Live Oak Rehab Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure standard infection prevention control practices (a set of practices that prevent or stop the spread of infections and or diseases in the healthcare setting) were followed in accordance with the facility's policy and procedure (P&P) when facility failed to ensure:1. Resident 3's tube feeding (the process of delivering liquid nutrition directly into the stomach or small intestine via a soft, flexible tube) machine was free of beige colored stains.2. Laundry staff followed infection control practices as evidenced by two used paper cups and paper towels left in the clean area of the laundry room, and by the presence of light brown splatter stains on the shelves where clean linens were stored.3. Facility staff observed infection control measures for Resident 89 who was on Enhanced Barrier Precautions (EBP- the use of gown and glove for nursing home residents with wounds and indwelling devices during specific-high contact resident care…

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 two (2) of 2 sampled residents (Residents 47 and 48) reviewed for environment were provided with a homelike environment by failing to maintain a scratch- free, non-discolored wall surface in the residents' room, in accordance with the facility's policy. This deficient practice had the potential for an unsafe and unclean environment and had the potential to negatively affect the residents' quality of life.Findings: 1. During a review of Resident 47's admission Record, the Admissions Record indicated Resident 47 was admitted to the facility on [DATE] with diagnoses that included unspecified dementia with anxiety (the loss of cognitive functioning, thinking, remembering, and reasoning to such an extent that it interferes with a person's daily life and activities, specific cause or type has not been determined, with symptoms like restlessness, fear, or panic), muscle weakness (a reduced ability of one or more muscles to generate force,…

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 confidentiality of the information of one (1) of five sampled residents (Resident 38) observed during medication administration in accordance with the facility's policy and procedure when Licensed Vocational Nurse 1 (LVN 1), left the laptop screen switched on with Resident 38's electronic medication administration record (eMAR, is the digital version of the traditional paper medication administration records used in healthcare facilities) displayed on the screen. This deficient practice had the potential to violate the resident's right to confidentiality (safeguarding the content of information including video, audio, or other computer stored information from unauthorized disclosure without the consent of the resident and/or the resident's representative) and privacy and misuse of Resident 38's Protected Health Information (PHI, any information that relates to an individual's health status, medical history, or treatment).Findings:During 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 facility failed to ensure one (1) of two (2) sampled residents (Resident 47) reviewed for environment was provided a homelike environment by failing to ensure Resident 47's call light (a communication device that allows residents to alert staff for assistance) was within arm's reach, and the resident's television (TV) was plugged in, and the TV's remote control was functioning. These deficient practices had the potential to negatively affect the residents' quality of life.Findings: During a review of Resident 47's admission Record indicated Resident 47 was admitted to the facility on [DATE] with diagnoses that included unspecified dementia with anxiety (the loss of cognitive functioning, thinking, remembering, and reasoning to such an extent that it interferes with a person's daily life and activities, specific cause or type has not been determined, with symptoms like restlessness, fear, or panic) muscle weakness (a reduced ability of one or more muscles 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 observation and interview, the facility failed to provide oral care for one (1) of three (3) sampled residents (Residents 103) reviewed for activities of daily living (ADL) as indicated on the facility policy. This deficient practice had the potential to cause dry mouth, infection mouth soreness, discomfort and reduce Resident 103's quality of life. Findings:During a review of Resident 103's admission Record, the admission Record indicated Resident 103 was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE]. Resident 103's diagnoses included occlusion and stenosis of right middle cerebral artery (the main blood vessel supplying the right side of the brain is either severely narrowed [stenosis] or completely blocked [occlusion], interrupting blood flow) and dysphagia oral pharyngeal phase ( difficulty initiating a swallow, where food or liquid cannot move properly from the mouth to the top of the esophagus). During a review of Resident 103's 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 the tube feeding (TF, a medical method of delivering liquid nutrition, formula, and medications directly into the stomach or small intestine) order for one of four sampled Residents (Resident 48) reviewed for tube feeding, was administered on 4/8/2026 in accordance with the physician's order. This deficient practice had the potential to cause Resident 48 to lose weight and for his health condition to decline. Findings: During a review of Resident 48's admission Record, the admission Record indicated Resident 48 was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE]. Resident 48's diagnoses included adult failure to thrive (a syndrome characterized by unintended weight loss, malnutrition (serious condition that occurs when a resident's diet does not contain the right amount of nutrients), dehydration (condition that occurs when the loss of body fluids, mostly water, exceeds the amount that is taken…

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 the peripherally inserted central catheter (PICC line- a long flexible catheter that is inserted through a vein in the upper arm) care was provided in accordance with standards of practice for one (1) of 19 sampled residents (Resident 100) by: Failing to ensure Resident 100's PICC line was assessed and documented upon admission.Failing to ensure the physician's telephone order to remove the PICC line (inserted from General Acute Care Hospital [GACH]) was followed.Failing to ensure Resident 100's PICC line dressing was changed upon admission and weekly as indicated in the facility's policy and procedure (P&P). These deficient practices had the potential to result in Resident 100 developing an infection on the PICC line insertion site.Findings: During a review of Resident 100's admission Record, the admission Record indicated Resident 100 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure licensed staff used two (2) person identifiers (the individual's name, an assigned identification number, date of birth or another person-specific identifier) prior to administering medications to ensure the accurate acquiring, administering of drugs and biologicals to meet the needs for one (1) of 5 sampled residents (Residents 38) observed for medication administration in accordance with the facility's policy and procedure (P&P) . This deficient practice had the potential for medication errors (any preventable event that may cause or lead to inappropriate medication use) result in harm to Resident 38.Findings:During a review of Resident 38's admission Record, the admission Record indicated Resident 38 was admitted to the facility on [DATE] and re-admitted on [DATE], with diagnoses that included renal insufficiency (is a condition where kidneys cannot adequately filter waste, balance electrolytes, or manage blood pressure), asthma…

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 proper labeling and storage of medication was provided for one (1) of five sampled residents (Resident 38) observed during the medication administration as indicated in the facility's Policy and Procedure (P&P) by failing to ensure one opened bottle of Promethazine (an antihistamine medication that prevents and treats the symptoms of an allergic reaction) was properly labeled with date opened and expiration date was legible and the Promethazine bottle was stored in a locked compartment. These deficient practices have the potential for Resident 38 to have an adverse reaction (an undesired, harmful, or unpleasant effect resulting from a medication) from the potentially expired medication. Findings:During a review of Resident 38's admission Record, the admission Record indicated Resident 38 was admitted to the facility on [DATE] and re-admitted on [DATE], Resident 38's diagnoses included renal insufficiency (is a condition where…

