City View Post Acute

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to coordinate Pre-admission Screening and Record Review (PASRR) for one of seven sampled residents (Resident 97) with a diagnosis of psychotic disorder (severe mental illness that cause individuals to lose touch with reality, characterized by hallucinations [false perceptions] and delusions [false beliefs]).This deficient practice could potentially result in Resident 97 not receiving specialized care and services appropriate for her condition.According to medicaid.gov, Preadmission Screening and Resident Review (PASRR) is a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care. PASRR requires that 1) all applicants to a Medicaid-certified nursing facility be evaluated for serious mental illness (SMI) and/or intellectual disability (ID); 2) be offered the most appropriate setting for their needs (in the community, a nursing facility, or acute care settings); and 3) receive 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 a written summary of the baseline care plan (BCP, an interim written plan implemented within 48 hours of admission that details the resident's immediate health and safety needs) to two of seven sampled residents (Resident 198 and Resident 197) or their representative.This failure could leave residents or their representatives not fully informed of the treatment plan and unable to participate in their care, putting them at risk for errors or unmet needs. 1. Resident 198 was admitted on [DATE] with diagnoses that included urinary tract infection (an infection in the bladder/urinary tract) and Alzheimer's disease (a disease characterized by a progressive decline in mental abilities).During a concurrent observation and interview on 4/27/26 at 10:53 AM with Resident 198's Representative (RR) 1 and RR 2, RR 1 was talking to RR 2 on speakerphone. When asked if they received a written summary of Resident 198's BCP, RR 2 stated, No, nothing was given 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.

Based on observation, interview, and record review, the facility failed to maintain a safe resident environment for a census of 173 residents when Resident 147's Over The Counter (OTC) medications were left unsecured in an area accessible to other residents. This failure exposed residents to the risk of accidental ingestion and avoidable harm.During an observation of Resident 147's room on 4/28/26 at 9:46 AM, three bottles of OTC medications were observed on the resident's bedside table, which included folic acid (a synthetic form of vitamin B9), zinc (a mineral that supports immune health), and men's multivitamin (a combination of different vitamins and minerals in one pill). These medications were unsecured and accessible to other residents.During an interview on 4/28/26 at 12:05 PM with the Director of Nursing (DON), the DON stated that the resident had a habit of buying many OTC medications and supplements, and the facility treated them as the resident's personal belongings.During an observation of Resident 147's room on 4/28/26 at 12:10 PM, the DON entered the resident's room…

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

Based on observation, interview, and record review, the facility failed to ensure pharmacy services were maintained for a census of 173 residents when non-controlled medications (medications with less risk of addiction and harm) were disposed of in a sharps container (a hard, puncture resistant box used to safely throw away items that can cut or poke someone, such as needles and syringes), which resulted in the improper disposal of medications.During an inspection of medication cart 3A on 4/27/26 at 9:43 AM, Licensed Vocational Nurse (LVN) 6 was observed finding and placing two unidentified loose pills in the sharps container which was on the side of the medication cart.During an interview on 4/27/26 at 9:43 AM with the Nursing Unit Manager (NUM), the NUM stated that staff should have checked and properly dispose of unidentified loose tablets to reduce the risk of medication errors and drug diversion.During an interview on 4/29/26 at 10:58 AM with the Director of Nursing (DON), the DON stated that unidentified loose pills should not have been disposed of in the sharps container. The…

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

Based on interview and record review, the facility failed to ensure the Consultant Pharmacist (CP) identified, recommended, and followed up on necessary medication regimen changes for one of 5 sampled residents (Resident 9) when the facility did not address the need for a Gradual Dose Reduction (GDR) of olanzapine (a type of psychotropic medication indicated for psychosis) and trazodone (a psychotropic medication used to promote sleep) for Resident 9This failure resulted in Resident 9 receiving psychotropic medications (a group of drugs prescribed to affect the mind, emotions, or behavior) for over 14 months.Clinical record review indicated Resident 9 was initially admitted to the facility from the acute care hospital in February 2025.A review of Resident 9's acute hospital transfer documents, dated 2/10/25, indicated a Physician's Order for olanzapine 15 mg (milligram-unit of measure) at bedtime for mood disorder manifested by constant yelling and/or screaming and a Physician's Order for trazodone 50 mg at bedtime for insomnia (having trouble sleeping) manifested by an 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.

