San Gabriel Valley Medical Ctr D/P SNF

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure its medication error rate was less than five (5) percent (%). Two (2) medication errors (the observed or identified preparation of administration of medication or biologicals which is not in accordance with the prescriber's order/manufacturer's specifications/accepted professional standards and principles) out of 25 opportunities (observed administered medications) for error which yielded a facility medication error rate of 8% for 2 of 5 sampled residents (Resident 19 and Resident 36) observed for medication administration. Licensed Vocational Nurse 2 (LVN 2) administered Resident 19's ferrous sulfate (a supplement used to increase iron levels to support red blood cell production) more than 2 hours of the scheduled dosing time of 8 AM as indicated on the physician's order and facility's policy. LVN 3 omitted (left out) Resident 36's order for doxazosin (Cardura, medication used to treat high blood pressure and symptoms of 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 interview and record review, the facility failed to ensure the medical records were complete and accurately documented for one (1) of 1 sampled resident (Resident 19) reviewed for abuse, (the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish) by failing to document Resident 19's report of hitting his head on the headboard while getting repositioned up in bed (to move a resident from the foot of the bed back toward the head of the bed) by Licensed Vocational Nurse 4 (LVN 4). This deficient practice had the potential to result in incomplete assessment of Resident 19's needs and could lead to a lack of or delay in delivery of necessary care and services.Findings: During a review of Resident 19's admission Record, the admission Record indicated Resident 19 was admitted to the facility on [DATE]. During a review of Resident 19's History and Physical (H&P), dated 1/19/2026, the H&P indicated Resident 19 had diagnoses that…

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

Based on observation, interview and record review, the facility failed to implement the discharge plan to ensure a safe discharge for one of one sampled residents (Resident 1) by failing to provide a written form of discharge notice to the resident and family members and re-evaluate resident 1's condition for discharge.These deficient practices placed Resident 1 at risk for unsafe discharge.During a review of Resident 1's History and Physical (H&P), dated 5/31/25, the H&P indicated the facility admitted Resident 1 on 5/31/2025 with diagnoses that included chronic hypoxic respiratory failure (lungs consistently cannot get enough oxygen into the blood, leading to low blood oxygen and often normal or low CO2, causing symptoms like breathlessness, bluish skin, fatigue, and fast heart rate, stemming from lung damage or blood flow issues), recent subdural hemorrhage status post craniotomy (surgery to treat a collection of blood between the brain), and protein malnutrition (conditions from insufficient intake or absorption of protein and energy [calories], leading to impaired growth,…

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 two (2) of 2 residents (Residents 12 and 24) by failing to ensure: 1. Licensed Vocational Nurse 1 (LVN 1) address Resident 12 with the resident's name instead of using a label prior to medication administration. 2. The curtain in Resident 24's room was fully drawn and/or the resident's door was closed while Certified Nurse Assistant 1 (CNA1) was providing incontinent care to Resident 24. This deficient practice had the potential to affect Resident 12 and 24's emotional and mental well-being. Findings: 1. During a review of Resident 12's admission Record, the admission record indicated Resident 12 was admitted to the facility on [DATE]. Resident 12's diagnoses included metabolic encephalopathy (ME, occurs when problems with your metabolism cause brain dysfunction), diabetes mellitus (DM, is a metabolic disease, involving inappropriately elevated blood glucose levels), and dementia (impaired 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 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 (LALM, mattress used for residents who are at risk for developing pressure ulcer or already have a pressure ulcer, designed to circulate a constant flow of air) was on the correct settings for three (3) of four (4) sampled residents (Residents 14, 21, and 136) in accordance with the facility's policy and procedure and physician's order. This deficient practice had the potential for Resident 14 and 136 to develop a pressure ulcer and for Resident 21's stage 4 pressure ulcer (full-thickness skin loss in which subcutaneous fat may be visible in the ulcer and granulation tissue and epibole [rolled wound edges] are often present) to worsen. Findings: 1. During a review of Resident 14's admission Record, the admission record indicated Resident 14 was admitted to the facility on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide appropriate care to prevent complications of enteral feeding (nutrition taken through the mouth or through a tube that goes directly to the stomach or small intestine) for two (2) of 2 sampled residents (Resident 12 and 4) in accordance with the facility's policy and procedure by failing to: 1. Turn off the enteral feeding pump before and during medication administration via gastrostomy tube (G-tube, surgical procedure wherein a tube is inserted through the abdomen wall and into the stomach used for nutrition and medication administration) for Resident 12. 2. Ensure medications were administered by gentle instillation or gravity via syringe into Resident 4's G- tube. This deficient practice had the potential for drug-nutrient interaction, G-tube clogging, less medication absorption and efficacy which could affect Residents 12 and 4's overall wellbeing. Findings: 1. During a review of Resident 12'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 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 five (5) of 13 sampled resident (Resident 26, 12, 4, 32, and 10) in accordance with the facility's policy and procedure when: 1. Resident 26's foley catheter drainage bag (a urine collection bag) was observed touching the floor on 3/25/2025. 2. Licensed Vocational Nurse 1 (LVN 1) failed to change gloves and perform hand hygiene in between tasks during medication administration to Resident 12. 3. LVN 2 failed to change gloves and perform hand hygiene in between task during Resident 32's gastrostomy tube (G-tube, is a tube inserted through the belly that brings nutrition directly to the stomach) dressing change 4. LVN 2 failed to change gloves and perform hand hygiene in between task during medication administration to Resident 4. 5. Facility failed to clean 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 secure the confidential medical records for one (1) of three (3) residents (Residents 4) as indicated on the facility's policy. 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 4's Protected Health Information (PHI, any information that relates to an individual's health status, medical history, or treatment). Findings: During a review of Resident 4's admission Record, the admission record indicated Resident 4 was admitted to the facility on [DATE]. Resident 4's diagnoses included Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination), diabetes mellitus…