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 diet order for one (1) of 1 sampled resident (Residents 92) reviewed for food in accordance with the facility's policy and procedure (P&P). This deficient practice had the potential to result in choking (medical emergency that occurs when a foreign object such as food becomes lodged in the upper airway blocking airflow and preventing normal breathing) and for Resident 92 not to receive the required amount of nutrition, which could lead to weight loss.Findings:During a review of Resident 92's admission Record, the admission Record indicated Resident 92 was admitted to the facility on [DATE] and re-admitted on [DATE]. Resident 92's diagnoses included hypertension (high blood pressure), history of small bowel obstruction (SBO, is a critical blockage in the small intestine that prevents food, fluids, and gas from passing through the digestive tract), chronic obstructive pulmonary disease (COPD, is a chronic inflammatory lung…

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 an individualized resident-centered care plan (a care plan that prioritizes the unique health needs and desired outcomes of the resident) with measurable objectives, timeframe, and interventions when Resident 1 was observed scooting herself off the wheelchair. This deficient practice has the potential to delay in the necessary care and services for Resident 1's which can potentially result in injury and harm.Findings:During a review of Resident 1's admission Record, the admission Record indicated the resident was originally admitted on [DATE] and was readmitted to the facility on [DATE] with the following but not limited to diagnoses of muscle weakness, dementia (a progressive state of decline in mental abilities) and a history of repeated falls. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 3/6/2026, the MDS also indicated the resident is moderately impaired in cognitive (the ability 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 observation, interview, and record review, the facility failed to protect one (1) of two (2) sampled residents (Resident 1) right to be free from sexual abuse (non-consensual [without the person's permission] sexual contact of any type with a resident who does not wish to engage in sexual activity or may not have the capacity to consent) when Resident 2 was observed in Resident 1's room on top of Resident 1. Resident 2 was observed touching Resident 1's breast while kissing Resident 1 on the lips on 3/7/2026. This failure resulted in Resident 1 being sexually abused by Resident 2 on 3/7/2026 and had the potential to result in Resident 1 experiencing negative psychosocial effects (a person's mental, emotional, social and spiritual health and hopelessness).Findings:During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was initially admitted to the facility on [DATE]. Resident 1's diagnoses included cerebrovascular disease (includes conditions that restrict or block…

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 the resident's environment was free from accident hazards such as call light and bed control cords that could be used to wrap the resident's fingers with for one (1) of two (2) sampled residents (Resident 1). This deficient practice had the potential to result in injuries related to Resident 1's behavior of wrapping her fingers onto call light cord. Findings: During a review of Resident 1's admission Record, the admission Record indicated the resident was initially admitted to the facility on [DATE] with diagnoses that included aphasia (a disorder that makes it difficult to speak) following cerebral infarction (a medical condition that occurs when brain tissue dies due to a lack of blood flow and oxygen) and gangrene (the death and decay of a body tissue, usually caused by a sudden loss of blood supply) not elsewhere classified. During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool), dated 1/20/2026, 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 report an allegation of resident- to resident abuse to local, state and federal officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) within two (2) hours, for 2 of 2 sampled residents (Residents 1 and 2) per facility policy. This resulted in a delay of an onsite inspection by the California Department of Public Health (CAPD) to ensure the alleged abuse was investigated, to protect and prevent further abuse of the residents in the facility.Findings:During a review of Resident 1's admission Record, (undated), the admission Record indicated Resident 1 was initially admitted to the facility on [DATE] with diagnoses that included but not limited to chronic respiratory failure (a condition that occurs when the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body), unspecified dementia (a progressive state of decline in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to ensure that one of two sampled residents (Resident 1) had an arranged transportation to bring the resident to an outside Primary Care Physician's (PCP) appointment. This deficient practice had the potential to cause delay in treatment and worsening of Resident 1's health condition.Findings:During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE]. Resident 1's diagnoses included heart failure (the heart's main pumping chamber [left ventricle] becomes stiff and thick, preventing it from relaxing and filling properly with blood between beats, leading to symptoms like shortness of breath, fatigue, and swelling, despite the heart's normal contraction strength), unspecified dementia, unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (the underlying cause or specific form of dementia is not documented, the degree of cognitive…

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 immediately inform the physician for one of two sampled residents (Resident 1), who had diagnoses that included history of falling, muscle weaknesses, dementia (a progressive state of decline in mental abilities), and abnormality in gait and mobility when Resident 1 had an unwitnessed fall on 12/23/2025. This deficient practice placed Resident 1 at risk for delayed intervention to ensure Resident 1 did not have complications from the fall such as fracture (break or crack in the bone). Findings:During a review of Resident 1' s admission Record, the admission Record indicated the resident was admitted to the facility on [DATE] with the following but not limited to diagnoses of muscle weaknesses, dementia and abnormality in gait and mobility. During a review of Resident 1's Fall Risk Assessment, dated 12/3/2025, the assessment indicated Resident 1 is at risk for falls. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool),…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to report an unusual occurrence (events or situations that do not happen daily or that may have had an impact on the residents) to the Department within 24 hours for one of the sampled residents (Resident 1) by failing to:a. Ensure the facility reported to the Department when the facility was made aware on 1/9/2025 of Resident 1's sustained further injury and dislocation (a disruption of the normal position of the ends of two or more bones where they meet at a joint) of the right hip in accordance with the facility's policy and procedure (P&P) titled, Unusual Occurrence Reporting.This failure had the potential to affect the health, safety, and well-being of the residents. Findings:During a review of Resident 1's admission record indicated Resident 1 was admitted to the facility on [DATE] with the diagnoses including, but not limited to, a right upper thigh fracture, recent right hip joint replacement surgery, encephalopathy (a condition affecting brain…

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 investigate an injury of an unknown source for one of four sampled residents (Resident 1) per the facility's policy and procedure (P&P).This failure had the potential to affect the health and safety of the resident.Findings:During a review of Resident 1's admission Record, the admission Record indicated the facility admitted the resident on 1/3/2025, with the diagnoses including but not limited to fracture of the right thighbone, aftercare following right hip surgery, Parkinson's disease (a progressive brain disorder that causes uncontrollable movements such as stiffness), and dementia (a progressive state of decline in mental abilities).During a review of Resident 1's Minimum Data Set (MDS, a standardized care screening and assessment tool), dated 1/9/2025, the MDS indicated resident had a short-term memory problem and is moderately impaired in cognitive skills for daily decision making.During a review of Resident 1's Change of Condition (COC, communicating significant changes in resident health) form, dated 1/9/2025, the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the residents' choices or preferences were honored for one (1) of three (3) sampled residents (Resident 1) in accordance with the facility's policy and procedure. This deficient practice had the potential to negatively affect Resident 1's self-worth, self-esteem, and psychosocial well-being. Findings:During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] and re- admitted on [DATE] with diagnoses included cerebral infarction (refers to damage to tissues in the brain due to a loss of oxygen to the area) affecting left dominant side, anxiety disorder (a disorder characterized by nervousness characterized by a state of excessive uneasiness and apprehension, typically with compulsive behavior [repetitive, persistent, and often uncontrollable actions that a person feels driven to perform] or panic attacks), and panic disorder (sudden, intense feelings of fear that cause…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to develop a care plan (a document that outlines the facility's plan to provide personalized care to a resident based on the resident's needs) for one (1) of two (2) sampled residents (Resident 1), when Resident 1 was noted to have a decline in the resident's cognitive skills (ability to understand and make decisions), mobility (ability to move or be moved) and function for Activities of Daily Living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) assistance, based on the Change of Condition Minimum Data Set (MDS - a resident assessment tool), dated 7/16/2025. This failure had the potential for Resident 1 to experience a lack of care, and/or care that is not personalized to the resident's specific needs, which could negatively affect the resident's overall well-being.Findings:During a review of Resident 1's admission Record, the admission Record indicated Resident 1 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 protect the resident's right to be free from physical abuse (willful infliction of injury which includes, but is not limited to, hitting, slapping, punching, biting, and kicking) for one of two sampled residents (Resident 1). On 4/10/2025 at around 4:42 PM, Certified Nurse Assistant 1 (CNA 1) grabbed Resident 1's shirt from the back and caused the shirt to choke Resident 1 from the neck area and CNA 1 slap Resident 1's back which made a loud smacking noise. This failure resulted in Resident 1 to experience physical abuse from CNA 1 and had the potential to affect the resident's emotional, mental, and psychosocial (relating to social factors and individual thought and behavior) well-being. Findings: During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 3/11/2025 with diagnoses that included, but not limited to, delirium (a serious disturbance in a person's mental abilities that results in a decreased awareness of one's environment and confused…

