Casa Bonita Convalescent Hospital

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure two of two sampled residents (Resident 68 and Resident 31), were treated with dignity while eating. Resident 68, who had limited mobility, did not have a clothing protector, while having breakfast in bed. For Resident 31, Treatment Nurse 1 remained standing and did not position themselves at the resident's eye level while assisting with the lunch meal. This deficient practice resulted in Resident 68 having food and drink spillage on Resident 68 causing potential feelings of humiliation and embarrassment. For Resident 31, there was a potential feeling of disconnection and dominance or authority from the staff during the feeding process. Findings: a. During a review of Resident 68's admission Record (AR), the AR indicated Resident 68 was admitted to the facility on [DATE] with multiple diagnoses including hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (weakness or the inability to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one sampled resident (Resident 2), was provided care in accordance with professional standards of practice by failing to conduct an Interdisciplinary Team (IDT - a group of healthcare professionals from various disciplines who collaborate, assess, coordinate, and manage each resident's comprehensive health care, including his or her medical, psychological, social, and functional needs) in accordance with the facility's policy and procedure (P&P) when Resident 2 had continuous episodes of hyperglycemia (high blood sugar). This deficient practice had the potential to result in Resident 2 developing serious health complications. Findings: During a review of Resident 2's admission Record (AR), the AR indicated Resident 2 was originally admitted to the facility on [DATE] and readmitted on [DATE] with multiple diagnoses including encounter for attention to gastrostomy (a surgical opening fitted with a device to allow feedings to be administered…

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 four sampled residents (Resident 87) was free from a significant medication error. Facility staff opened a specially formulated (how the drug is prepared and put together to make it into a usable medicine that can be taken) antibiotic capsule which disrupted the time-release (when the medicine is designed to release small amounts of the drug into your body over a long period, rather than all at once) mechanism of the medication. This deficient practice resulted in Resident 87 receiving the medication in a manner that altered its intended pharmacokinetics (what your body does to a drug after you take it), potentially impacting its therapeutic effectiveness and increasing the risk of adverse effects. Findings: During a review of Resident 87's admission Record (AR), the AR indicated the facility admitted Resident 87 on 1/15/2025, with diagnoses including rheumatoid arthritis (a chronic progressive disease-causing inflammation in the joints and resulting in painful deformity and immobility),…

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 one of five sampled residents (Resident 59) by failing to wear appropriate personal protective equipment (PPE- clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments) when handling soiled linens under Enhanced Barrier Precautions (EBP-extra measures, like wearing gowns and gloves, used during high-contact care activities with residents who are at a higher risk of having or spreading germs that are hard to treat, like multidrug-resistant organisms (MDROs). This deficient practice had the potential to transmit infectious microorganisms and increase the risk of infection for the residents. Findings: During a review of Resident 59's admission Record (AR), the AR indicated the facility admitted Resident 59 on 12/25/2021, with diagnoses including peripheral vascular disease (PVD - a slow progressive narrowing of the blood flow to the arms and legs), chronic obstructive pulmonary disease (COPD - 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 maintain and implement its Infection Control Program to prevent the transmission of disease and infection for one of two sampled residents (Resident 1), by placing another resident's (unidentified) dentures in Resident 1's mouth. This failure had the potential to result in the spread of infection to Resident 1. Findings: During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident 1 on 9/5/2024 with diagnoses that included urinary tract infection (UTI, an infection in any part of the urinary system, including the kidneys, bladder, or urethra), dementia (a group of thinking and social symptoms that interferes with daily functioning), and type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar). During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 10/28/2024, the MDS indicated Resident 1 was severely impaired in cognitive skills (ability to make daily decisions). The MDS indicated Resident 1 required…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to ensure five of nine sampled residents (Residents 41,30, 25, and 53) and/or their legal representatives (RP) were informed and/or provided written information about Advance Directives (AD, legal document that provides instructions regarding medical care according to the resident's wishes and only goes into effect if the resident can no longer communicate their wishes). This failure had the potential to result in lack of knowledge regarding care and treatment decision making for Residents 41, 30, 25, and 53. Findings: A. During a review of Resident 41's admission Record (AR), the AR indicated the facility admitted Resident 41 on [DATE] with multiple diagnoses including dementia (impaired ability to remember, think, or make decisions that interferes with daily activities) and type 2 diabetes mellitus (disorder causing elevated sugar level in the blood). The AR indicated Resident 41 had Responsible Party 1 (RP 1) as the emergency contact. During a 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 interview and record review, the facility failed to ensure comprehensive assessments of the disease diagnoses, health conditions, and/or medications, were complete and accurate, for two of two sampled residents (Residents 27 & 20). This failure had the potential to result in a decline in the residents' physical and psychosocial well-being due to inaccurate or inconsistent plan of care. Findings: A. During a review of Resident 27's admission Record (AR), the AR indicated the facility admitted Resident 27 on 5/7/2021 with multiple diagnoses including dementia (impaired ability to remember, think, or make decisions that interferes with daily activities), Parkinsonism (brain conditions that cause slowed movements, stiffness, and tremors), and major depressive disorder (depression, mental disorder with persistently depressed mood or loss of interest in activities that interfere with daily life]). During a review of Resident 27's History and Physical (H&P), dated 7/6/2023, the H&P indicated Resident 27 did…

