a progressive neurodegenerative disease that altered memory, thinking, and behavior). A review of Resident 3 ' s clinical record titled admission RECORD, the record indicated Resident 3's diagnoses included Dementia, Bipolar…

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 7 of 25 sampled residents (Resident 56, Resident 69, Resident 91, Resident 24, Resident 3, Resident 75, and Resident 82) rights related to treatment choices were known and protected when: 1. Resident 69, Resident 24 and Resident 3's POLST (Physician Orders for Life Sustaining Treatment: care directives during life threatening situations), did not have documented evidence that an Advance Directive (legal documentation consistent with a person's medical preference when they were no longer able to make decisions for themselves) was requested/discussed with Resident 69, Resident 24 and Resident 3; 2. Resident 56's and Resident 91's code status order (to provide or not provide life saving measures in the event of an emergency) in the electronic medical record (EMR) did not match the code status listed on the POLST; 3. Resident 75's POLST did not have documented evidence that an Advanced Directive was discussed with Resident 75's 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 develop and implement care plans (a list of resident specific problems, goals, and interventions) for 3 of 25 sampled residents (Resident 8, Resident 18, Resident 91) when: 1. Resident 8 and Resident 18, who were roommates, were on Enhanced Barrier Precautions (EBP - use of gown and gloves to prevent the spread of Multi-Drug Resistant Organisms (MDRO's illnesses/infections resistant to some antibiotics) but did not have a care plan for MDRO's developed and implemented; and, 2. Resident 91's care plan for Do Not Resuscitate (DNR - allow natural death to occur) was not implemented (Refer F684). These failures placed Resident 8 and Resident 18 at risk for infection and had the potential for other residents residing in the facility to acquire an MDRO, and resulted in facility staff initiating a Full Code (CPR cardiopulmonary resuscitation is emergency treatment when someone's breathing or heartbeat has stopped) on Resident 91 against her…

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 from the kitchen was prepared and served to meet the needs of 3 out of 13 Residents (Resident 8, Resident 42, and Resident 54) on a fortified (added calories) diet, and 1 of 1 Residents (Resident 65) on a finger food diet, for the lunch meal on 2/5/25, when: 1. Resident 8, Resident 42, and Resident 54, who were on an ordered fortified diet did not receive the added food items to increase calories; and, 2. Resident 65 did not receive his/her ordered diet of finger foods. These failures had the potential to result in residents not receiving adequate nutrients, which could lead to unplanned weight loss, vitamin imbalances, and further compromise their medical status. Findings: 1. During an observation on 2/5/25, at 11:48 AM, the lunch tray line staff prepared the trays for Resident 8, Resident 42, and Resident 54 with regular mashed potatoes instead of the fortified mashed potatoes. During an interview on 2/5/25, at 1:24 PM, the Dietary Manager (DM) stated the importance of following the ordered…

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 safe food storage and preparation, as well as maintain kitchen equipment and food contact surfaces in accordance with professional standards for food safety for the 89 residents who received facility prepared meals when: 1. The stove, oven, convection oven (ovens that have a fan to circulate heat and bake more evenly), back splash, and sides of oven contained grease, buildup of food particles, and white, black, brown colored encrusted grimy areas; and, 2. Sliced yellow cheese was removed from its original package and was stored in the refrigerator without being labeled; Food stored in the refrigerator was available for use beyond the use by date (UBD). 3. The kitchen was found with following unsanitary conditions: a. A floor sink located between the oven and a commercial food steamer was observed to have rust-colored stains, chipped, peeling white paint, debris, dirt, and unknown type of liquid splatter marks on the metal wall behind it. b. A wall behind a food preparation table was damaged with areas…

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 its infection prevention and control program, for a census of 89 residents, when: 1. Physical therapy assistant (PTA) 1 was not wearing an N95 respirator (a respiratory protective device designed to achieve a very close facial fit and very efficient filtration of airborne particles) in a COVID 19 positive resident room; 2. Certified nurse assistant (CNA) 5 was not wearing a gown when transferring a resident on enhanced barrier precautions (EBP a set of infection control measures that use gowns and gloves to reduce the spread of multidrug-resistant organisms (MDROs microorganisms that are resistant to multiple classes of antibiotics and antifungals)), from her wheelchair to her bed; 3. Two residents (Resident 8 and Resident 18), who were roommates with MDROs, were not placed on EBP; and, 4. A glucometer (used to check blood sugar) was not sanitized between resident's use. These failures had the potential to spread COVID-19, MDROs, and bloodborne illnesses to residents residing in the facility.…

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

Based on observation, interview, and record review, the facility failed to accommodate the needs of 3 of 25 sampled residents (Resident 16, Resident 58, and Resident 83) when: 1. Resident 16's call light was not within reach; 2. Residents 58's call light was attached to the bottom of the bed rail not within reach; and, 3. Resident 83's call light was on a chair not within reach. These failures placed Resident 16, Resident 58, and Resident 83 at risk of falls and unmet needs due to the inability to request assistance from staff. Findings: 1. During a concurrent observation and interview on 2/3/25, at 11:31 AM, with Licensed Nurse (LN) 1 in Resident 16's room, Resident 16 was observed trying to find the call light to call for help. LN 1 confirmed the call light was not in reach. LN 1 stated the call light was found under the pillows and pulled it out and handed it to Resident 16. LN 1 further stated Resident 16 had limited movement and would not have been able to find the call light under the pillows. LN 1 explained the call light not being in reach was a risk to residents who depend…