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 provision of pharmaceutical services as indicated in the facility policy by failing to: 1. Lock/secure over the counter medications (OTC, medications that can be bought without a prescription) in the facility's central supply room. 2. Lock/secure a liquid vial of Lorazepam (brand name of a controlled anxiety medication) in the medication fridge in the medication room. 3. Ensure OTC medications were kept in a locked storage room that was not accessible by non-licensed and authorized staff. This deficient practice had the potential to result in unauthorized access to medications by residents, visitors, and staff and predisposing them to possible medication overdose (taking a toxic or poisonous amount of a drug or medication), unauthorized use of medications, adverse reactions (any unexpected or dangerous reaction to a drug), and drug-to-drug interactions (a reaction between two or more drugs or between a drug, and a good, beverage, or supplement). Findings: 1. During an observation on 2/20/2025 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide two (2) of 2 sampled residents (Residents 61 and 82) meal trays that were appetizing and palatable (agreeable to one's sense of taste). This failure had the potential to result in dissatisfaction, decreased food intake and placed Residents 61 and 82 at risk for unplanned weight loss. Findings: 1. During a review of Resident 61's admission Record, the admission Record indicated the resident was initially admitted to the facility on [DATE] and readmitted [DATE] with diagnoses of gastro-esophageal reflux disease (GERD, a condition where stomach contents flow back up into the esophagus [a muscular tube that connects the throat to the stomach]) and type two (2) diabetes mellitus (DM2, a disease in which glucose [sugar] levels in the blood are higher than normal). During a review of Resident 61's Minimum Data Set (MDS - a resident assessment tool), dated 11/13/2024, the MDS indicated the resident had intact cognitive (ability to think,…

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 proper food handling practices in accordance with its policy and procedure (P&P) by failing to ensure: 1. To discard expired food items which were stored in Refrigerator 3. 2. Staff's personal food container was not in the kitchen refrigerator. 3. Food items stored in the dry food storage were labeled with delivery and use by dates. 4. Micro-kill germicidal alcohol wipes (a powerful disinfectant solution premoistened with alcohol solution that effectively kills bacteria and viruses) and ThickenUp instant food and drink thickener (a powder based, instant thickening agent that can be used with both liquids and food to help manage swallowing difficulties) were not stored together (one area) in the kitchen, by the coffee machine. 5. Dietary [NAME] 1 perform hand hygiene prior to handling food and after touching/opening trash can lid. These deficient practices had the potential to result in pathogen (germ) exposure to residents and placed 95 residents at risk for developing foodborne illness (food…

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 promote dignity and respect for one (1) of 1 sampled resident (Resident 44) when Certified Nursing Assistant 6 (CNA 6) was observed standing above Resident 44's eye level while assisting the resident during mealtime. This failure had the potential to affect Resident 44's self-esteem and self-worth and violated Resident 44's right to be treated with dignity. Findings: During a review of Resident 44's admission Record, the admission Record indicated the resident was initially admitted to the facility on [DATE] and readmitted [DATE] with diagnoses of metabolic (the chemical process in the body that creates energy and materials for life) encephalopathy (a general term for brain damage or disease that affects how the brain functions) and generalized muscle weakness (weakness or lack of strength in most muscles throughout the body making it difficult to perform normal movements). During a review of Resident 44's Minimum Data Set (MDS - a 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 follow up to ensure a Level 2 Preadmission Screening and Resident Review (Level 2 PASARR, comprehensive evaluation conducted by the appropriate state-designated authority that determines whether an individual has mental disorder [MD-a health condition that affects a person's thinking, mood, behavior, or feelings], intellectual disability [ID-a condition characterized by significant limitations in both intellectual functioning and adaptive behavior that originates before the age of 22] or related condition, determines the appropriate setting for the individual, and recommends what if any, specialized services and/or rehabilitative services the individual needs) was conducted for one of one sampled resident (Resident 79) with a diagnosis of schizophrenia (serious mental illness in which people interpret reality abnormally) as indicated in the facility policy. This failure placed Resident 79 at risk for not receiving care and services in 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 facility failed to develop a comprehensive person-centered care plan (a document that outlines the facility's plan to provide personalized are to a resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs) to reflect a pharmacological intervention (refers to the administration of medication to treat or prevent a disease or illness) for pain for one of 20 sampled residents (Resident 197) in accordance with the resident's physician order. This deficient practice resulted in inadequate pain management and interventions for Resident 197. Findings: During a review of Resident 197's admission Record, the admission Record indicated Resident 197 was initially admitted to the facility on [DATE] with diagnoses that included fracture (a crack of break in a bone that occurs when there is too much force applied to it) of upper and lower end of right fibula (calf bone), other displaced fracture of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of four sampled residents (Resident 60), who was a non-English speaking resident had access to a communication board (a visual tool that displays pictures, symbols, or illustrations, allowing individuals with limited verbal communication abilities to express themselves by pointing to the images to convey their needs, wants, or thoughts; essentially acting as a bridge for communication through visual cues instead of spoken words.) or translation services. This failure placed Resident 60 at risk for unmet needs which may have led to increased distress and a decline in psychosocial well-being. Findings: During a review of Resident 60's admission Record, the admission Record indicated Resident 60 was admitted on [DATE] with diagnosis of dementia (progressive impaired ability to think, remember or make decisions that interferes with doing everyday activities) and that resident's primary language was not English. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility staff failed to provide nail care (the practice of keeping resident's fingernails clean, short, and properly trimmed) for one of one sampled resident (Resident 80), who needed total physical assistance with personal hygiene (the ability to maintain personal hygiene, including combing hair, shaving, applying makeup, washing/drying face and hands). This deficient practice had the potential to place Resident 20 at risk for increased risk for infection, skin breakdown around the nails and potential complications. Findings: During a review of the admission record, the admission record indicated Resident 80 was admitted to the facility on [DATE] with diagnoses that included but not limited to cerebral infarction (a medical condition where blood flow to the brain is interrupted, leading to damage or death of brain tissue), respiratory failure (a serious medical condition where the lungs are unable to adequately exchange gases, leading to insufficient…