Based on observation, interview, and record review, the facility failed to ensure medications were stored according to the manufacturers' specifications for a census of 173, when:1. A bottle of brimonidine eye drops, an eye medication used to treat high pressure inside the eye, was stored in the medication refrigerator, which had the potential to result in medication degradation and reduce efficacy.2. An expired vial of insulin glargine, a medication used to lower blood sugar levels, was available for use in the medication cart which put Resident 12 at risk of receiving expired and ineffective medication. 1. During an inspection of the medication room on the third floor on 4/27/26 at 9:49 AM, a 10 ml (milliliter, unit of measure) vial of brimonidine 0.1% (percentage, unit of measure) eye drops was observed stored in the medication refrigerator at 38 degrees F (Fahrenheit, unit of measure).During an interview on 4/27/26 at 9:50 AM with the Nursing Unit Manager (NUM), the NUM stated that the eye drops should have been stored at room temperature. Furthermore, the NUM stated 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 facility document review, the facility failed to provide: An entree of similar nutritive value to one resident (Resident 111) who chose not to eat the entree listed on the planned menu. The failure to provide substitute food of similar nutritive value to the food on the planned menu had the potential for a resident to receive inadequate nutrients.Meals that reflected Resident 150's preferences and failed to ensure adequate nutritional intake to reduce the resident's dependence on enteral feedings for one of one sampled residents (Resident 150). This failure resulted in ongoing inadequate meal consumption and repeated meal refusals, placing Resident 150 at risk for unintentional weight loss, nutritional decline, and continued reliance on tube feeding.1. Review of the Diet Spreadsheet Menu: [facility name] Fall/Winter Menu dated 2025/2026 Week 3 and used for lunch 4/27/26, showed a Regular textured, Consistent Carbohydrate diet (a diet typically prescribed to regulate blood sugar), received 1 square (3 inches by 2.5 inches) of Tater Tot Casserole.…