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 residents (Resident 91) sampled for a closed record review, received care in accordance with Resident 91's Physician Orders for Life-Sustaining Treatment (POLST; a medical document that outlines a resident's treatment preferences for when they are seriously ill or dying ) when, Resident 91's POLST indicated Do Not Resuscitate (DNR; a medical order that instructs healthcare providers not to perform CPR (cardiopulmonary resuscitation; an emergency lifesaving procedure performed when the heart stops beating) and the facility provided CPR to Resident 91 on [DATE]. This failure resulted in Resident 91 receiving CPR against Resident 91's wishes to be DNR, with the potential to cause trauma and psychosocial harm to Resident 91 and Resident 91's family. Findings: A review of Resident 91's clinical record titled, admission RECORD, indicated Resident 91's diagnoses included atrial fibrillation (a condition where the upper chambers of the…

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

Based on observation, interview, and record review, the facility failed to ensure proper hydration (process of providing fluid to the body) for 1 of 25 sampled residents (Resident 16) per facility policy and Resident 16's care plan when Resident 16's water was out of reach. This failure resulted in Resident 16 having dry, cracked lips and had the potential to have complications associated with fluid imbalance (when the body loses or gains too much water/fluids). Findings: During a concurrent observation and interview on 2/3/25, at 11:31 AM, with Licensed Nurse (LN) 1 in Resident 16's room, Resident 16 stated she was thirsty. Resident 16 looked on the bedside table for something to drink but nothing was there. LN 1 stated the risk to Resident 16 not having fluids available to drink at bedside was becoming dehydrated (when the body loses too much fluid). During a concurrent observation and interview on 2/3/25 at 11:42 AM, with Certified Nursing Assistant (CNA) 3 in Resident 16's room, Resident 16 stated the staff got her water but moved her bedside table with the water on it out 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 respiratory care was provided in accordance with professional standards of practice for 2 of 19 residents when: 1. Oxygen therapy was provided without a physician order for Resident 192 and an oxygen in use sign was not posted outside of Resident 192's room; and, 2. An oxygen in use sign was not posted outside of the room for Resident 296. These failures had the potential to result in negative impacts on the residents' health and safety including risks for ineffective oxygen therapy, and respiratory distress. Findings: 1. A review of Resident 192's admission Record indicated Resident 192 was admitted to the facility with diagnoses which included chronic obstructive pulmonary disease (COPD: a group of lung diseases that block airflow and make it difficult to breathe). During an observation on 2/03/25, at 11:25 a.m., Resident 192 was observed in her room with the oxygen concentrator on at a flow rate of 1.5 liters per minute (LPM-unit of measurement for oxygen delivery) via nasal cannula (a small…

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 1 of 25 sampled residents (Resident 3) was provided pain management that met professional standards of practice when Resident 3's Lidocaine patch (used to relieve nerve pain) was signed off by licensed nurse (LN) 9 as if it had been applied as ordered by the physician but was not placed until three hours later. This failure resulted in Resident 3's pain being unrelieved, negatively impacting Resident 3's health and well-being. Findings: A review of Resident 3's clinical document titled, admission RECORD, indicated Resident 3 was admitted to the facility with diagnoses which included, MALIGNANT NEOPLASM OF AMPULLA OF [NAME], (a type of cancer) and rheumatoid arthritis (a disease that causes pain, swelling, and stiffness in the joints). During a concurrent observation and interview on 2/3/25, at 10:56 AM, with Resident 3, Resident 3 stated LN 9 had not applied her Lidocaine Patch and she was in pain. Resident 3 stated the Lidocaine…

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 2 of 25 sampled residents' (Resident 3 and Resident 24) medications were administered as prescribed when: 1. Resident 3's PRN (as needed) pain medication, acetaminophen, was left at the bedside; and, 2. Resident 24's medication Sucralfate (used to prevent stomach ulcers) was not administered before meals as prescribed. These failures resulted in Resident 3's pain going unrelieved, the potential for Resident 3 to accumulate the medication, or for another resident to take the medication, and for Resident 24 to experience abdominal discomfort, negatively impacting Resident 3's and Resident 24's health and well-being. Findings: 1. A review of Resident 3's clinical document titled, admission RECORD, indicated Resident 3 was admitted to the facility with diagnoses which included, MALIGNANT NEOPLASM OF AMPULLA OF [NAME] [cancer], and rheumatoid arthritis (causes pain, swelling, and stiffness in the joints). During a concurrent observation…

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 closed garbage dumpster bin. This failure had the potential to lead to insect and rodent (mice and rats) infestation for the 89 residents who lived at the facility. Findings: During a concurrent observation and interview on 2/3/25, at 9:59 AM, with the Dietary Manager (DM), the lid to one of the garbage dumpster bins located outside behind the building was observed propped open. The DM confirmed the lid was open. The DM stated the garbage dumpster lid should be kept closed and secured to avoid attracting rodents. During an interview on 2/4/25, at 12:58 PM, with the Registered Dietician (RD), the RD stated his expectation was for the garbage dumpster bin to be closed. The RD further stated the risk of it being opened was attracting rodents. A review of the 2022 Food Code, published by the Food and Drug Administration (FDA), dated 1/18/23, in the Section 5-501.15, 111, and 115, indicated, .Proper storage and disposal of garbage and refuse are necessary to minimize the development of odors, prevent…

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 complete and accurate medical records for 2 of 25 sampled residents (Resident 43 and Resident 77) when: 1. Protected Health Information (PHI - any information that can be used to identify a person and is related to their health including any information about a person's physical or mental health, treatment, and payment for healthcare) of another person was found in Resident 43's medical record; and, 2. The facility failed to ensure psychotropic medication (type of drug that affects behavior, mood, thoughts, or perception) informed consent documents included the frequency, dose, and duration for Resident 77. These failures resulted in an inaccurate account of information in Resident 43 and Resident 77's medical records. Findings: 1. During a concurrent interview and record review on 2/3/25, at 8:56 AM, with the Director of Nursing (DON), the DON confirmed laboratory results for another Resident were in Resident 43's medical record. The DON stated this was done by accident. The DON further stated that this could…