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 assess and provide specific resident preferred activities and interests for one of one sampled resident (Resident 39). This deficient practice had the potential to negatively affect Resident 39's sense of self-worth and psychosocial well-being Findings: During a review of Resident 39's admission Record, the admission Record indicated Resident 39 was admitted to the facility on [DATE] with diagnoses that included hemiplegia affecting right dominant side (paralysis or weakness affecting the right side of the body), unspecified sequelae of nontraumatic intracerebral hemorrhage (deficit that occurs after a brain bleed), and aphasia (a language disorder caused by damage to parts of the brain that control speech and understanding of language). During a review or Resident 39's MDS, dated [DATE], the MDS indicated it was very important for Resident 39 to do his favorite activities, listen to music he liked, have books/newspapers/and magazines 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 observation, interview, and record review, the facility failed to ensure that one of five (5) sampled residents (Resident 79), who was experiencing significant weight loss, received Restorative Nursing Assistant (RNA-helps patients regain their ability to perform daily tasks after an illness or injury. They work in long-term care settings like nursing homes and rehabilitation centers) feeding assistance as ordered by physician and that staff accurately and timely documented Resident 79's nutritional intake on 2/18/2025 and 2/19/2025. This failure had the potential for Resident 79 for inadequate nutrition and hydration (the process of replacing water in the body) causing further weight loss. Findings: During a review of Resident 79's admission Record, the admission record indicated resident was admitted on [DATE] with diagnosis of metabolic encephalopathy (A problem in the brain caused by a chemical imbalance in the blood. The imbalance is caused by an illness or organs that are not working as well 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to assess and manage the resident's pain timely and effectively for one of one sampled resident (Resident 197) when the licensed nurses failed to: 1. Ensure the licensed nursing staff assessed Resident 197's potential to have pain after the Fentanyl patch was removed. 2. Reorder Fentanyl (a potent synthetic pain medication used to treat chronic severe pain or severe pain following surgery) five days in advance per facility policy 3. Implement Resident 197's care plan (a document that outlines the facility's plan to provide personalized are to a Resident that includes measurable objectives and timeframes to meet a Resident's medical, nursing, and mental and psychosocial needs) interventions to address and manage resident's pain. This deficient practice resulted in Resident 197 not receiving pain medication as scheduled and experience unnecessary pain. Findings: During a review of Resident 197's admission Record, the admission Record 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide trauma-informed care (an approach to delivering care that involves understanding, recognizing, and responding to the effects of all types of trauma and recognizes the widespread impact and signs and symptoms of trauma in residents, and incorporates knowledge about trauma into care plans [a document that outlines the facility's plan to provide personalized care to resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs] to avoid re-traumatization [when stress reactions experienced as a result of a previous traumatic event are relived when faced with a new similar incident]) for one of 20 sampled residents (Resident 71) who was diagnosed with post-traumatic stress disorder (PTSD- a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event). This deficient practice had the potential for Resident 71 to experience…

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 physician's order to Give with food when administering Oyster Shell Calcium/D tablet (medication used to prevent or treat low blood calcium levels in people who do not get enough calcium from their diets) for one of two sampled residents (Resident 54). This failure increased the risk for Resident 54 to experience adverse reactions and or reduced effectiveness of the medication. Findings: During a review of Resident 54's admission Record, dated 2/20/2025, the admission record indicated Resident 54 was admitted on [DATE], with diagnosis of dementia (a progressive state of decline in mental abilities) and multiple fractures of ribs and vertebra (bone and cartilage that form the spine). During a review of Resident 54's Minimum Data Set (MDS- a resident assessment tool), dated 11/27/2024, the MDS indicated Resident 54 had mildly impaired cognitive (ability to think, reason, and make decisions) skills for daily decision making. 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 observation, interview, and record review the facility failed to ensure one (1) of 1 sampled resident (Resident 61) received food that accommodated resident intolerances and preference as indicated on the facility policy. This failure had the potential to result in Resident 61 having a decreased meal intake which would lead to weight loss and malnutrition (a state of nutritional deficiency or imbalance that occurs when the body does not receive or absorb sufficient nutrients [calories, protein, vitamins, minerals] to maintain health and function properly). Findings: During a review of Resident 61's admission Record, the admission Record indicated the resident was initially admitted to the facility on [DATE] and readmitted [DATE] with diagnoses of gastro-esophageal reflux disease (GERD; a condition where stomach contents flow back up into the esophagus [a muscular tube that connects the throat to the stomach]) and type two (2) diabetes mellitus (DM2; a disease in which glucose [sugar] levels in the blood…

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 observe infection control measures for two of eight sampled residents (Residents 49 and 299) as indicated on the facility policy by failing to ensure: 1. Resident 49's indwelling catheter drainage bag (Foley catheter- a tube that allows urine to drain from the bladder into a drainage bag) was not touching the floor. 2. Licensed nurse adhered to enhanced barrier precaution (EBP, infection control interventions, primarily used in nursing homes, that focus on reducing the transmission of multidrug-resistant organisms (MDROs) by emphasizing the use of gowns and gloves during high-contact resident care activities) policy by failing to wear a gown when handling Resident 299's feeding tube. This failure had the potential to expose Residents 49 and 299 to harmful bacteria and viruses, leading to infection, delayed recovery, prolonged illness, and/or hospitalization. Findings: 1. During a review of Resident 49's admission Record, the admission…

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 the visitor for one of five sampled residents (Resident 2) wore required personal protective equipment (PPE - clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments) of gloves and gown while in a contact isolation (separation of residents with an infection from residents without an infection) room. This failure had the potential to spread infectious agents throughout the facility to residents, staff and/or other visitors. Findings: During a review of Resident 1 ' s admission Record, the admission record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included urinary tract infection (UTI- an infection in the bladder/urinary tract), Klebsiella pneumoniae (a bacteria that can cause a wide range of infections) and depression (mood disorder that causes a persistent feeling of sadness and loss of interest in life). During a review of Resident 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure two (2) of seven (7) sampled residents (Residents 2 and 3) had call lights (one of the major communication technologies that link nursing home staff to the needs of residents) were placed within the residents' reach. This deficient practice had the potential for the delay in residents receiving care and/or risk for injury from falls if residents attempted to get out of bed on their own. Findings: 1. During a review of Resident 2's admission Records indicated the resident was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses including hemiplegia (weakness to one side of the body) and hemiparesis (inability to move one side of the body) following cerebral infarction (stroke - damage to the tissues in the brain due to a loss of oxygen to the area) affecting left non-dominant side, muscle weakness, and hypertension (high blood pressure). During a review of Resident 2's History and Physical Examination (H&P)…