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 133 entered into a legally binding arbitration agreement only after fully understanding its terms. (Resident affected). The facility did not provide the required explanation of the agreement in a form and manner the resident could understand. This failure has the potential to result in residents signing legally binding documents without informed understanding of their rights, including the right to rescind or the fact that signing is not required to receive care.During a concurrent observation and interview on 05/01/2026 at 1:41 PM, in Resident 133's room, Resident 133 and Resident 133's friend (RF 1) were presented with a paper copy of the Arbitration Agreement that Resident 133 had signed on 04/09/2026. At that time, Resident 133 stated to RF 1 that they did not remember signing the Arbitration Agreement and did not know what the document was. RF 1 stated that Resident 133 does not have a good memory.During a concurrent interview 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement infection prevention and control measures for one of 34 sampled residents (Resident 195) when Resident 195's urinary catheter tubing and urine drainage bag were touching the floor.This deficient practice placed Resident 195 at risk for transmission of infectious organisms from the floor to the urinary tract.Resident 195 was admitted on [DATE] with diagnoses that included dementia (a progressive decline in mental ability, including memory, reasoning, and behavior, severe enough to interfere with daily life) and urinary retention (the inability to fully or partially empty the bladder, causing urine to remain in the bladder even when one feels the need to urinate).During the initial tour observation on 4/27/2026 at 10:05 AM, Resident 195 was in bed, with a urinary catheter attached to an uncovered urine drainage bag, positioned under the bed and touching the floor.During a subsequent observation on 04/29/2026 at 1:02 PM, 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 facility document review, the facility failed to prevent pests from entering the kitchen when there was a gap between one open window and the window screen. This failure had the potential for pests to enter the kitchen and contaminate food and food equipment and utensils.Findings: Review of the Policy and Procedure titled Maintenance Policies & Procedures Interior General Maintenance dated 12/31/2015, showed to replace or repair defective or bend screens or screens that do not fit securely into the frame. Review of the Policy and Procedure titled Pest Control dated 2001, showed windows are screened at all times. An observation in the kitchen on 4/27/26 at 10:05 a.m., showed a window was open and the window screen was not completely attached to the window frame creating a gap to the outside. During an observation and interview in the kitchen on 4/28/26 at 10:35 a.m., the Dietary Manager (DM) confirmed there was a gap between the open window and the window screen. DM stated he did not put in a work order to fix the screen because he did not notice…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain an effective pest control program when:Cockroaches were found in rooms [ROOM NUMBER].Staff complained of cockroaches in residents' rooms on the second floor.A resident reported seeing cockroaches in his room during a resident council meeting.This failure created an unsanitary environment for residents, staff, and visitors, and can contribute to the spread of infections and foodborne illnesses.During an observation on 12/4/25, at 2:29 PM in room [ROOM NUMBER], a live cockroach was observed crawling on the floor and on top of the trash bin adjacent to Resident B's bed. Additionally, three dead cockroaches were found on the floor next to the nightstand. Furthermore, food particles and brownish discolorations were observed on the floor.During a concurrent interview on 12/4/25 at 2:31 PM, CNA 2 acknowledged the presence of live and dead cockroaches and stated, I have seen it before.During an interview on 12/4/25 at 2:32 PM, Licensed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to safeguard the personal property for one of four sampled residents (Resident A) whose black pouch containing cash was reported missing on 11/10/25. Furthermore, the facility failed to update and document in the inventory of personal effects after a Certified Nursing Assistant (CNA) verified that Resident A had $1,000 in the missing pouch.These failures resulted in the loss of Resident A's cash, causing emotional distress, including feelings of distrust towards staff, tearfulness, and sadness.Review of Resident A's admission record indicated, was readmitted to the facility on [DATE] with diagnoses including acute respiratory failure (a condition where there's not enough oxygen or too much carbon dioxide in your body), recurrent major depressive disorder (also known as clinical depression, causes a persistently low or depressed mood and a loss of interest in activities that you used to enjoy), generalized anxiety disorder (a mental health condition 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to thoroughly investigate Resident A's report of a missing black pouch with cash on 11/10/25. Furthermore, the facility did not take action after a Certified Nursing Assistant (CNA) verified that Resident A had $1,000 in the missing pouch.These failures resulted in the loss of Resident A's cash, causing emotional distress, including feelings of distrust towards staff, tearfulness, and sadness.Review of Resident A's admission record indicated, was readmitted to the facility on [DATE] with diagnoses including acute respiratory failure (a condition where there's not enough oxygen or too much carbon dioxide in your body), recurrent major depressive disorder (also known as clinical depression, causes a persistently low or depressed mood and a loss of interest in activities that you used to enjoy), generalized anxiety disorder (a mental health condition that causes fear, a constant feeling of being overwhelmed and excessive worry about everyday things), 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure self-administration of medications was clinically appropriate when one of four sampled residents (Resident 2) was allowed to do so without the assessment and approval of the interdisciplinary team (facility staff members who coordinate the care provided to the residents). This failure had the potential to result in unsafe medication administration or omission of medications. Findings: Review of Resident 2's admission record indicated, Resident 2 was admitted on [DATE] with diagnoses including hypertension (high blood pressure) and pulmonary embolism (occurs when a blood clot gets stuck in an artery in the lung, blocking blood flow to part of the lung). Review of Resident 2's Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 3/15/25 indicated Resident 2 had moderate cognitive impairment (a noticeable decline in thinking and learning abilities that significantly impacts daily life). During a concurrent…