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 1 of 25 sampled residents (Resident 75) was offered the Pneumococcal booster Vaccine (vaccine to prevent pneumonia) even though Resident 75 was eligible to receive the vaccine. This failure resulted in Resident 75 being at higher risk for contracting pneumonia from not receiving the pneumococcal vaccine when eligible. Findings: 1. A review of Resident 75's admission Record indicated Resident 75 was admitted to the facility with diagnoses which included muscle weakness, anemia (when the body does not have enough red blood cells), Type 2 Diabetes Mellitus (the inability to regulate sugar levels in the body) and chronic obstructive pulmonary disease (lung disease). A review of Resident 75's medical record titled, Immunization Record and History, dated 10/25/17, indicated Resident 75 had received the PCV13 vaccination (protects against 13 types of bacteria that can cause pneumonia) on 10/25/17. During a concurrent interview and record review 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 maintain kitchen equipment for 89 residents who received food from the kitchen when the steamer (small appliance that cooks food using steam) was leaking water onto the ground. This failure had the potential to injure staff due to a wet floor and compromise food safety for the 89 residents receiving food from the kitchen. Findings: During the initial kitchen tour on 2/3/25, at 9:01 AM, the steamer (which sat next to the stove) was observed leaking water from the bottom onto a maroon kitchen tray and then overflowed onto the ground. There were no signs that cautioned wet floors in the area. During a concurrent observation and interview on 2/5/25, at 10:14 AM, standing water was observed puddling onto an overflowing maroon serving tray on the floor under the steamer and being tracked across the kitchen. Dietary [NAME] (CK) 1 stated they needed to keep emptying the tray or it overflowed. CK 1 stated it has been repaired a few times but continuously leaked. CK 1 confirmed a wet floor caution sign was not in use.…

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

Based on interview, and record review, the facility failed to ensure one of four sampled residents (Resident 1) remained free of accidents and hazards when Certified Nursing Assistant (CNA) 1 gave Resident 1 a vape pen (also known as using an electronic cigarette - the act of inhaling an aerosol from a battery-powered device) that contained tetrahydrocannabinol (THC – the mind-altering compound of marijuana - a federally illegal drug that can cause increased heart rate and blood pressure, and confusion). This failure could have resulted in Resident 1 having an adverse reaction to the drug such as lung injury, confusion, and/or injury from the vape pen which could have been being laced with an unknown drug. Findings: A review of Resident 1 ' s clinical record titled, admission RECORD, indicated Resident 1 ' s diagnoses included anxiety (an emotion that could feel like dread or fear) and chronic obstructive pulmonary disease (COPD - a chronic lung disease that made it difficult to breathe). A review of Resident 1 ' s clinical record titled, N Adv – Smoking and Safety, (smoking…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to protect the rights of Resident 3 to be free from physical abuse, when on [DATE] unsupervised Resident 2 with history of inappropriate behavior and aggression grabbed Resident 3 by the neck. This deficient practice resulted in Resident 3 sustained skin marks to the neck and voicing safety concerns, distress of being chocked by the beast (Resident 2), and having a hurt reputation. Findings: A review of Resident 2 ' s medical record included the following documents: -An admission record printed on [DATE], indicated that resident was admitted to the facility in October of 2023 with diagnoses including Alzheimer ' s disease, dementia, psychosis (a collection of symptoms that affect the mind, where there has been some loss of contact with reality) and anxiety (a feeling of fear, dread, and uneasiness). - A care plan dated [DATE], indicated, [Resident 2] has had a wander guard [electronic monitoring alarm system] placed for safety precautions after several…

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 professional standards were met when Licensed Nurse (LN2) left refused medications scheduled for the morning administration at Resident 4 ' s bedside, marked them as administered and took medications back during the evening shift, crushed them and mixed them with food and attempted to administer the medications to the Resident 4. These failures resulted in Resident 4 ' s distrust of staff, refusing care and food, and stating that staff are trying to poison her. These failures also had the potential for unattended medications to be taken by other residents which could result in bodily harm. Findings: A review of Resident 4 ' s admission record indicated Resident 4 was most recently admitted to the facility early 2024 with diagnoses which included sepsis (A life-threatening complication of an infection), diabetes (a chronic health condition that affects how body processes sugar), depression (a mental condition of feeling down), and anxiety (a feeling of fear, dread, and uneasiness). A review of Resident 4 ' s…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide an environment free of accident hazards for one of two sampled residents (Resident 1) with falls when, Resident 1 was left alone in the wheelchair in her room while staff attempted to locate the footrests for the wheelchair and Resident 1 sustained a fall from the wheelchair during that time on the morning of 2/15/24. These deficient practices resulted in Resident 1 sustaining an avoidable fall [NAME] resulted in a scalp laceration (cut on the head). Findings: A review of Resident 1 ' s admission Record indicated Resident 1 was admitted to the facility in fall of 2018 with diagnoses that included Alzheimer ' s disease (A progressive disease that destroys memory and other important mental functions), muscle weakness, need for assistance with personal care, and unspecified convulsions. A review of Resident 1 ' s progress note dated 2/15/24 indicated, patient had an unwitnessed fall with injury that began on 02/15/2024 6:30 AM and…

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

Based on interview and record review, the facility failed to ensure professional standards of care were met for Resident 1, when neurological checks (neuro checks, assessment of nerve and motor responses to determine if the nervous system is impaired) and 72-hour alert charting (documentation of assessments and observations) were not completed after Resident 1 sustained a fall in the facility. These failures increased the risk of unrecognized injuries for Resident 1, and could result in a delay in treatment for an injury. Findings: A review of Resident 1 ' s admission RECORD, indicated she was admitted to the facility in 2022 with diagnoses which included dementia (condition characterized by memory disorders, personality changes and impaired reasoning), muscle weakness, and difficulty in walking. A review of Resident 1 ' s clinical record, Progress Notes dated 1/31/24, at 8:30 PM, indicated, .writer was called to room, saw [Resident 1] sitting on the floor next to wheelchair by restroom. Stated she was coming from restroom and fell on floor .stated she was not hurt. Writer and aide…