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 appropriate treatment and services were provided for three of three sampled Residents (Resident 36, 25 and 252) by failing to ensure: A.Resident 36's head of bed (HOB) was elevated to at least 30 - 45 degrees while receiving g-tube (GT, gastrostomy tube; a type of tube that is placed directly into the stomach through an abdominal wall incision for administration of food, fluids, and medications) feedings as indicated in the facility's policy and procedure (P&P), titled, Enteral Feeding- Safety Precautions. B - C.Residents 25 and 252, who were receiving enteral feeding (nutrition taken through the mouth or through a tube that goes directly to the stomach or small intestine) received appropriate care and services by failing to respond timely to the GT pump that was continuously beeping (alarming). These failures had the potential to result in GT complications and harm to Residents 36, 25 and 252, additionally, there was a potential…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to ensure three of five sampled residents (Residents 11, 20, & 96) did not receive unnecessary psychotropic medications (medications used to treat mental health disorders that alter neurotransmitters [transmit messages from neurons to muscles] in the brain, affects brain activities associated with mental processes and behavior) by failing to: A. Monitor the side effects upon administration of Resident 11's duloxetine (psychotropic drug used to treat major depressive disorder [depression, mental disorder with persistently depressed mood or loss of interest in activities that interfere with daily life]. B. Provide a documented rationale for the continuation of Resident 20's as needed (PRN) Ativan (generic name lorazepam, psychotropic medication to treat anxiety [excessive and persistent feelings of worry, fear, dread, and uneasiness that interfere with daily life]) physician orders. C. Ensure Resident 96's order for PRN Lorazepam (psychotropic medication…