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 post the nurse staffing information (refers to the actual hours of work performed per patient day by a direct caregiver) at the start of each shift on 11/13/2024 in accordance with the facility policy. This deficient practice had the potential for the residents and visitors being unaware of the nursing hour and number of nurses working for each shift. Findings: During a concurrent observation and interview on 11/13/2024 at 2:01 PM at the nursing station with the Administrator (ADM). ADM stated the Daily Nursing Staffing form indicating the projected nursing hours and actual nursing hours had not been posted for 11/13/2024 at the beginning of the morning shift (7 AM - 3 PM). The ADM stated it is important of making the residents and families aware of the daily nursing hours. During an interview with Director of Staff Development (DSD) on 11/13/2024 at 2:11 PM, the DSD stated she was supposed to update and post the staffing information every day at 9 AM The DSD stated she forgot to post the staffing information…

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 have a copy of employee's vaccination cards, and an updated and accurate list of employees with COVID 19 (Coronavirus Disease 19; a respiratory viral infection that affects primarily the lungs and result in cough and difficulty breathing) vaccination for the year 2023-2024. This deficient practice placed the residents and staff at risk for possible COVID-19 infection. Findings: During a concurrent record review of the facility's National Healthcare Safety Network (NHSN; a Centers for Disease Control and Prevention [CDC] tracking system for healthcare-associated infections) reporting report dated 1/14/2024 to 6/9/2024, and interview on 6/14/2024 at 8:35 AM, Infection Preventionist Nurse (IPN) stated the facility did not have 100% COVID 19 vaccination for the employees and the NHSN indicated 100% COVID 19 vaccination for the staff which is incorrect. IPN also stated she does not have a current vaccination list for the facility's employees. During a concurrent record review of the facility's NSHN reporting report 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 observation, interview and record review, the facility failed to reasonably accommodate the needs of two of two sampled Residents (Resident 1 and 2) by failing to answer the call light (an alerting device for nurses or other nursing personnel to assist a patient when in need) timely. This deficient practice had the potential for the residents not to be able to call the staff for assistance, which could result to not receiving or delayed needed care or services necessary for the resident's well-being. Findings: 1. A review of Resident 1's admission Record indicated resident was originally admitted on [DATE] and was readmitted on [DATE] with the following diagnoses of muscle weakness and left non-dominant side hemiplegia (muscle weakness on one side of the body) and hemiparesis (weakness and inability to move on one side of the body). A review of Resident 1's History and Physical (H&P), dated 2/18/23, indicated the resident has the capacity to understand and make decisions. A review of Resident 1's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure three (1) of two (2) sampled residents (Resident 1) was free from an unnecessary psychotropic drug (any medication capable of affecting the mind, emotions, and behavior) in accordance with the facility policy and procedure by failing to ensure: 1. Resident 1 have a specific target behavior in addition to panicky feeling for the use of Ativan (Lorazepam, medication used to treat anxiety). 2. Resident 1 have a physician's order for Ativan prior to administering it to the resident on 5/5/2024. This deficient practice had the potential to place Resident 1 at risk for significant adverse (harmful) consequences from the use of unnecessary psychotropic drug. Findings: A review of Resident 1's admission Record indicated an initial admission to the facility on 8/29/2022, and readmission on [DATE] with diagnoses of dementia (a brain disorder that results in memory loss, poor judgment, and confusion), anxiety disorder (persistent 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 one of three sampled resident (Resident 1) was free of unnecessary physical restraint (any direct physical contact where the intention of the person intervening is to prevent, restrict, or subdue movement of the body, or part of the body of another person). On 4/1/2024 at 3:30 am, Licensed Vocational Nurse (LVN) 1 and LVN 2, tied Resident 1 with a white linen from waist down, and tied at the back of the wheelchair which restricted the resident from movement and getting up from her wheelchair. This deficient practice resulted to unnecessary restraint and placed the resident at risk of physical harm from impeding the circulation of resident's whole body from the restraint and it can also cause psychosocial harm, skin break down for Resident 1. Findings: During a review of Resident 1 ' s admission record, it indicated Resident 1 was initially admitted on [DATE] and readmitted on [DATE], with diagnoses of, unspecified cerebrovascular…