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 fall prevention measures were implemented according to the plan of care for Resident 1, when Resident 1 ' s anti-slip pad was not on her wheelchair and her fall risk bracelet was not in place. These failures had the potential for Resident 1 to sustain further falls and injuries. Findings: A review of Resident 1 ' s admission RECORD, indicated she was admitted to the facility in 2022 with diagnoses which included dementia (condition characterized by memory disorders, personality changes and impaired reasoning), muscle weakness, and difficulty in walking. A review of Resident 1 ' s care plan revised on 11/22/23, indicated, .is at risk for falls related to Confusion, Incontinence, osteoporosis, history of falls .Goal .will not sustain serious injury .dycem [anti-slip pad] on wheelchair . A review of Resident 1 ' s clinical record, Progress Notes, dated 1/31/24, at 8:30 PM, indicated, .writer was called to room, saw resident sitting on the floor next to wheelchair by restroom. Stated she was coming from…

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 did not implement its abuse program for 1 of 21 sampled residents (Resident 45) when Resident 45 was involved in sexual interactions with another resident (Resident 36) who had a history of sexually inappropriate behavior with staff and residents, and the facility did not report the incidents as possible sexual abuse. This failure resulted in three instances of possible sexual abuse on 12/15/23; 12/17/23; and 12/23/23 not being reported; and resulted in the State Agency being unaware of potential danger to Resident 45. Findings: A review of Resident 45's admission Record indicated Resident 45 was admitted to the facility with diagnoses which included dementia (the loss of cognitive functioning - thinking, remembering, and reasoning - to such an extent that it interferes with a person's daily life and activities). A review of Resident 36's admission Record indicated Resident 36 was admitted to the facility with diagnoses which did not include dementia. A review of Resident 36's clinical records titled, Progress Notes,…

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 did not implement its abuse program for 1 of 21 sampled residents (Resident 45) when Resident 45 was subjected to sexual interactions with another resident (Resident 36) who had a history of sexually inappropriate behavior with staff and residents, and the facility did not investigate the incidents. This failure resulted in three instances of sexual interaction on 12/15/23; 12/17/23; and 12/23/23, not being investigated, and had the potential for further incidents to occur. Findings: A review of Resident 45's admission Record indicated Resident 45 was admitted to the facility with diagnoses which included dementia (the loss of cognitive functioning - thinking, remembering, and reasoning - to such an extent that it interferes with a person's daily life and activities). A review of Resident 36's admission Record indicated Resident 36 was admitted to the facility with diagnoses which did not include dementia. A review of Resident 36's clinical records titled, Progress Notes, ranging 12/15/23 through 1/8/24 indicated…

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

Based on interview and record review the facility failed to consistently complete Interdisciplinary Team (IDT, care team consisting of different disciplines who assess and coordinate care) care plan conferences (a meeting which provides opportunities for the resident's and/or their representative, and each discipline to revise the residents care plans) for 5 of 21 sampled residents (Resident 54, Resident 2, Resident 18, Resident 45, and Resident 30). These failures had the potential for unmet care needs for Resident 54, Resident 2, Resident 18, Resident 45, and Resident 30. Findings: 1a. A review of Resident 54's admission RECORD, indicated he was admitted to the facility in October of 2022 with diagnoses which included, dementia (condition characterized by memory disorders, personality changes and impaired reasoning) and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). During an interview on 1/22/24, at 11:56 AM, Family Member (FM) 4 stated she remembered attending only one care conference since Resident 54 had been 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.

Based on observation, interview, and record review, the facility failed to ensure professional standards of quality were met when: 1. One of five sampled residents' (Resident 15) medical record was marked with schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves) as a diagnosis for use of risperidone (antipsychotic drug class, a mind-altering medication used to treat mental disease) with no prior history of such a diagnosis; 2. The facility did not ensure an accurate psychiatric (mental health) diagnosis was documented in the medical record for one resident (Resident 30) based on the standards of practice; and, 3. The facility did not ensure 1 of 3 sampled residents (Resident 49) with a Foley catheter (a flexible tube used to empty the bladder and collect urine in a drainage bag) had an appropriate diagnosis for Foley catheter use. These failures had the potential to result in unsafe treatment and care of the residents. Findings: 1. Review of Resident 15's medical record from a previous hospitalization (Hospital A) titled, History and…

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

Based on interview and record review the facility failed to provide adequate and sufficient nursing staff to ensure the Restorative Nursing Aide program (RNA, nursing aide who helps residents to maintain their function and joint mobility) services were available for the 19 residents on the RNA schedule for the month of January. This failure had the potential to decrease the residents' range of motion and mobility, which could adversely affect their overall function. Findings: A review of a facility handwritten document, provided by RNA 1, listed the names of 19 residents receiving RNA services for the month of January. A review of facility documents titled, RNA Program Assignment sheet, which listed the names of the residents who received RNA services each day, indicated: .January 1, 2024 . 16 resident names were listed .January 2, 2024 . 14 resident names were listed .January 3, 2024 . 3 resident names were listed .January 4, 2024 . 0 resident names were listed .January 5, 2024 . 5 resident names were listed .January 6, 2024 . 0 resident names were listed .January 7, 2024 . 0…

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 narcotic medication patches were disposed of and accounted for appropriately, non-narcotic medications were disposed of properly, and medications were administered in a timely manner when: 1. Licensed nurses were not aware of where to dispose of narcotic medication patches (Fentanyl patch-a very strong narcotic which is absorbed through the skin) and did not co-sign the disposal of narcotic medication patches; 2. The facility did not ensure non-narcotic medications were disposed of appropriately; and, 3. Medications were not administered in a timely manner for 1 sampled resident (Resident 30), and 9 unsampled residents (Resident 22, Resident 3, Resident 41, Resident 60, Resident 12, Resident 56, Resident 4, Resident 31, and Resident 11). These failures had the potential for: 1. Accidental exposure to narcotics by residents and staff, and diversion of controlled substances; 2. Access to medications by unauthorized persons; and, 3. Ineffective medication therapy for the ten residents who received their…