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

Based on observation, interview and record review, the facility failed ensure three of four sampled glasses of milk/mocha mix were served at 40 degrees Fahrenheit (F, a unit used to measure temperature) or lower as indicated in the facility's policy. This deficient practice had the potential to compromise the residents' taste by serving unfresh or spoiled milk/mocha mix to the residents. Findings: During an observation with the Dietary Supervisor (DS) and Kitchen Aid 1 (KA 1), in the facility kitchen, on 5/29/2024 at 12:27 PM, several 8 ounces of glasses of milk were on the trays ready to be served with the residents' lunch. Three of the four glasses of milk were randomly selected and observed to have a temperature higher than 41F. The first glass measured at 42 F, the third glass measured at 44 F and the fourth glass measured at 51 F. During an interview with KA 1, on 5/29/2024 at 12:29 PM, KA 1 stated the milk temperature should be below 41 F because above 41F is the danger zone (the temperature range between 40F and 140F in which bacteria can grow rapidly) and the residents 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 resident-centered care plans (CP) related to risk of side effects of medication use for Depakote (medication used to control seizures, a sudden uncontrolled burst of electrical activity in the brain) and a CP related to Resident 2's allergies were developed for one of one sampled resident (Resident 2) in accordance with the facility's policy and procedure (P&P). This failure had the potential for Resident 2 to not receive the necessary care and services to achieve their optimal level of functioning. Findings: During a review of Resident 2's admission Record (AR), the AR indicated Resident 2 was admitted to the facility on [DATE] with diagnoses including Type 2 Diabetes Mellitus (disease that occurs when a person's blood sugar is too high), generalized anxiety disorder (a condition in which a person has excessive worry and feelings of fear, dread and uneasiness) and bipolar disorder (serious mental illness that causes unusual shifts in mood). The…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide necessary care and services for one of one sampled resident (Resident 96) when Certified Nursing Assistant (CNA) 2 did not utilize a communication board when attempting to communicate with Resident 96 as indicated in the facility's Policy and Procedure (P&P) titled, Accommodation of Needs Related to Communication. This failure had the potential to result in unmet needs to Resident 96. Findings: During a review of Resident 96's admission Record (AR), the AR indicated Resident 96 was admitted to the facility on [DATE] with severe dementia (a group of conditions, decline in mental ability, that interfere with daily activities) with agitation, hypertension (high blood pressure), and dysphagia (difficulty swallowing foods or liquids). During a review of Resident 96's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 4/22/2024, the MDS indicated Resident 96 was severely impaired with cognitive skills (ability to make…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide care and services, for one of three sampled residents (Resident 30), to reduce the risk of developing pressure ulcer-injuries [PU/PI, localized injury to the skin and or underlying tissue usually over a bony prominence as result of pressure or pressure in combination with shear (mechanical force that cause the skin to break off) and/or friction (movement of one surface of the skin against the other]) by failing to: follow the facility's Policy and Procedures (P&P), titled, Prevention of Pressure Injuries, Pressure Sore Management, and the, Certified Nursing Assistant [CNA] Job Description, for Resident 30, who was on a low air loss (LAL, a mattress designed to distribute body weight and prevent and treat pressure wounds) mattress and who was at high risk for developing PIs. This deficient practice had the potential to result in a physical decline and the development of PIs to Resident 30. Findings: During a review of Resident 30'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 interviews and record review, the facility failed to ensure one of two sampled residents (Resident 41), who had limited range of motion (ROM, full movement potential of a joint), received the necessary rehabilitation services to maintain or prevent further decline in ROM by failing to follow up on the Occupational Therapist 2's (OT 2's, healthcare professional who involves the use of daily activities [occupations] to treat the physical, mental, and emotional ailments that impact a resident's ability perform daily tasks) recommendation to obtain an OT evaluation/treatment order on 5/30/2022. This failure had the potential to cause further decline in ROM with worsening contractures (deformity and joint stiffness) to both upper extremities (arms), which could lead to increased pain to Resident 41. Findings: During a review of Resident 41's admission Record (AR 1), AR 1 indicated the facility admitted Resident 41 on 9/29/2020 with multiple diagnoses including dementia (impaired ability to remember, think, or make decisions that interferes with daily activities), osteoarthritis…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based an observation, interview, and record review, the facility failed to ensure one of one sampled resident (Resident 61) received proper respiratory (relating to breathing) care such as oxygen (02 [a colorless, odorless, tasteless gas essential for living]) therapy to meet Resident 61's needs and in accordance with the physician's order. This failure resulted in Resident 61 receiving 02 therapy at a lower level and had the potential to result in compromised respiratory status (the movement of air in and out of the lungs and exchange of carbon dioxide [a colorless, odorless gas] and 02 at the alveolar level [alveoli, the functional units of the lung with the overall task to warrant gas exchange, i.e., 02 supply and carbon dioxide removal from the body]) to Resident 61. Findings: During a review of Resident 61's admission Record (AR), the AR indicated Resident 61 was admitted to the facility on [DATE] with multiple diagnoses including respiratory failure, unspecified with hypoxia (absence of enough oxygen in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of one sampled resident (Resident 49) was administered an eye drop medication properly in accordance with the facility's policy and procedure (P&P). This failure had the potential for Resident 49 to not receive the full benefits of the eye drop medication. Findings: During a review of Resident 49's admission Record (AR), the AR indicated, Resident 49 was originally admitted to the facility on [DATE] and readmitted on [DATE] with multiple diagnoses including ventricular fibrillation (a life-threatening heart rhythm that results in a rapid, inadequate heartbeat), tracheostomy (a surgically created hole [stoma] in your windpipe [trachea] that provides an alternative airway for breathing) status, and gastrostomy (a surgical procedure used to insert a tube, often referred to as G-Tube [GT] through the belly that brings nutrition and/or medications directly to the stomach). During a review of Resident 49's Care Plan (CP) titled,…

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

Based on interviews and record review, the facility failed to ensure irregularities in the monthly Medication Regimen Review (MRR, thorough evaluation a resident's medication regimen) was identified for one of one sampled resident (Resident 11) who was on psychotropic medications (used to treat mental health disorders, alter neurotransmitters [transmit messages from neurons to muscles] in the brain). The facility's Consultant Pharmacist (FCP) failed to identify and report inadequate monitoring of duloxetine (psychotropic medication used to treat depression [a mental disorder with persistently depressed mood or loss of interest in activities that interferes with daily life] during the MRR done on 5/14/2024 to 5/15/2024. This failure had the potential to cause a decline Resident 11's physical and psychosocial well-being related to the administration of unnecessary psychotropic medications. Findings: During a review of Resident 11' s admission Record (AR), the AR indicated the facility admitted Resident 11 on 4/27/2024 with multiple diagnoses including Alzheimer's disease (progressive…