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 promote dignity and respect for 5 of 6 residents (Residents 16, 85, 89, 72, and 90) for dignity care area as indicated on the facility's policy when: 1. Resident 16 was found with food on her clothes, face, and hands. 2. Resident 85 was not provided privacy when he was sitting in bed wearing an incontinent brief with the privacy curtain opened. 3. Resident 89 was found with food debris on his shirt and dried white colored liquid on his chin after eating breakfast. 4. Resident 72's personal space was not protected when Resident 90 grabs Resident 72's food and/or the resident's foot. 5. Resident 90 was assisted with feeding by the staff standing over the resident (above the resident's eye level) during meal assistance. This deficient practice had the potential to affect Residents 16, 85, 89, 72, and 90's sense of self-worth and self-esteem which could result in problems with emotional and mental well-being. Findings 1. 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 follow its Advance Directives (a written instruction, such as a living will or durable power of attorney for health care, recognized under State law relating to the provision of health care when the individual is incapable) policy for three (3) of seven (7) sampled residents (Resident 44, 68, and 251) for Advance Directive care area when: 1. Resident 44 did not have documented evidence on being informed of his choice to complete an Advanced Directive. 2. Resident 68's advance directive was not maintained in the residents' chart. 3. Resident 251's advance directive was not maintained in the residents' chart. These deficient practices have the potential not to carry out Residents 44, 68, and 251's wishes regarding health care decisions during an emergency. 1. A review of Resident 44's admission Record indicated the resident was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included end stage renal disease…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to develop an individualized resident-centered care plan (a care plan that prioritizes the unique health needs and desired outcomes of the resident) with measurable objectives, timeframe, and interventions to meet the residents' needs for three (3) of 23 sampled residents (Residents 58, 37, and 79). 1. Resident 58 did not have a care plan to address resident's behavior of not wanting to share the shared restroom with other residents. This deficient practice can lead to worsening of resident's behavior and can affect another resident and not able to used the shared restroom. 2. Resident 37's comprehensive care plan on the use of antibiotic medication (a drug used to treat infections caused by bacteria and other microorganisms). This deficient practice had the potential for Resident 37 to experience infection, complications from inadequate monitoring. 3. Resident 79 did not implement the resident's care plan for the use of anticoagulant…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide appropriate treatment and services to increase, prevent, or maintain range of motion (ROM, full movement potential of a joint) by not providing restorative nursing services (a program available in nursing homes that helps residents maintain any progress made during therapy treatments, enabling them to achieve their highest practicable level of functioning) for three (3) of four (4) sampled residents (Residents 64, 63, and 15) for position or ROM care area, as ordered by the physician. This deficient practice placed Residents 64, 63, and 15 at risk for decline in physical functions and developing contractures (condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints) in other extremities (a limb of the body, such as the arm or leg) for not receiving the needed exercises. Findings: 1. A review of Resident 64's admission Record indicated Resident 64 was admitted 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 observation, interview, and record review, the facility failed to ensure the residents' head of bed (HOB) was elevated above 30 to 45 degrees when receiving enteral feedings through a gastrostomy tube (GT, a tube inserted through the belly that brings nutrition directly to the stomach) for two of five sampled residents (Resident 62 and 68) for the tube feeding care area. This deficient practice had the potential for Resident 62 and 68 to aspirate (when something enters the airway or lungs by accident) which can lead to lung problems such as pneumonia (a lung infection). Findings: 1. A review of Resident 62's admission Record indicated the resident was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis that included dysphagia, oropharyngeal phase (difficulty transferring food from the mouth into the pharynx and esophagus to initiate an involuntary swallowing process) and gastro-esophageal reflux disease (a common condition in which the stomach contents move up into 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 observation, interview, and record review, the facility failed to provide necessary respiratory care services for two (2) of 2 sampled residents (Residents 36 and 40) for respiratory care area by failing to: 1.a. Ensure Resident 36's oxygen humidifier (a device used to make supplemental oxygen moist) was changed per physician's order. This deficient practice had the potential for Resident 36 to develop a respiratory infection. 1.b. Place a visible oxygen signage by Resident 36's door/wall prior to entering the room. This deficient practice had the potential for harm to Resident 36 and other residents, in an event of fire. 2.a Ensure Resident 40's humidifier and oxygen tubing were changed every seven (7) days per policy. This deficient practice had the potential for Resident 40 to develop a respiratory infection. 2.b. Place a visible oxygen signage by Resident 36's door/wall prior to entering the room. This deficient practice had the potential for harm to Resident 36 and other residents, in an event of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure a resident who received dialysis (process of removing waste products and excess fluid from the body) received care and treatment in accordance with the resident's care plan for three (3) of five (5) sampled residents (Resident 5, 14, and 20) for dialysis care area by failing to ensure: 1. A dialysis emergency kit was placed at the bedside for Resident 5 and an alert sign postage to indicate precautions on the resident's dialysis site access. 2. A dialysis emergency kit was placed at the bedside for Resident 14 and an alert sign postage to indicate precautions on the resident's dialysis site access. 3. A dialysis emergency kit was placed at the bedside for Resident 20. These deficient practices had the potential for Residents 5, 14, and 20 to be at risk for complications such as bleeding and potential for delay in provision of dialysis care and treatment in case of emergencies. Findings: 1. A review of Resident 20 admission Record…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide social services by not assisting and arranging care and services for two of two sampled residents (Resident 70 and Resident 79). 1. Social Services did not follow up on Resident 70's misplaced hearing aids. 2. The facility did not follow their policy to call law enforcement when Resident 70 hearing aids were missing. 3. Social Services did not follow up on Resident 79 dental services for new dentures. These deficient practices had the potential for residents to have a delay in care and services. Findings: 1. A review of Resident 70's admission Record indicated resident was admitted to the facility on [DATE] with diagnoses of dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities) and glaucoma (a group of eye diseases that can cause vision loss). A review of Resident 70's History and Physical (H&P), dated 2/6/23, indicated resident did not have the capacity to understand 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 label foods in the kitchen with item 'use by' date (the last date recommended for the use of the product) and failed to discard expired food as indicated in the facility's policy and procedure. These deficient practices had the potential to result in pathogen (germ) exposure to residents and placed residents at risk for developing foodborne illness (food poisoning) with symptoms including upset stomach, stomach cramps, nausea, vomiting, diarrhea, and fever and can lead to other serious medical complications and hospitalization. Findings: During a concurrent observation and interview on 3/12/24 at 8:04 AM with the Dietary Trayline (DT), the kitchen was observed with food items not labeled to indicate the food items use by date. The DT stated all food items were supposed to be labeled with used by date and discarded when expired. The DT stated the following items were found in the kitchen's refrigerators: a. A clear container filled with cut up watermelon labeled fruit with used by date of 3/11/24. b. A clear…

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 antibiotic stewardship program protocols for prescribing the appropriate antibiotics (medication used to treat or prevent some types of bacterial infection) was provided for eight of ten sampled residents (Resident 73, 64, 29, 87, 37, 3, 11, and 65) prior to the administration of their antibiotic therapy. 1. The facility did not complete the Surveillance Data Collection form for (Resident 73, 64, 29, 87, 37, 3) who were receiving antibiotics in March 2024. 2. The facility did not follow the surveillance data collection form prior to prescribing antibiotics for Resident 11 and 65 residents in February 2024. This deficient practice had the potential for the residents to be prescribed inappropriate antibiotics and increased the risk for developing antibiotic-resistant organisms (bacteria that are not controlled or killed by antibiotics). Findings: A review of Resident 73's admission Record indicated resident was admitted on [DATE] with 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 wipe down the handle of two (2) of 2 laundry washers (Washer 1 and Washer 2) with an Environmental Protection Agency (EPA, federal government agency created to protect human health and environment by providing environmental laws, and provides technical support to minimize threats) approved disinfectant solution (approved by EPA that is safe to use and at the same time effective in disinfecting the surface/ killing the bacteria to avoid spread of infection and illness) as indicated on the facility policy. This deficient practice had the potential for spread of infection to the residents in the facility. Findings: During an observation on 3/15/24 at 9:20 AM, Laundry Staff (LS) was observed loading soiled clothes in Washer 1 with bare hands. LS did not disinfect the machine/Washer 1's handle and door after loading the soiled clothes. LS proceeded to open Washer 2 (after cleaning cycle) and unloaded the clean clothes with her bare hands. LS was not observed disinfecting the machine/Washer 2's handle. During an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to notify the physician of a significant weight loss for one (1) of two (2) sampled residents (Residents 40) who experienced severe weight loss (weight loss greater than five [5] % in one month) for nutrition care area. This deficient practice placed Resident 40 at risk for further decline in nutritional status and continued weight loss. Findings: A review of Resident 40's admission Record indicated Resident 40 was initially admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses encounter for attention to gastrostomy (a surgical procedure for inserting a tube through the abdomen wall and into the stomach used for feeding or drainage), type 2 diabetes mellitus (a disease that occurs when there is a problem in the way the body regulates and uses sugar as fuel) with diabetic chronic kidney disease (gradual loss of kidney damage where kidneys cannot filter the blood the way they should), and dementia (progressive brain…