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 a medication rate of less than 5 % when 5 of 33 opportunities resulted in an error rate of 15.15 % as follows: 1. A medication was not administered in a timely manner for 1 of 21 sampled residents (Resident 30); 2. Medications for administration were crushed for one unsampled resident (Resident 12), who did not have an order to crush her medications. This failure had the potential to negatively impact the therapeutic benefits of the medications prescribed to residents receiving medications in the facility. Findings: 1. During a concurrent observation and interview with licensed nurse (LN) 11, on 1/24/24, at 10:14 AM, LN 11 was observed passing Resident 30's medication as follows: Cefuroxime (an antibiotic), 250 MG, one tablet by mouth every 12 hours, due at 8 AM, was administered at 10:19 AM. During a concurrent interview and record review with the Director of Nurses (DON), on 1/24/24, at 1:48 PM, the DON confirmed the medication was passed late. The DON explained she gave a copy of the clinical…

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

Based on observation, interview, and record review, the facility failed to ensure medications were labeled and stored appropriately when: 1. The facility did not ensure consistent temperature monitoring in the Central Supply room where over the counter (OTC) medications were stored; 2. The facility did not ensure two of five medication carts were locked when left unattended; and, 3. The facility did not ensure a bottle of turberculin solution (a medication used to test for a severe lung disease called tuberculosis) was labeled with the use-by date after opening. These failures had the potential to affect all residents in the facility, with the potential to result in medications losing their efficacy (the therapeutic benefit of the medications), and for mobile residents to gain access to the unsupervised, unlocked medication carts resulting in residents self-administering medications they were not prescribed. Findings: 1. During a concurrent interview and record review with Licensed Nurse (LN) 2, in the Central Supply room where OTC medications were stored, on 1/22/24, at 8:54 AM, LN…

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 food production when: 1. Multiple food items were found not labeled with a use by date in the refrigerator, freezer, and the dry storage area (foods that do not require to be kept cold), and were available for resident consumption; 2. Expired (outdated) food products were not removed from the kitchen, and were available for resident consumption; 3. Kitchen appliances were dirty with grease and food particles; 4. Kitchen drawers containing clean utensils had dirt and debris; 5. Kitchen staff were not wearing a hairnet properly while handling food; and, 6. Plastic cups were stacked wet. These failures had the potential to expose 73 residents who received meals from kitchen to food borne illnesses (illnesses caused by the ingestion of contaminated food or beverages). Findings: 1.a. During a concurrent observation and interview on 1/22/24, at 8:48 a.m., with the Certified Dietary Manager (CDM) in the reach in freezer, the CDM confirmed an opened box of 100 frozen biscuit dough was not labeled with a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the failed to maintain and implement its infection protection and control program when: 1a. Resident 50 was not placed on contact precautions (residents with known or suspected infections that could be spread by contact. Health care personnel must wear a gown and gloves for all interactions that involve contact with the patient and the patient environment) for MRSA (methicillin resistant staphylococcus aureus - a multi-drug resistant organism also called an MDRO); 1b. Resident 6 was not placed on airborne (for residents with known or suspected to be infected with microorganisms transmitted by airborne droplet germs) and droplet (used to prevent the spread of pathogens that are passed through respiratory secretions and do not survive for long in transit) precautions for shingles and COVID-19; 1c. Staff were not wearing the appropriate personal protective equipment (PPE- equipment worn to minimize exposure to hazards that cause serious workplace injuries and…

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

Based on observation and interview the facility failed to ensure 2 of 21 sampled residents (Resident 6 and Resident 67) needs were accommodated when their call lights were not in reach. These failures had the potential risk of falls and unmet care needs for Resident 6 and Resident 67. Findings: 1a. A review of Resident 6's admission RECORD, indicated she was admitted to the facility in March of 2022 with diagnoses which included Alzheimer's disease (a progressive disease that affects the parts of the brain that control thought, memory and language) and muscle weakness. A review of Resident 6's care plan initiated 2/23/23, indicated, .risk for falls related to .impaired coordination/poor balance with dx of Alzheimer's disease .Interventions .Be sure resident's call light is within reach . During an observation on 1/23/24, at 10:22 AM, Resident 6 was sitting up on the edge of her bed calling for help. Resident 6's call light was observed on the floor on the opposite side of the bed from where she was sitting. During an observation and interview on 1/23/24, at 10:32 AM, Certified Nurse…

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 a change of condition (COC, a change in the residents normal physical, mental, or behavioral state) to the responsible party (RP) and the physician for 1 of 21 sampled residents (Resident 54) when Resident 54 had a weight loss of 17.6 pounds (Lbs) in 3 weeks and his responsible party and physician were not informed of the change. This failure had the potential for a delay in interventions and care for Resident 54 and resulted in the RP not being able to participate in and make decisions about Resident 54's plan of care. Findings: A review of Resident 54's admission RECORD, indicated he was admitted to the facility in October of 2022 with diagnoses which included, dementia (a condition characterized by memory disorders, personality changes and impaired reasoning) and protein calorie malnutrition (a condition that occurs when not enough protein and calories are consumed resulting in muscle loss). A review of Resident 54's clinical document titled, Weights and Vitals Summary, indicated, .01/01/2024 .188.6 Lbs.01/21/2024…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to provide one of three sampled Residents (Resident 273) a Notice of Medicare Non-Coverage (NOMNC, a form that contains information regarding the end date of Medicare covered services and how to initiate an appeal). This failure had the potential for Resident 273 to be uninformed of her specific rights and protections related to financial liability for potential incurred medical expenses as well as the right to appeal the discharge. Findings: A review of Resident 273's admission RECORD, indicated, she was admitted to the facility in October of 2023 with diagnoses which included nontraumatic intracerebral hemorrhage (bleeding in the brain). A review of Resident 273's clinical document titled, Occupational Therapy OT [occupational therapy] Discharge Summary, indicated .Dates of Service 10/21/23 - 11/23/23 .Destination: Home .Reason: Highest Practical Level Achieved . A review of Resident 273's clinical document titled, Social Service Discharge, dated…