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 a snack to one of one sampled resident (Resident 48) in accordance with the facility's Policy and Procedure (P&P) titled, Frequency of Meals. This deficient practice had the potential for Resident 48 to be hungry and to negatively affect his feeling of well-being. Findings: During a review of Resident 48's admission Record (AR), the AR indicated Resident 48 was admitted to the facility on [DATE] with spinal stenosis (the spaces in the spine narrow and create pressure on the spinal cord and nerve roots), post laminectomy syndrome (a condition in which the patient continues to feel pain after undergoing a laminectomy [back surgery] or another form of back surgery), and type 2 diabetes mellitus (a chronic [long standing] condition that affects the way the body processes blood sugar). During a review of Resident 48's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 5/6/2024, the MDS indicated Resident 48 had no…

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

Based on observation, interview, and record review, the facility failed to ensure safe and sanitary conditions were maintained in the kitchen as indicated in the facility's policy when one of one sampled Registered Dietician (RD 1) did not wear a beard cover, while working in the kitchen food preparation area. This deficient practices had the potential for the RD's beard/facial hair to fall into the residents food and contaminate the residents' food. Findings: During an observation in the facility kitchen, on 5/29/2024 from 11:49 AM to 12:44 PM, the Registered Dietician (RD), who had visible beard, was observed walking around the kitchen while the residents' lunch was being prepared. The RD walked from the cold drinks preparation area to the food assembly tray line that served food to the residents. The RD did not wear a beard cover. The RD wore a surgical mask. The RD's beard was uncovered from the mid of the RD's left and right cheeks to the RD's ear. The RD's goatee beard (a small, pointed beard) was protruding under the RD's chin, outside of the RD's surgical mask. During an…

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

Based on observation, interview, and record review, the facility failed to follow infection prevention and control practices and implement interventions to prevent and control the spread of infections in the facility for one of five sampled residents (Resident 41) in accordance with the facility's policy and procedure (P&P) on Enhanced Standard Precautions (ESP, approach for preventing the transmission on Multidrug-Resistant Organisms [MDROs, germs resistant to many antibiotics] in skilled nursing facilities [SNFs]). This failure had the potential to result in the increased spread of infections throughout the facility. Findings: During a review of Resident 41's admission Record (AR 1), AR 1 indicated the facility admitted Resident 41 on 9/29/2020 with multiple diagnoses including dementia (impaired ability to remember, think, or make decisions that interferes with daily activities), type 2 diabetes mellitus (disorder causing elevated sugar level in the blood), and presence of gastrostomy (surgical opening into the stomach for the introduction of food). During a review of Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to readmit one of one sampled resident (Resident 1) from the General Acute Care Hospital (GACH) after the resident was cleared by the GACH to return to the facility on 5/13/2024, according to the facility's Policy and Procedure (P&P). This deficient practice had the potential to result in the denial of Resident 1's rights to return to the facility. Findings: During a review of Resident 1's admission Record (AR), the AR indicated Resident 1 was admitted to the facility on [DATE] and readmitted on [DATE] with multiple diagnoses that included hemiplegia (muscle weakness or partial paralysis on one side of the body) and hemiparesis (muscle weakness or partial paralysis on one side of the body) following unspecified cerebrovascular (relating to the brain and its blood vessels) disease affecting left dominant side, respiratory failure (when the lungs can't get enough oxygen into the blood), and dysphagia (difficulty swallowing foods or liquids). During a 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, interview, and record review, the facility failed to follow the repositioning (turning) schedule for one of two sampled residents (Resident 1). This failure had the potential for Resident 1 to be at risk for worsening skin condition and/or pressure injury (damage to an area of the skin caused by constant pressure on the area for a long time). Findings: During a review of Resident 1's admission Record (AR), the AR indicated, the facility admitted Resident 1 to the facility on [DATE] with diagnoses of acute respiratory failure (a condition in which the lungs were not able to release enough oxygen into the blood), dependence on ventilator (a machine to support or replace the breathing of a person who was ill or injured), type 2 diabetes mellitus (characterized by high levels of blood sugar in the blood) with foot ulcer (an open sore or wound), and pressure induced deep tissue damage (area of intact skin that looks purple or dark red due to damage to tissues under the skin) of right and left…

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.