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 a comprehensive person-centered care plan for the use of Apixaban (Eliquis, a prescription medicine used to treat blood clots in the veins of the legs or lungs) by not having a documented evidence to monitor the side effects and effectiveness of the medication for one (1) of 5 sampled residents (Resident 26) as indicated on the facility's policy. This deficient practice had the potential for Resident 26 not to receive the care and treatment if the medication is ineffective and resident suffers from the side effects of Eliquis such as bleeding, which may result in injury and harm. Findings: During a review of Resident 26's admission Record, the admission record indicated Resident 26 was admitted to the facility on [DATE]. Resident 26's diagnoses included respiratory failure (a serious condition that makes it difficult to breathe on your respiratory system [organs/ structures in the body that allows you to breath such as lungs]),…

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 24), who was dependent on the staff, was provided with appropriate care for activities of daily living (ADLs, activities related to personal care including bathing or showering, dressing, personal hygiene, using the toilet, and eating). Resident 24's fingernails on both contracted hands (a condition where the fingers or palm of the hand become permanently bent or curled) were observed long and untrimmed. This deficient practice had the potential for Resident 24 to develop infection, skin breakdown, and injury, which could negatively affect resident's overall wellbeing. Findings: During a review of Resident 24's admission Record, the admission Record indicated Resident 24 was originally admitted to the facility on [DATE]. During a review of Resident 24's History and Physical Examination (H&P) dated 8/23/2024, the H&P indicated Resident 24's diagnoses included chronic (long-term) subdural…

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 two (2) of 13 sampled residents (Resident 19 and Resident 24) received treatment and care by failing to administer sequential compression device (SCD, a medical device that uses inflatable sleeves to apply pressure to the legs to help blood flow and prevent clots) as ordered by the physician. This deficient practice had the potential to result in Resident 19 and Resident 24 to develop deep vein thrombosis (DVT, occurred when a blood clot develops in one of the deep veins in the body) which could lead to hospitalization and death. Findings: 1. During a review of Resident 19's admission Record, the admission Record indicated Resident 19 was originally admitted to the facility on [DATE]. Resident 19's diagnoses included chronic respiratory failure (lung cannot properly exchange gases, causing abnormal levels of oxygen and carbon dioxide in the blood), encephalopathy (a decrease in blood flow or oxygen to the brain), and quadriplegia (paralysis…

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 pharmaceutical services including procedures to ensure the safe administration of drugs meet the needs of one (1) of five sampled residents (Resident 4) in accordance with the facility's policy and procedure (P&P) by failing to ensure Licensed Vocational Nurse 2 (LVN 2) did not mix Lactulose (used to treat constipation) and Rivastigmine (used to treat dementia [a progressive state of decline in mental abilities] in people with Alzheimer's disease [a disease characterized by a progressive decline in mental abilities]) and administer to Resident 4 on 3/27/2025. This deficient practice had the potential for medication interaction, affect the efficacy of the medications, cause clogging in Resident 4's gastrostomy tube (G-tube, surgical procedure wherein a tube is inserted through the abdomen wall and into the stomach used for nutrition and medication administration) and result in adverse reactions such as gastrointestinal (GI)…