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 273) discharge information was documented in the medical record when Resident 273 was discharged home and the facility did not document the date or time of her discharge, where she discharged to, how she was transported, a summary of her stay, or the disposition (a detailed list) of her personal effects and her medications. This failure had the potential risk of Resident 273 receiving inadequate care or services after discharge. Findings: A review of Resident 273's admission RECORD, indicated she was admitted to the facility in October of 2023 with diagnoses which included nontraumatic intracerebral hemorrhage (bleeding in the brain). A review of Resident 273's clinical document titled, Social Service Discharge, dated 11/21/23, indicated, .Planned discharge date [DATE] . During an interview on 1/29/24, at 9:21 AM, the Minimum Data Set (a resident assessment and screening tool) Coordinator (MDSC)…

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 issue a transfer/discharge notice for one of three closed record review sampled residents (Resident 72), when Resident 72 was transferred from the facility to the hospital on [DATE] and the facility did not provide a transfer/discharge notice to Resident 72's Responsible Party (RP) and the State Long-Term Care Ombudsman (an advocate for residents in long term care facilities). This failure resulted in the State Long-Term Care Ombudsman being unaware of Resident 72's transfer and removed the opportunity for Resident 72's RP and/or the State Long-Term Care Ombudsman to advocate on their behalf. Findings: During a review of Resident 72's admission RECORD, the record indicated that Resident 72 was admitted to the facility in 2023 with diagnoses which included Cirrhosis of the liver (a condition in which the liver is damaged). During a telephone interview on 1/29/24, at 12:09 p.m., with Resident 72's RP 2, Resident 72's RP 2 stated a transfer/discharge…

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 Pre-admission Screening and Resident Review (PASARR- a federal requirement to screen all potential nursing home residents for mental illness and intellectual disability, to help ensure that individuals are not inappropriately placed in a nursing home, and to ensure they receive any specialized services that are required) provided accurate information for 3 of 21 sampled residents, (Resident 14, Resident 15, and Resident 23) when Resident 14 and Resident 15's PASARR screenings did not include diagnoses of schizophrenia (a mental disorder that affects a person's ability to think, feel and behave clearly) and Resident 23's PASARR did not reflect diagnoses of bipolar disorder (a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration) and anxiety disorder These failures had the potential for Resident 14, Resident 15, and Resident 23 to not receive the necessary services to meet their mental and psychosocial (the link between social factors and individual thought and…

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

Based on observation, interview, and record review, the facility failed to develop and/or implement a person-centered care plan for 3 of 21 sampled residents (Resident 10, Resident 44, and Resident 49) when: 1.Resident 10's fall risk care plan intervention of a fall mat at bedside (a specially designed floor mat that is placed on the floor near the bed to protect the elderly from serious physical injury resulting from a fall) was not implemented; and 2. Resident 44 did not have a care plan developed for his fluid restriction (physician ordered limited amount of fluid per day) ; and 3. Resident 49 did not have a care plan developed for the use of a foley catheter (flexible tube that empties urine from the bladder into a collection bag). These failures had the potential to result in a fall with the potential for injury for Resident 10, and the potential for Resident 44 and Resident 49's care needs to not be addressed. Findings: 1. During a concurrent observation and interview on 1/23/24 at 10:47 a.m., in Resident 10's Room, Licensed Nurse (LN) 2 confirmed Resident 10 did not have fall…

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 neurological checks (neuro checks, assessing mental status, pupil response, strength, and sensation) were completed for one of three sampled residents (Resident 30) who had a fall with injury when Resident 30 had a fall with a head laceration. This failure had the potential to result in unrecognized head trauma negatively impacting Resident 30's health and well-being. Findings: A review of Resident 30's admission Record indicated Resident 30 was admitted to the facility with diagnoses which included generalized (all over) muscle weakness and osteoarthritis (a joint disease in which the tissues in the joint break down over time, causing pain and stiffness). A review of Resident 30's clinical document titled, Morse Fall Scale [an assessment used to determine a resident's risk for falls] . dated 11/28/23, indicated a score of 55, with the range as follows, High Risk: 45 and higher . A review of Resident 30's clinical document titled, Morse Fall Scale ., dated 12/29/23, indicated a score of 75, with the range as…

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

Based on observation, interview, and record review, the facility failed to ensure interventions were in place for the prevention of pressure ulcers (PU, areas of damaged skin typically caused by staying in one position for too long) for two of twenty-one sampled residents (Resident 18 and Resident 49) when: 1. Resident 18 was at risk for developing pressure ulcers and her care plan interventions were inadequate to prevent skin breakdown from occurring; and, 2. Resident 49 was at risk for a worsening pressure ulcer and her care plan interventions were inadequate to prevent further skin damage, and did not address Resident 49's refusal to reposition. These failures put Resident 18 and Resident 49 at potential risk of increased pain, infection, and muscle or bone loss. Findings: 1. A review of Resident 18's admission RECORD, indicated she was admitted to the facility in August of 2023 with diagnoses which included, multiple sclerosis (a disease in which the body eats away at the protective covering of nerves) and muscle weakness. A review of Resident 18's care plan revised on 8/25/23,…