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 necessary care and services to one of four sampled residents (Resident 1) when Resident 1's fingernails were not kept clean. This failure had the potential for Resident 1's fingernails to harbor germs and bacteria that could contribute to spread of infection. Findings: During a concurrent observation and interview on 5/5/25 at 1:35 PM, Resident 1 was lying in bed, awake, with her hands placed on her chest. Resident 1 stated, You see my nails. They're nasty. No one comes here to clean my nails. I have been asking them to do it, no one does it. The underside of all of Resident 1's fingernails had black-colored matter. Resident 1 stated, I don't want my nails dirty. During a concurrent observation of Resident 1's fingernails and interview on 5/5/25 at 1:47 PM, Licensed Vocational Nurse (LVN) 1 stated, They're dirty. That's dirt under the nails. LVN 1 added, That could be an infection issue. We need to keep them clean to prevent infection. During an interview on 5/5/25 at 4:02 PM, The Director of Nursing…

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 needed care and treatment for two of three sampled residents (Resident 1 and Resident 2) when: 1. The facility failed to provide a therapeutic environment conducive for sleep and address difficulty sleeping for Resident 1. 2. The facility failed to implement interventions for insomnia (persistent problems falling asleep and staying asleep), paranoia (excessive mistrust and suspicion of others) that could have contributed to the consistent yelling and screaming for Resident 2. The facility failure resulted to ongoing difficulty sleeping for Resident 1, and ongoing behavioral problems with Resident 2. Findings: a. A review of the face sheet indicated Resident 1 was admitted with diagnoses including squamous cell carcinoma of the anal skin (a type of cancer) and diabetes (abnormally high blood sugar level). During an interview on 4/9/25, at 1:05 PM, Resident 1 stated, It's difficult to sleep here because there is a person yelling and screaming constantly. If I ever get to sleep, I'll be awakened because…

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, record review, and facility policy review, the facility failed to refer the resident to the appropriate state-designated authority for Level II PASARR evaluation after the resident was identified to have a newly evident mental illness diagnosis for 2 (Resident #56 and Resident #86) of 7 sample residents reviewed for preadmission screening and resident review (PASARR). Findings included: An undated facility policy titled, Admissions Criteria, did not indicate the procedure staff should follow should a resident be diagnoses with a newly evidence or possible serious mental disability, intellectual disability, or a related condition. 1. An admission Record revealed the facility admitted Resident #56 on 05/03/2016. According to the admission Record, the resident had a medical history that included diagnoses of gastro-esophageal reflux disease without esophagitis, constipation, and age-related osteoporosis. Per the admission Record, the resident received a diagnosis of psychotic disorder with delusions on 11/15/2021. A quarterly Minimum Data Set (MDS), with 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 interview, record review, and facility policy review, the facility failed to ensure a new Level I screening was completed for 1 (Resident #37) of 7 sampled residents reviewed for preadmission screening and resident review (PASARR). Findings included: An undated facility policy titled, admission Criteria, specified, 9. All new admissions and readmissions are screened for mental disorders (MD), intellectual disabilities (ID), or related disorders (RD) per the Medicaid Pre-admission Screening and Resident Review (PASARR) process. The policy specified, b. When/if the level I screen indicates that the individual may meet the criteria for a MD, ID, or RD, he or she is referred to the state PASARR representative by the system for the Level II (evaluation and determination) screening process. An admission Record revealed the facility admitted Resident #37 on 06/21/2023. According to the admission Record, the resident had a medical history to include a diagnosis of schizophrenia. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/28/2024, revealed…