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 its medication error rate was less than five (5) percent (%). Two (2) medication errors (the observed or identified preparation or administration of medications or biologicals which is not in accordance with the prescriber's order/ manufacturer's specifications / accepted professional standards and principles) out of 25 opportunities (observed administered medications) for error which yielded a facility medication rate of 8% for one (1) of 5 sampled residents (Resident 4) observed during medication administration (med pass). Licensed Vocational Nurse 2 (LVN 2) did not mix Lactulose (used to treat constipation) and Rivastigmine (used to treat dementia [a progressive state of decline in mental abilities] in people with Alzheimer's disease [a disease characterized by a progressive decline in mental abilities]) and administer to Resident 4 on 3/27/2025. This deficient practice had the potential to result in gastrointestinal (GI)…

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

Based on observation and interview, the facility failed to store and prepare food items served to facility residents by failing to ensure: 1. Refrigerated opened food items were properly labeled with used by date 2. Unopened food items were removed from the original boxes were labeled with used by date This deficient practice had the potential to result in food borne illness (any sickness that is caused by the consumption of food or beverages that are contaminated with certain infectious or noninfectious agents) to all residents who consume food by mouth and served by the facility kitchen. Findings: During a concurrent observation the walk-in refrigerator and interview with the Dietary Supervisor 1 (DS 1) on 3/25/2025 at 9:45 AM, DS 1 stated one (1) opened container with peeled garlic did not have a label to indicate opened date and used by date. DS 1 also stated several unopened food items which were removed from their original boxes did not have a label to indicate the name of the item, expired date, opened date, and used by date. 1. Four (4) unopened 1 Gallon (gal., a measure…

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 adhere to its policy titled Change in Resident Condition by not reporting a bruise sustained on the left leg for one of two sampled patients (Resident 1) to the physician and Resident 1's next of kin (daughter) This failure to escalate and address the bruise in a timely manner potentially compromised the quality and safety of care provided to Resident 1. Findings: During a review of Resident 1's Face Sheet (document containing the resident's demographic and clinical data), the Face Sheet indicated Resident 1 was admitted on [DATE] for chronic respiratory failure with hypoxia (condition where the patient does not have enough oxygen in the blood). During a concurrent observation and interview on 11/26/2024 at 2:30 p.m. with License Vocational Nurse (LVN, an entry-level health care provider who is responsible for rendering basic nursing care) in Resident 1's room, Resident 1 had yellow and light purple discoloration (bruise) on the left…

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

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 five sampled residents (Residents 3, 27, and 236) were provided necessary treatment and services to prevent formation of and promote healing of pressure injury (pressure ulcers- injury to the skin and underlying tissue resulting from prolonged pressure on the skin) in accordance with the facility's policy and procedure and physician's order by failing to: 1. Accurately monitor, assess, and document Resident 3's skin from 4/1/2024 to 4/26/2024. Facility also failed to measure and document assessment of Resident 3's newly developed stage 2 pressure injury (when the wound extends into the bottom layers of the skin) on the right shoulder. Facility also failed to measure Resident 3's stage 2 pressure injury (when the wound extends into the top two layers of the skin as well as the fatty tissue) on the left ischium (the large bone in the lower part of the hip) and stage 3 pressure injury on the right ischium. This deficient…

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 its policy to check gastrostomy tube (G-tube, a tube that is placed directly into the stomach through an abdominal wall incision for administration of food, fluids, and medications) placement by auscultating the epigastric (upper central region of the abdomen) area while injecting a small amount of air for two (2) of two (2) sampled residents (Residents 14 and 24). This deficient practice had the potential for Resident 14 and 24 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 14's admission Record indicated the resident was initially admitted to the facility on [DATE] with diagnoses of anemia (a condition in which the body does not have enough healthy red blood cells [provide oxygen to body tissues]), coronary artery disease (caused by plaque buildup in the wall of the arteries that supply blood to the heart),…