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 an accurate assessment was conducted regarding the resident's active diagnoses (current diagnosis) for one of three sampled resident (Resident 19) in the resident assessment care area. This deficient practice had the potential to negatively affect Resident 19's plan of care and delivery of necessary care and services. Findings: A review of Resident 19's admission Record (AR, a record containing diagnostic and demographic resident information), dated 3/15/24, the AR indicated she was readmitted to the facility on [DATE], with diagnoses that included dementia (a condition or illness that affects the way the person's brain is working ), major depressive disorder (mood disorder that caused a persistent feeling of sadness and loss of interest), generalized anxiety disorder (you were worrying constantly and can't control the worrying), and paranoid schizophrenia (a disorder that affected a person's ability to think, feel, and behave). A review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure two (2) of 23 residents (Residents 4 and 37) received treatment and services to maintain or improve level of assistance needed with Activities of Daily Living (ADL), as indicated on the facility's policy: 1. Resident 4 was not provided assistance with eating. 2. Resident 37 was not provided with a communication board. This deficient practice had the potential for Residents 4 and 37's functional abilities to decline. Findings: 1. A review of Resident 4 admission Record indicated resident was originally admitted on [DATE] and was readmitted on [DATE]. Resident 4 's diagnoses included dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities) and anorexia (an eating disorder characterized by restriction of food intake leading to low body weight). A review of Resident 4's Care Plan, revised 7/8/23, focus on nutritional status indicated an intervention to provide assistance 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide audiology (audiology is the branch of science and medicine concerned with the sense of hearing. Audiologists are health care professionals who diagnose, manage, and treat hearing, balance, or ear problems) and Ear, Nose, Throat (ENT) for hearing loss in accordance with physician's order for one of four sampled residents (Resident 20) for the communication and sensory care area. This deficient practice had the potential for Resident 20 to have increased hearing loss. Findings: A review of Resident 20 admission Record indicated resident was originally admitted on [DATE] and was readmitted on [DATE] with the following diagnosis for blindness and dysphagia (difficulty swallowing). A review of Resident 20's History and Physical (H&P), dated 2/27/24, indicated the resident has the capacity to understand and make decisions. A review of Resident 20's Minimum Data Set (MDS, a standardized care screening and assessment tool), dated 12/16/23, 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement treatment for the prevention of pressure ulcer (painful wound caused as a result of pressure or friction) by failing to ensure that the low air loss mattress (LAL, operates using a blower based pump that is designed to circulate a constant flow of air through the mattress, commonly used to heal pressure ulcers) was on the correct settings for one (1) of two (2) sampled residents (Residents 48) for pressure injury care area, in accordance with the facility's policy and procedure. This deficient practice had the potential to place Resident 48 to be at risk for progression of pressure ulcer. Findings: A review of Resident 48's admission Record indicated the resident was admitted to the facility on [DATE]. Resident 48's diagnoses included Unstageable pressure injury (obscured full-thickness skin and tissue loss) of the sacral region (triangular-shaped bone at the base of the spine just superior to the coccyx[tailbone]), right…

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 act upon the consultant pharmacist's recommendation to include manufacturers recommendation for the use of Carvedilol (medication to treat high blood pressure) for 1 of 5 sampled residents (Resident 20). This deficient practice had the potential for Resident 20 to have fast absorption of Carvedilol, if not taken with food, and may suffer from the medication side effects such as feeling of dizziness or fainting when standing up. Findings: During a review of Resident 20's admission Record, the record indicated Resident 20 was recently readmitted on [DATE] with diagnosis that included hypertension (a condition in which the force of the blood against the artery walls is too high) and end stage renal disease (a condition in which the kidneys lose the ability to remove waste and balance fluids). During a review of Order Summary Report, dated 3/15/24, the report indicated on 2/8/2024, Resident 20 was prescribed Carvedilol 3.125 mg by mouth 2 times a day.…

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 two (2) of 5 sampled residents (Residents 44 and 19), for unnecessary medication care area, were free from the use of unnecessary psychotropic drug (any medication capable of affecting the mind, emotions, and behavior) when: 1. Resident 44 did not receive a Gradual Dose (GDR, is the stepwise tapering of a dose to determine if symptoms, conditions, or risks can be managed by a lower dose or if the dose or medication can be discontinued). for the use of Mirtazapine (a medication used to treat depression [a mood disorder that causes a persistent feeling of sadness and loss of interest]). 2. There was no rationale documented by the physician for Resident 19's extended use (more than 14 days) of as needed (PRN) Temazepam (medication to treat sleep problem). This deficient practice had the potential to place Residents 44 and 19 at risk for significant adverse consequence (unwanted, uncomfortable, or dangerous effects that a drug may have)…

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 standard infection prevention control practices (a set of practices that prevent or stop the spread of infections and or diseases in the healthcare setting) were followed for (1) of thirteen (13) sampled resident (Resident 3) for the infection control care area in accordance with the facility's policy and procedure when: a) There was no proper sign for Contact Isolation (used for patients with diseases caused by microorganisms [bacteria and viruses] that are spread through direct and indirect contact) posted on Resident 3's door. b) Certified Nurse Assistant 2 (CNA 2) did step out of the isolation room multiple times and touched the clean linen cart then came back inside the Resident 3's room wearing the same gown. c) Licensed Vocational Nurse 1 (LVN1) used her own equipment for vital signs instead of the designated equipment inside Resident 3's room. These deficient practices have a potential to contaminate clean items and can…

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 designate a full-time (work 40 or more hours in a week) Infection Preventionist Nurse (IPN) per facility policy. This deficient practice had the potential for infection control practices to be unaccounted for including identifying, controlling, and containing the spread of infections within the facility. Findings: During an interview with the Director of Nursing (DON) on, 3/15/24 at 12:51 PM, the DON stated the Director of Staff Development (DSD) is the one covering the duties of the IP Nurse when the previous IPN left January of 2024 and when the new IPN started 2 weeks ago. During an interview with DSD on, 3/15/24 at 12:52 PM, DSD stated, the previous IP Nurse worked until middle of January 2024 (unable to recall exact date). The DSD stated I was the one covering last middle of January 2024 when the IP nurse left. I only do National Healthcare Safety Network (NHSN, is a national healthcare-associated infection [HAI] reporting system developed and maintained by the CDC [Centers for Disease Control and Prevention])…

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 call light (used in healthcare facilities as an alerting device for nurses or other nursing personnel to assist a resident when in need) was within reach for one (1) of 23 sampled residents (Resident 63) as indicated in the facility's policy and procedure and care plan. This deficient practice had the potential not to meet Resident 63's needs and preference. Findings: A review of Resident 63's admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses which included hemiplegia (paralysis of one side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction (refers to damage to tissues in the brain due to a loss of oxygen to the area) affecting left non-dominant side, dysarthria (a condition in which the resident have difficulty saying words because of problems with the muscles that help resident talk) and history of falling. A review of Resident 63's Minimum Data…