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 accurately reconcile post-discharge medications for one out of three sampled residents (Resident 1) when Resident 1 was discharged home with another resident's medication (Resident 2). This failure has the potential to result in a medication error after discharge if Resident 1 were to take medications that were not prescribed to them. Findings: A review of Resident 1's MDS, dated [DATE], indicated that Resident 1 had a Brief Interview for Mental Status (BIMS, a cognitive screening tool) score of 6 (scores of 0-7 suggests severe cognitive impairment, 9 to 12 suggests moderate cognitive impairment, and 13 to 15 suggest that cognition is intact). A review of Resident 1's discharge summary note, dated 09/11/24, indicated that that Resident 1 was discharged on 09/11/24 and Post Discharge Plan of Care form filled out and signed by patient. All medications and follow up appointments reviewed by patient. A review of Resident 1's Post-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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide the necessary care and services to one of three sampled residents (Resident 1) when the physician's order for magnetic resonance imaging (MRI, a medical imaging procedure that uses a magnetic field and radio waves to take pictures of the body's internal parts) was not carried out timely. This failure caused a delay in provision of services and had the potential to negatively impact Resident 1's physical, mental, and psychosocial well-being. Findings: Resident 1 was admitted on [DATE] with diagnoses that include chronic pain syndrome (pain that lasts longer than three months). During an interview on 3/21/24 at 11:21 AM, Resident 1 stated, My legs hurt 24 hours a day. I'm in so much pain. I have had this (chronic pain) a long time, for several years . it burns, spasms from my ankles to my legs, to my hips. Resident 1 stated pain is severe most of the time. It starts from my feet, goes up to my legs, hits both knees. I have no idea what causes 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure prescribed medication was available to administer to one of three sampled residents (Resident 1). This failure created a risk for poor health outcome to Resident 1. Finding: Resident 1 was admitted on [DATE] with diagnoses that include chronic obstructive pulmonary disease (COPD, a common lung disease causing restricted airflow and breathing problems). During an interview on 5/17/24 at 11:23 AM, Resident 1 stated, I get short of breath, this is chronic . I've always had this because of my COPD. They (facility staff) know that. That's why I have inhaler. Review of Resident 1's Order Summary Report, dated 11/1/23 to 4/30/24, indicated Trelegy Ellipta (also known as (fluticasone furoate, umeclidinium, & vilanterol) Inhaler Aerosol (a substance released in very fine mist) Powder breath activated 200-62.5-25 mcg(micrograms)/actuation (delivery of a dose of medicine as a mist with the use of an inhaler [a small handheld device that delivers medication…

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

Based on observation, interview, and record review the facility failed to ensure the resident's care planning and implementation was communicated efficiently to the family when: 1.The son of Resident-A complained that the social worker (SW) did not return his calls on five different times. The complainant gave his telephone number, and texted the SW, but the SW never called back. 2. Resident -A's doctors' appointments were cancelled on 7/6/23 and 7/14/23 due to mismanagement of transportation arrangement by the facility. This failure resulted in the potential decline of Resident-A's clinical condition and psychosocial well-being. Findings: Resident A was admitted with diagnoses of cerebral infarction (also called an ischemic stroke - occurs as a disrupted blood flow to the brain due to problems with the blood vessels that supply it.), enterocolitis (an inflammation that occurs throughout the intestine) due to clostridium difficile (C-diff - is a germ that causes serious diarrhea and other problems. It can be caused by taking antibiotics), urinary tract infection (UTI- an illness 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 Resident 1's nutritional needs are met when: 1) Resident 1 was ordered CCHO Diet (Controlled Carbohydrate Diet) since admission when Resident 1 is not a diabetic 2) Resident 1 had a poor appetite and a significant weight loss of almost 10 lbs. from 9/24/23 to 11/17/23. This failure had the potential to result in decline of Resident 1's clinical health, poor appetite, and psychosocial well-being, including avoidable significant weight loss of 9.5 lbs. Findings: Resident 1 was admitted on [DATE] with diagnoses of: Burns involving 10-19% of body surface with 0% to 9% third degree burns (extend into the fat layer that lies beneath the dermis [third skin layer]), hyperkalemia (high potassium level in the blood), and dysphagia (difficulty swallowing) among others. The admission record or face sheet of Resident1 had no indication of diabetes mellitus as a diagnosis. During a review of Resident 1's clinical record, the minimum data set (MDS…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure Resident 1 who had no diagnosis of diabetes mellitus was free from unnecessary drugs and interventions when: 1. Resident 1 was admitted to the facility on [DATE]. The resident had an order for a sliding scale of insulin Lispro (a rapid acting human insulin analog that works parenterally to lower blood glucose by regulating the metabolism of carbohydrates, proteins, and fats.). Resident 1 received Lispro on 9/26/23 1 unit for blood glucose of 160, on 10/9/23 1 unit, on 10/10/3 1 unit, on 10/11/23 1 unit, . 2. Resident 1's blood glucose was checked three times a day from September 25 to October 20, 2023, with her blood glucose range from 112 to 188. This failure resulted in the mismanagement and monitoring of Resident1's drug/medication regimen that potentially caused the decline of the resident's highest practicable mental, physical, and psychosocial well-being. Findings: Resident 1 was admitted on [DATE] with diagnoses of: burns…

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.