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 three (3) of three (3) sampled residents (Resident 4, 28, and 34) by failing to provide emergency equipment in the activity room for accidental decannulation (the process whereby tracheostomy [trach- a surgically created hole in the windpipe that provides an alternate way of breathing)]tube is removed) for a resident with a tracheostomy in the activity room. This deficient practice had the potential for Residents 4, 28, and 34 to have respiratory distress during accidental decannulation. Findings: 1. A review of Resident 4's admission Record indicated Resident 4 was admitted to the facility on [DATE]. A review of Resident 4's History and Physical Examination (H&P), dated 8/27/2023, indicated Resident 4 had a history of seizure disorder (abnormal electrical activity in the brain that happens quickly), hypertension and chronic respiratory failure (a long term condition in which 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 ensure safe provision of pharmaceutical services as indicated on the facility policy by failing to: 1. Dispose expired medication found in Medication cart 1 drawer. This deficient practice had the potential for adverse reaction in the event that expired medication was administered to the residents. 2. Ensure Resident 4's Primidone (Mysoline, a medication used to treat convulsions) was stored and not found on the floor by Resident 4's doorway. 3. Ensure medications were kept locked at all times to prevent unauthorized access of the medications in the facility. These deficient practices have the potential to result in unauthorized access to medications by visitors and staff and predisposing them to possible medication overdose (taking a toxic or poisonous amount of a drug or medicine), unauthorized use of medications, adverse reactions (any unexpected or dangerous reaction to a drug), and drug-to-drug interactions (a reaction between two or…

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 proper food handling practices in accordance with its policy and procedure by failing to: 1. Label food in the kitchen with item name, date opened, and expiration date. 2. Ensure kitchen surfaces were clean. 3. Ensure there were no personal belongings stored in the kitchen storage. These deficient practices had the potential to result in pathogen (germ) exposure to residents, which could place the residents at risk for developing foodborne illness (food poisoning with symptoms including upset stomach, stomach cramps, nausea, vomiting, diarrhea, and fever) which could lead to other serious medical complications and hospitalization. Findings: 1. During concurrent observation of the facility's kitchen storage area and interview on 4/26/2024 at 6:26 PM with the Dietary Staff 4 (DS 4), DS4 stated the rice, flour, oyster sauce, and salsa containers were not and should have been properly closed. During concurrent observation of the…

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

Based on observation, interview, and record review the facility failed to properly dispose garbage in the kitchen by failing to have a lid on the garbage containers in accordance with the facility's policy and procedure. This deficient practice had the potential to attract pests and rodents contributing to an unsanitary kitchen. Findings: During a concurrent observation and interview with Dietary Director (DTD) on 4/27/2024 at 9:54 AM, there were multiple uncovered garbage cans observed in the kitchen. DTD stated, It is okay not to have covers so we are not touching the lid every time we have to throw trash inside the garbage can. During a concurrent observation and interview with DTD on 4/27/2024 at 10:23 AM, the garbage can in the dirty dishwashing area was full and did not have a cover. During a concurrent record review of the facility's policy titled, Infection Control - Food and Nutrition Services, revised 2/2022 and interview with the DTD on 4/27/2024 at 3:52 PM, DTD stated, We need to have a fitting lid on the garbage cans per policy. We also need to change gloves every time…

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 promote respect and dignity for one (1) of 1 sampled resident (Residents 236) by not ensuring Resident 236's indwelling catheter (soft, plastic or rubber tube that is inserted into the bladder to drain the urine) urine collection bag was inside the dignity bag (a bag used to cover and hold the catheter drainage/collection bag, so it is not visible). This deficient practice had the potential for Resident 236 to experience loss of dignity and self-esteem. Findings: A review of Resident 236's admission Record indicated the facility admitted Resident 236 on 4/1/2024 A review of Resident 236's History and Physical Examination, indicated Resident 236 was alert and oriented (it refers to a person's level of awareness of self, place, time, and situation). A review of Resident 236 's Minimum Data Set (MDS, standardized care and screening tool), dated 4/27/2024, indicated Resident 236 cognition was intact (processes of thinking and reasoning) skills for daily decision making. The MDS indicated Resident 236 was dependent…

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 three (3) sampled residents (Resident 3) was provided a homelike environment in accordance with the facility's policy and procedure by: 1. Using Resident 3's room to store 3 hospital computers workstations (used to store resident medication records and for documentation) and one tablet stand (used by facility staff, residents, and families to translate or for video calls). 2. Not replacing the window screen in Resident 3's room and leaving it propped against the wall. 3. Leaving a used disposable plastic cup on the floor next to the trash in Resident 3's room. This deficient practice had the potential for an unsanitary and unkempt resident environment and had the potential to negatively impact the resident's quality of life. Findings: A review of Resident 3's admission Record indicated Resident 3 was admitted to the facility on [DATE]. A review of Resident 3's History and Physical Examination (H&P), dated 4/2/2024,…

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