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 interventions to prevent falls and accidents for 1 of 21 sampled residents (Resident 45) when: 1. Resident 45's bed was not in a low position and Resident 45's call light was not within reach; 2. Resident 45's wheelchair (W/C) seatbelt with an alarm was not secure; and the alarm was not on when Resident 45 was in her W/C; and, 3. Staff were not knowledgeable in how to check the [Brand Name] signaling bracelet (device which alarms if the wearer leaves the building without staff knowledge) for functioning. These failures had the potential to result in Resident 45 sustaining injuries from falls, being unable to call for help, staff being unaware of Resident 45 getting out of her WC, and for Resident 45 to leave the facility without staff knowledge. Findings: 1. A review of Resident 45's admission Record indicated, Resident 45 was admitted to the facility with diagnoses which included dementia (the loss of cognitive functioning - thinking, remembering, and reasoning - to such an extent that it…

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 in accordance with professional standards of practice for 2 of 16 residents (Resident 5 and Resident 15) receiving oxygen therapy when: 1. Resident 15's physician order did not indicate parameters for increasing or decreasing her oxygen flow rate; and, 2. Resident 5 and Resident 15's oxygen concentrator (machine used to deliver oxygen to a person) filters contained dust and debris. Findings: 1. A review of Resident 15's admission RECORD, indicated she was admitted to the facility in the Fall of 2022 with diagnoses which included bronchiectasis (a lung condition that causes persistent cough and excess mucous [a slippery sticky substance] produced by the lungs) and shortness of breath. During an observation on 1/22/24, at 2:20 PM, Resident 15's oxygen was in use at 2 liters per minute (flow rate) via nasal cannula (small flexible tube that contains two open prongs intended to sit just inside the nostrils). A review of Resident 15's Order Summary Report,' indicated, .Oxygen…

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 complete annual performance evaluations for 2 of 3 sampled nursing assistants when Certified Nurse Assistant (CNA) 3 and CNA 4 did not have annual performance evaluations completed every 12 months. This failure had the potential for resident needs to go unmet by CNA's whose competence had not been determined through annual performance evaluations. Findings: During a concurrent interview and review of employee files, on 1/29/24, at 7:55 AM, the Director of Staff Development (DSD) confirmed CNA 3's performance evaluation was due in November of 2023 and CNA 4's performance evaluation was due in September of 2023. The DSD confirmed the annual performance evaluations were not completed on an annual basis. The DSD stated performance evaluations were important to determine if staff were competent to provide care to the residents and to recognize any areas of weakness that may need improvement. The DSD further stated resident care could be affected if CNA performance was not evaluated. During an interview on 1/30/24, at 3:43 PM,…

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

Based on interview and record review, the facility failed to ensure one out of ten residents (Resident 30) on anti-psychotic medication had an appropriate diagnosis obtained by a comprehensive assessment for anti-psychotic drug use; and that a gradual dose reduction (GDR) was completed. This failure resulted in Resident 30 receiving an anti-psychotic medication without an appropriate diagnosis and potentially resulted in Resident 30 receiving the medication unnecessarily, placing Resident 30 at risk for adverse effects from the use of an anti-psychotic medication. Findings: a. A review of Resident 30's admission Record indicated Resident 30 was admitted to the facility with a primary diagnosis of dementia (the loss of cognitive functioning - thinking, remembering, and reasoning - to such an extent that it interferes with a person's daily life and activities), and unspecified psychosis (symptoms include disordered thinking and disconnection from reality, may be caused by mental illnesses or other medical conditions) which was given as a diagnosis 1 year and 4 months after she 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 provide the correct portion size for one of five residents (Resident 12) during dinner tray line on 1/23/24, when Resident 12's preference was a small portion size and [NAME] (CK)1 did not follow Resident 12's preference. This failure had the potential to negatively impact Resident 12's health and well-being. Findings: During a review of Resident 12's admission RECORD, the record indicated that Resident 12 was admitted to the facility in 2022 with diagnoses which included body myositis (a condition of the muscles that causes weakness), hypothyroidism (a condition when the small, butterfly-shaped gland located at the base of the neck does not produce enough thyroid hormones), gastroesophageal reflux disease (acid reflux and/or heartburn), diverticulum of esophagus (a pouch that protrudes outward in a weak portion of the throat) and dysphagia (difficulty swallowing). During an observation on 1/23/24, at 5:02 p.m., with CK 1 in the kitchen, CK 1 was observed plating Resident 12's dinner tray using a measured…

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 facilty failed to implement an antibiotic stewardship program and monitor antibiotic use when 1 of 21 sampled residents (Resident 14) received an antibiotic without an ending date. This failure could contribute to antibiotic resistance for Resident 14. A review of Resident 14's admission Record indicated Resident 14 was admitted to the facility with diagnoses which included diabetes (problems with blood sugar) and adult failure to thrive (when an older adult has a loss of appetite, eats and drinks less than usual, loses weight, and is less active than normal). A review of Resident 14's medical record titled, Order Summary Report, indicated, Doxycycline Hyclate (an antibiotic - used to treat infections) Oral Tablet 100 MG (milligrams - a unit of measure) .Give 1 tablet by mouth one time a day for prophylaxis against chronic UTI (urinary tract infections) .Order Date 11/29/23 .Start Date 11/30/23 .End Date [blank] . During a concurrent interview and record review with the Infection Preventionist (IP), on 1/26/24, at 1:26 PM, the IP reviewed…

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 residents received vaccine education and residents were offered the Pneumococcal (vaccine to prevent pneumonia) vaccine when: 1. The facility did not have documented evidence of educating one of five sampled residents (Resident 26) on the influenza and Pneumococcal vaccines received; and, 2. The facility did not offer the Pneumococcal vaccine to two of five sampled residents (Resident 30 and Resident 48) when they were eligible to receive the vaccine. These failures resulted in Resident 26 not receiving information on the risk and benefits of the vaccines administered and Resident 30 and 48 being at higher risk for pneumonia from not receiving the pneumococcal vaccine when eligible. Findings: 1. A review of Resident 26's admission Record indicated Resident 26 was admitted to the facility with diagnoses which included obesity and muscle weakness. A review of Resident 26's medical record titled, Update Immunization, dated 9/28/23, indicated…