F 607 Develop/Implement Abuse /Neglect, etc. Policies Based on Interview and record review the facility failed to maintain and or implement the policies and procedure for Abuse, Neglect and Exploitation Training when the facility could not produce documentation. Findings: Review on Clinical record of resident 5, dated 04/14/2023 at 06:30AM, by RN 1indicated there was a reported resident to resident physical abuse allegation from this resident ' s roommate to this resident approximately between 6:15am and 6:30am, Ombudsman and CDPH notified via phone at 8:15am. DON and administrator made aware. MD notified at 9:45am and resident is self-responsible. Resident was asked if she would like to go to the hospital, but she declined. Resident has no injuries, no c/o pain, and skin is intact. Resident ' s roommate was moved to a different room to suit both residents need, promote safety and prevent further incidents. During review of In-service Compliance Training Record- Patients ' rights, dated 4/07/2023, at 7:30am-8:30am, indicated that only 5 staff attended and at 2pm-3pm, indicated 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to Develop and Implement comprehensive care plan for resident 4, when there was no evidence of documentation of a completed care plan that would identify the needs for supervision and risk elopement for altered mental status resident. Findings: During a review of resident Face sheet, (Resident 4) was admitted on [DATE], discharge date : [DATE] with a diagnoses of End stage Renal Disease, Hypertensive Chronic Kidney Disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease. Unspecified Dementia, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety, unspecified hearing loss, Altered Mental Status. A review resident 4, Nurses progress notes, dated 4/10/2023 indicated, at 1500 the RN received a call from the resident ' s daughter in law asking if the resident is already back from the dialysis appointment. Informed the daughter in law that the resident is still in the dialysis per dialysis…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to provide a discharge summary for Resident 1, when Resident 1 was sent home with no documentation where to discharge, no receiving responsible party teachings, no medications, no arrangements made for follow up care. This failure has the potential for Resident 1 not being cared for in the community, not able to adjust to new living situation. Findings: Review of admission Record, dated, 1/24/24, indicated, admitted on [DATE] with diagnoses including : Fracture of the right tibia, Heart Failure( a heart condition caused by another medical condition that damages the heart),Epilepsy(a condition caused by irregular brain activity) Opioid Dependence (using habit forming drugs). Interview on 1/24/24 at 2PM, with SW (Social Worker), stated, on discharge process. not here yet that date Discharge process is, SW sets up transportation, set up discharge meeting with rehab team, nursing, SW, and Activities and arrange the discharge. Review of facility document,…

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 implement measures to relieve and prevent constipation in accordance with Physician ' s order and care plan for one Resident 1, when the patient experienced serious harm related to not having bowel movement for 4 days. Findings: Review of admission Record, dated, 1/24/24, indicated,admitted [DATE] with diagnoses including: Emphysema( fluids in the lungs), Urinary Tract Infection, Chronic Kidney Disease, Type 2 Diabetes ( high blood sugar levels). Review of MDS Section C, dated 9/10/23, indicated BIMS (Brief Interview for Mental Status) score is 13, no cognitive impairment. Review of MDS Section H, dated 9/10/23, Bowel and Bladder: 0100. Appliances A. Indwelling catheter H0400. Bowel Continence: 3- Always Incontinent H0500: Bowel Toileting Program : 0 – No toileting programcurrently being used to manage bowel incontinence. Review of progress notes, dated 12/1/23, 72 hr charting. Covid 19 Vaccine booster administered on left deltoid, no adverse reaction…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to provide annual training to their staff on preventing and training to address, forms of abuse, neglect, misappropriation of property, exploitation and dementia management of one staff when Staff 1, did not receive annual abuse training . This failure resulted in Resident 1 was financially abused by Staff 1. Findings: Review of admission Record, dated, 1/25/24, indicated, admitted on [DATE] with diagnoses including: Acute Kidney Failure(a condition which the kidneys lose the ability to remove waste and balance fluids),Type 2 Diabetes (high blood sugar), Irritable Bowel Syndrome ( a condition with recurrent abdominal pain and diarrhea associated with stress, depression or anxiety). Review of Investigation Summary, dated ,11/22/23, indicated, on 11/17/23, resident ' s friend informed the Activity Director (AD), that a staff named Staff 1 from activities department was allegedly taking money from the resident .Licensed nurse was notified and went 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.