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 to their assigned state agency (California Department of Public Health, CDPH) of an unusual occurrence of injury of unknown (source of injury was not observed by any person and origin could not be explained by the resident) origin for one out of two sampled residents (Resident 1). This failure had resulted to the facility not reporting injury of unknown origin and can place Resident 1 at risk for sustaining another injury. Findings: During a review of Resident 1's admission Record (Face Sheet), admission Record indicated Resident 1 was admitted to facility on 02/07/2023 with diagnosis that included but was not limited to, unspecified dementia (a condition with a loss of thinking, remembering, and reasoning to an extent that it interferes with daily life and activities), age-related osteoporosis (a medical condition which bones are brittle and fragile), and anxiety (a feeling of worry or unease). During a review of Resident 1's Minimum Data Sheet (MDS, a standardized assessment and screening tool) dated 11/29/2023,…

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

Based on observation, interview, and record review the facility failed to ensure the safety for one of three sampled residents (Resident 1) by not monitoring residents while in the activity room. This deficient practice resulted in Resident 1 obtaining paint from the activity cart and ingesting (swallowing) the paint. Findings: A review of Resident 1 ' s admission Record indicated the facility admitted Resident 1 on 10/17/2022 with diagnosis which include history of falling, Alzheimer disease (a progressive disease beginning with mild memory loss and possibly leading to loss of the ability to carry on a conversation and respond to the environment), anxiety (a feeling of fear, dread, and uneasiness). A review of Resident 1 ' s Minimum Data Set (MDS, standardized care and screening tool), dated 10/13/2023, indicated Resident 1 was severely impaired with cognitive (processes of thinking and reasoning) skills for daily decision making. The MDS indicated Resident 1 required partial/ moderate assistance (helper does less than half the effort, helper lifts, hold or supports trunk or limb,…

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 (1) of three (3) sampled Residents (Resident 3) received care with elimination/toileting in accordance with the facility's policy and procedure. This deficient practice resulted in Resident 3's diapers left wet for an extended period which could potentially result in skin irritation or skin breakdown. Findings: A review of Resident 3's admission Record indicated the resident was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis that included hemiplegia and hemiparesis (a condition caused by brain injury that results in a varying degree of weakness, stiffness, and lack of control on one side of the body) following cerebral infarction (lack of adequate blood supply to the brain). A review of Resident 3's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 11/10/23, indicated Resident 3 was severely impaired with cognitive (thought process and ability to reason or make decisions)…

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 three (3) of six (6) sampled residents (Residents 1, 2, and 3) was free from an unnecessary psychotropic drug (any medication capable of affecting the mind, emotions, and behavior) in accordance with the facility policy and procedure by failing to ensure: 1. Resident 1 have a specific target behavior for the use of Ativan (Lorazepam, medication used to treat anxiety). 2. Resident 2 have a physician's order for Ativan received for 17 days. 3. Resident 3 have a physician's order for Ativan received for one (1) day. This deficient practice had the potential to place Residents 1, 2 and 3 at risk for significant adverse (harmful) consequences from the use of unnecessary psychotropic drug. Cross reference with F756 Findings: 1. A review of Resident 1's admission Record indicated an initial admission to the facility on 8/29/22, and readmission on [DATE] with diagnoses of dementia (a brain disorder that results in memory loss, poor…

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 address the use of Ativan (Lorazepam, medication used to treat anxiety [persistent and excessive worry that interferes with daily activities]) on the medication regimen review (MRR, or Drug Regimen Review, a thorough evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medication) for two (2) of six (6) sampled Residents (Resident 2 and 3) in accordance with the facility policy. This deficient practice had the potential for unnecessary medication administered to Residents 2 and 3, which could result to serious harm. Cross Reference with F758 Findings: 1. A review of Resident 2's admission Record indicated an admission to the facility on 1/4/23 with diagnoses of seizure (abnormal electrical activity in the brain that happens quickly), schizophrenia (a chronic and severe mental disorder that affects how a person thinks, feels, and behaves),…

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 standard infection prevention control practices (a set of practices that prevent or stop the spread of infections and or diseases in the healthcare setting) were followed in accordance with the facility's policy and procedure by: 1. LS failed to wipe down the handle of the washer Washer 1 with an EPA (Environmental Protection Agency, federal government agency created to protect human health and environment by providing environmental laws, and provides technical support to minimize threats) approved disinfectant solution (approved by EPA that is safe to use and at the same time effective in disinfecting the surface/ killing the bacteria to avoid spread of infection and illness) after loading the washer with soiled linens and/ or clothes. that were from the facility's red zone. 2. LSs did not perform hand hygiene after handling the soiled linens and/ or clothes after loading them in the washer. This deficient practice had the potential for spread of Coronavirus 2019 (COVID- 19, infectious disease caused…

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 communicate the planned discharge to the family of one of one sampled resident (Resident 1) to Skilled Nursing Facility 2 (SNF 2). This deficient practice violated Resident 1's right to be treated with respect and has the potential to have negative psychosocial outcomes for the residents. Findings: During a review of the admission Record indicated Resident 1 was admitted to the facility on [DATE], with diagnosis of dementia (a loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life) with unspecified severity, without behavioral, psychotic (disconnection from reality), and mood disturbance (periods of extreme happiness, extreme sadness, or both). A review of Resident 1 ' s Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 7/25/23, indicated the resident had moderately impaired cognitive skills (mental action or process of acquiring knowledge 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 interview and record review, the facility failed to readmit one of one sampled resident (Resident 1) on 9/18/23 and did not make an effort to find out an accurate status of the resident's condition based on the facility's policy and procedure. This deficient practice resulted to Resident 1 discharge to Skilled Nursing facility 2 (SNF 2) and is in the violation of Resident 1's rights to resume residency at the facility. Findings: During a review of the admission Record indicated Resident 1 was admitted to the facility on [DATE], with diagnosis of dementia (a loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life) with unspecified severity, without behavioral, psychotic (disconnection from reality), and mood disturbance (periods of extreme happiness, extreme sadness, or both). A review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 7/25/23, indicated the resident had moderately impaired…

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 treatment and services for one of one sampled resident (Resident 1) by failing to assess the resident ' s peripherally inserted central catheter (PICC- a long, thin tube that's inserted through a vein in your arm and passed through to the larger veins near your hear) line venous access site in accordance with the current professional standard of practice, and facility policy. This deficient practice had the potential for Resident 1 to develop complications that includes bleeding, infection, blocked or PICC line venous access, which could result to harm and death. Findings: An announced visit was made on 8/16/23 to investigate an allegation of Improper Infection Control Practiced By Facility. A review of Resident 1's Face Sheet (document gives resident quick information at a glance) indicated the resident was originally admitted on [DATE] and was readmitted to the facility on [DATE] with diagnoses including sepsis (a life-threatening…

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.