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

Based on interview and record review the facility failed to ensure one of five sampled residents (resident 30) received education regarding the COVID-19 vaccine when Resident 30's clinical record did not contain documented evidence that Resident 30 was educated regarding the risk and benefits of the COVID-19 vaccine. This failure had the potential to result in Resident 30 being unaware of the risks and benefits to receiving the vaccination and being unable to make an educated decision on whether to receive the vaccine. Findings: A review of Resident 30's admission Record indicated Resident 30 was admitted to the facility with diagnoses which included chronic obstructive pulmonary disease (COPD - a common lung disease causing restricted airflow and breathing problems) and heart disease. A record review of Resident 30's medical record titled, Update Immunization, dated 8/10/22, indicated Resident 30 received the COVID-19 Vaccine. There was no documented evidence Resident 30 was educated on the risk and benefits of the COVID-19 vaccine. During a concurrent interview and record review…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview the facility failed to ensure equipment utilized by residents received preventative maintenance when 2 of 13 facility owned oxygen concentrators (machine used to deliver oxygen to a person) annual preventative maintenance (PM) checks were not performed, and the concentrators were in use by Resident 5 and Resident 15. This failure had the potential to affect the health and well being of Resident 5 and Resident 15. Findings: 1a. A review of Resident 5's admission RECORD, indicated she was admitted to the facility in March of 2008 with diagnoses which included chronic obstructive pulmonary disease (COPD, long term lung disease that causes shortness of breath and cough). A review of Resident 5's Order Summary Report, indicated, .02 [oxygen] @ 2LPM VIA NC [at 2 liters per minute by nasal cannula], PRN [as needed] . During an observation on [DATE], at 10:11 AM, an oxygen concentrator was observed next to Resident 5's bed with a PM sticker dated 7/2022. 1b. A review of Resident 15'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 a safe environment free of accidents and hazards when: 1 of 16 residents at risk for falls did not have all the required fall prevention interventions in place (Resident 2) This failure had the potential to contribute to an injury related to a fall or elopement while residing at the facility. Findings: Review of Resident 2 ' s clinical record, admission RECORD, indicated Resident 2 ' s diagnoses included benign neoplasm of meninges (non-cancerous brain tumors), muscle weakness, dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), and difficulty walking. A review of Resident 2 ' s clinical record, MORSE FALL SCALE, (an assessment tool used to determine a resident ' s risk for falls) dated 12/1/23, 12/5/23, and 12/11/23, indicated Resident 2 had a fall risk score of 75 (score of 45 and higher = high risk for falls). A review of Resident 2 ' s clinical record, [HOSPITAL NAME] ED [EMERGENCY DEPARTMENT] HP, [History and Physical] dated 12/4/23, at…

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 person centered care planned interventions including the use of a seat belt alarm and sensory blanket to prevent accidents for one of three sampled residents (Resident 1). These failures potentially resulted in Resident 1 having three falls including one that required transfer to an acute care hospital for staples (used to close deep cuts in the skin) to her head. Findings: A record review of Resident 1's clinical record indicated a history of Parkinson ' s Disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination) and confusion. During a concurrent observation and interview on 10/3/23, at 12:35 p.m., with Resident 1 and Family Member 1, in the facility dining room, Resident 1 was seated in her wheelchair. There was not a seat belt alarm or sensory lap blanket (a blanket that can have weight, and sensory items to touch) observed to be in place for Resident 1 in her wheelchair. Family Member 1 stated 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 consistently implement care planned interventions including the use of a wheelchair seatbelt alarm and a sensory lap blanket (a blanket that can have weight, and sensory items to touch) to prevent falls and injury for one of three sampled residents (Resident 1). These failures potentially allowed for Resident 1 to have three falls including one that required transfer to an acute care hospital for staples (used to close deep cuts in the skin) to her head. Findings: A review of Resident 1's clinical record indicated a history of Parkinson ' s Disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination) and confusion. During a concurrent observation and interview on 10/3/23, at 12:35 p.m., with Resident 1 and Family Member 1, in the facility dining room, Resident 1 was seated in her wheelchair. There was not a seatbelt alarm or sensory lap blanket observed to be in place for Resident 1 in her wheelchair. Family Member 1…

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

Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1), who was assessed at a high risk for falls due to a history of falls, received adequate supervision and assistance to prevent a further fall and a left thigh bone fracture. This failure resulted in Resident 1 to experience pain related to the fall and having a surgical procedure to fix the bone fracture which led to decreased level of functioning. Findings: A review of the admission record, indicated the facility admitted Resident 1 in the spring of 2023 with multiple diagnoses that included muscle weakness, difficulty in walking, and repeated falls. Resident 1's history and physical indicated that prior to the admission, the resident fell and sustained a left arm fracture. A review of Resident 1's Minimal Data Set (MDS, a standardized assessment and care screening tool), dated 7/7/23, indicated the resident had no cognitive impairment. The MDS assessment indicated that Resident 1 required assistance with transferring, ambulation, toileting, and 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 interviews and record reviews the facility failed to provide two of two sampled residents (Resident 1 and 2) with quality care in accordance with professional standards when: 1. Staff did not monitor Resident 1's ostomy (An ostomy is a medical device that provides a means for the collection of waste from the body) output. 2. Staff did not monitor Resident 1's clinical laboratory values (blood tests) while on intravenous fluids (liquids given to replace water, sugar and salt given through the vein.) 3. Staff did not perform dressing changes per policy on Resident 1 and Resident 2's Peripherally Inserted Central Catheters (PICC, a long thin tube which is inserted in the vein in the arm then passes through the larger veins and ends near the heart). 4. Staff did not monitor Resident 2's foley catheter (a tube inserted into the bladder to drain urine) for signs and symptoms of infection or injury. These failures led to hospitalizations for critical laboratory values and signs and symptoms of infection including sepsis (the body's extreme response to an infection. It is a…

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