Based on observations, interviews, and record review the facility failed: 1. To ensure one of six (6) sampled employees, (Certified Nurse Assistant CNA 1) was provided an in- service training on abuse before allowing to work. 2. To ensure the facility's Policy and Procedure (P&P) included the required components of abuse policy such as, Screening, Training, Prevention, Identification, and Protection. These deficient practices had the potential to negatively impact the care and services rendered to the residents. Findings: 1. In an interview on 11/9/23, at 5:16 PM, with the Nursing Supervisor (NS 1) and the DON 1, NS 1 stated, on 4/4/23, the Certified Nursing Assistant (CNA 1) reported to the NS 1 that Resident 2 (roommate of Resident 1) alleged the CNA 1 of spanking Resident 1 while changing the resident's adult brief. The CNA 1 reported to the NS 1 that all she did was to turn the resident on her side and change the resident's adult brief, but Resident 2 said something different, she (CNA 1) was spanking the resident like a baby, and Resident 2 was upset. Record review of the April…

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: 1. Investigate an allegation of abuse for one of four sampled residents (Resident 1) when the allegation of spanking the resident by a Certified Nurse Assistant, CNA 1) while changing the resident's adult brief. 2. Ensure one staff (CNA 1) was not allowed to return to work following the allegation of physical abuse. These deficient practices had the potential to place the resident's health and safety at risk and had the potential for further abuse to happen. Findings: 1.In an interview on 11/9/23, at 5:16 PM, with the Nursing Supervisor (NS 1) and the DON 1, NS 1 stated, on 4/4/23, the Certified Nursing Assistant (CNA 1) reported to the NS 1 that Resident 2 (roommate of Resident 1) alleged the CNA 1 of spanking the resident 1 while changing the resident's adult brief. The CNA 1 reported to the NS 1 that all she did was, to turn the resident on her side, and change the adult brief but Resident 2 said something different, the CNA 1 was spanking the resident like a baby, and Resident 2 was upset. Record review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure the Minimum Data Set (MDS, an assessment tool) was accurately coded for one of three sampled residents (Resident 1) when, the Quarterly MDS dated [DATE] incorrectly coded the presence of chronic ulceration (areas in the body where the underlying tissue damage has caused skin loss which shows no tendency to heal after three months of appropriate treatment) on the resident's legs. This deficient practice had the potential to negatively affect the care and services rendered to the resident. Findings: Record review of the Annual MDS, dated [DATE] indicated, Section M1030 Number of Venous and Arterial Ulcers, the total number of venous ulcer present was 2. In an interview on 11/9/23, at 2:39 PM, with the Director of Nursing (DON 1), DON 1 stated, the resident has ulcerations of both legs and was receiving treatment. Review of the Care Plan titled, The resident has an actual impairment to skin integrity (multiple open wounds on both posterior lower…

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 observations, interviews and record reviews the facility failed to provide the needed care and services for one of four sampled residents (Resident 1) when: 1. One staff (LVN 2) failed to perform an observation and document the signs and symptoms of the resident's respiratory problem and failed to check the resident's Vital Signs (VS, include the body temperature, pulse rate, respiratory rate, blood pressure and oxygen saturation which are indicators of the person's health status) before the resident was sent to the emergency room (ER) on 8/12/23. 2. The nursing staff failed to notify the physician when the O2 sat (oxygen saturation, amount of oxygen circulating in the blood) level de-saturating below 50% and failed to obtain a physician' order to place a non-rebreather mask (NRM, oxygen supplementation device that is used to provide continuous oxygen flow. It consists of a mask, reservoir bag, and two or three one-way valves) on the resident. 3. The staff failed to obtain a physician's order 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 observations, interviews, and record review the facility failed to ensure one of three sampled residents (Resident 1) was provided with the appropriate resident-centered treatment and care when: 1. Multiple skin discoloration on Resident 1's back observed on 6/28/23 did not have a follow-up assessment, evaluation, and appropriate interventions by the Wound Care Team (Clinicians who develops and implements wound prevention, skin management, and wound care). 2. The Weekly Skin Assessments (WSK, supposed to be documented on the Comprehensive Skin Evaluation/Assessment, CSEA) form were not done for the months of May and June 2023. For the month of July 2023, the WSKs were done only on 7/6/23 and on 7/14/23, not on a weekly basis, as per policy. 3. The Braden Scale for Predicting Pressure Sore Risk (BSPPSR, a tool to identify patients at-risk of forming pressure sores, injuries to skin and underlying tissue resulting from prolonged pressure) was not completed on a quarterly basis after 2/28/23 and after…

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

Based on interviews and record reviews the facility failed to ensure nursing staff had the competencies and skill to provide the nursing care and services for one of three sampled residents (Resident 1) when there was no assessment performed by a Registered Nurse to evaluate the resident when the resident's O2 sat (oxygen saturation, amount of oxygen circulating in the blood) level de-saturating below 50%. Resident 1 was sent out to the emergency room (ER) on 8/12/23. This deficient practice had the potential to place the resident's safety and well-being at risk of harm. Findings: Review of the Care Plan titled, At risk for Respiratory Complications due to shortness of breath on 8/10/23, the Goal was, will have effective gas exchange . and the Interventions were, assess signs and symptoms . Monitor for shortness of breath, irregular respiration . and inform physician promptly. Monitor vital signs . oxygen saturation . In an interview on 12/14/23, at 10:05 AM, with the Nursing Supervisor (LVN 4 (Licensed Vocational Nurse)/ NS 1), LVN 4/NS 1 stated, on 8/12/23 between 11:30 pm to 12…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to thoroughly investigate the allegation of abuse for two of four sampled residents (Residents 2 and 3) after the facility was made aware of the allegation. This failure to thoroughly investigate the allegation of abuse had the potential to not ensure Residents 2 and 3 and other residents from possible abuse. Findings: Review of Resident 2 ' s clinical record indicated, Resident 2 was admitted to the facility on [DATE] with diagnoses that included end stage renal disease (ESRD - occurs when the kidneys are no longer able to work at a level needed for day-to-day life) and diabetes mellitus (disease that result in too much sugar in the blood). Review of Resident 2 ' s Minimum Data set (MDS - resident assessment tool), dated 3/7/23, indicated, Resident 2 was cognitively intact. Review of Resident 3 ' s clinical record indicated, Resident 3 was admitted to the facility with diagnoses that included ESRD and congestive heart failure (chronic condition in which…

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

Based on observation, interview, and record review the facility failed to ensure doses of the medication was received and administered in a timely manner for one out of three sampled residents (Resident 74), when the routine doses of Amlodipine (medication use to treat high blood pressure) three (3) tablets were not delivered by the contracting Pharmacy to the facility and were not administered during Med Pass (term used to describe the process through which medication is administered to residents) as ordered on 10/19/21. This failure had the potential to negatively affect the health and well being of the resident. Findings: During Med Pass Observation on 10/19/21, at 7:47 AM, the Licensed Nurse (LN 1) stated, the Amlodipine tablets were missing in the Medication Cart. LN 1 went to the Medication Storage Room, searched the medication supply for Amlodipine bubble pack but did not find it. LN 1 stated it was last given yesterday (10/18/21) at 9:00 AM and she would call the Pharmacy to have the medication delivered. During a review of the October, 2021 Recap Physician's Order (PO), 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.