Westwood Post Acute

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 2) received therapy services as ordered by a physician.The failure decreased the facility's potential to ensure Resident 2 reached his highest rehabilitation potential. During an interview on 7/18/25 at 12:49p.m., with Resident 2, he stated issue with the manpower in therapy, they are skipping on therapy to 4x a week and then until 3x a week. Resident 2 stated the staff said they don't have enough staff in therapy when he spoke to one of the therapists. Resident 2 stated the therapy is helping with self-care and he needed more therapy, and he ran out of Medicare (a health insurance program) days.During a review of Resident 2's admission record on 7/18/2025, dated 5/29/2025 indicated Resident 2 was admitted to the facility with diagnosis including muscle weakness.During a review of Resident 2' s physician's order indicated an order dated 5/30/25 Occupational Therapy clarification: skilled OT (occupational therapy- a therapy aimed at helping individuals perform daily activities…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, and record review, the facility failed to implement their abuse policy and procedure for one of one resident (Resident 1) when the facility did not report Resident 1's injury of unknown source. This failure resulted in Resident 1's injury of unknown source not reported to required agencies (California Department of Public Health [CDPH], law enforcement agency, and Long-Term Care Ombudsman). This failure had the potential to compromise the safety of the residents in the facility. Findings: Review of Resident 1's clinical record titled, admission Record, dated 4/17/2025, indicated Resident 1 was admitted to the facility with diagnoses including COVID-19 (Coronavirus disease, an infectious disease caused by the SARS-CoV-2 virus, which can be very contagious, and spread quickly), hemiplegia (paralysis of one side of the body), and hemiparesis (a condition that causes partial paralysis or weakness on one side of the body) following cerebral infarction (commonly referred to as stroke) affecting…

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 their infection prevention practices were implemented when: 1. A urinary catheter (a semi-flexible plastic tube, one end inserted into the bladder [body organ that stores urine] and the other end is attached to a bag that collects urine) drainage bag touched the floor; 2. Hand hygiene (the practice of cleaning your hands to prevent the spread of germs and illness) and the removal/change of isolation gowns (a type of personal protective equipment (PPE) used in healthcare settings to protect healthcare personnel and patients from the spread of infection or illness, particularly from contact with blood and body fluids) was not completed between tasks; 3. There was no notification to the Dialysis center of the resident's isolation precautions (measures taken to protect both patients and healthcare personnel from infection by isolating individuals who are either infected or potentially infected with a contagious disease) and type 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 dignity and privacy was upheld for residents when: 1. Resident 23's privacy curtain was not fully drawn when Resident 23 removed her facility gown; 2. Assistant Director of Nursing (ADON) A referred to Resident's clothing protector as bibs in front of approximately 15 residents; and, 3. Certified Nursing Assistant (CNA) B was observed to assist feeding Resident 194 while standing over her. These failures had the potential for adverse effects on the psychosocial well-being and health of Resident 23, Resident 194 and approximately 14 others residents in the dining room during mealtime. Findings: 1. Review of Resident 23's clinical record titled, admission Record, dated 4/16/2025, indicated Resident 23 was admitted to the facility with diagnoses including obstructive hydrocephalus (a condition where the normal flow of cerebrospinal fluid [CSF - a clear, colorless liquid that surrounds and cushions the brain and spinal cord] is blocked…

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 two of 36 sampled residents (Resident 21 & Resident 445) from physical abuse. When: 1.Resident 231 was observed to physically hit Resident 21 2. Resident 231 was observed to physically hit Resident 445 These failures resulted in Resident 21 & Resident 445 to be physically abused by Resident 231. Findings: 1. During a review of the facility's SOC 341 (mandated report of suspected dependent adult/elder abuse form) dated 4/12/25, indicated an abuse allegation was reported to the California Department of Public Health (CDPH). SOC 341 indicated, Victim [Resident 21].suspected abuser [Resident 231]. SOC 341 indicated, At approximately 8:05 AM on 4.12.25, Resident [231] had hit another resident [Resident 21] in the face and pushed her to the floor. CNA had witnessed the incident and immediately ran over, called for help and separated both residents. SOC 341 indicated, Reported Type of Abuse Physical. Abuse resulted in Minor medical Care During a review…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to notify The Office of the State Long -Term Care (LTC) Ombudsman (an advocate for residents of nursing homes, board and care centers, and assisted living facilities) of resident's transfer or discharge in a timely manner when: 1. The Office of the State LTC Ombudsman was not notified for 16 of 51 discharged residents (Residents 151, 166, 237, 233, 183, 408, 103, 409, 410, 411, 404, 412, 414, 415, 416, and 417); and, 2. The facility's notification to The Office of the State LTC Ombudsman for six of 51 discharged residents (Residents 418, 419, 420, 421, 404, 422, and 423) were submitted late. These failures resulted in the State LTC Ombudsman not being informed in a timely manner and removed the opportunity for the State LTC Ombudsman (LTC-O) to advocate on resident's behalf. Findings: During a phone interview with LTC-O on 4/3/2025 at 10:12 a.m., LTC-O stated the facility's resident discharges were not reported to their office since 12/2024. During…

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 services were provided to prevent and/or heal pressure ulcers (damage to the skin or underlying tissue as a result of prolonged pressure) for two residents (Residents 190 and 546) when staff did not turn and reposition the residents every two hours. This failure had the potential to delay wound healing, worsening pressure ulcers and the development of new pressure ulcers for Resident 190 and Resident 546. Findings: 1. During multiple observations on 4/16/25 at 9:38 a.m., 11:40 a.m., 1:45 p.m., and 4:00 p.m., Resident 190 was lying in bed positioned on his back and was not able to turn himself. During multiple observations on 4/17/25 at 8:40 a.m., 10:45 a.m., 12:15 p.m., and 2:30 p.m., Resident 190 was lying in bed positioned on his back and was not able to turn himself. Review of Resident 190's medical record indicated he was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including aphasia…

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 that proper care and treatment services for oxygen (O2, a colorless, odorless gas) use was provided for three of 12 sampled residents (residents on oxygen therapy) when: 1. Residents 28's and Resident 152's O2 concentrator's (a device which concentrates the oxygen from ambient air) filters had some grayish substance build up; and, 2. Resident 212 was administered the wrong dosage of oxygen. These deficient practices had the potential for Residents 28, 152, and 212 to have complications related to improper treatment while receiving O2 therapy. Findings: 1a. Review of Resident 28's clinical record titled, admission Record, indicated Resident 28 was admitted to the facility with diagnoses including acute respiratory failure (lungs are unable to adequately deliver oxygen to the blood) with hypoxia (a condition where there is an insufficient amount of oxygen in the body's tissues or organs), influenza (a highly contagious respiratory illness caused by influenza viruses), emphysema (a chronic lung 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.

Based on observation, interview and record review, the facility failed to ensure staff had appropriate competencies to provide nursing care for one (Resident 192) out of seven sampled residents when Resident 192 was not assisted by staff when requested. This failure had the potential for physical injury and psychosocial distress. Findings: During a concurrent observation and interview on 4/14/25 at 10:55 a.m. with Resident 192 in her room, Resident 192 was trying to transfer from the bed to the wheelchair. Resident 192 pressed the call light. Certified Nurse Aide (CNA) X entered the room, turned off the call light button near Resident 192 and left the room. During an interview on 4/14/25 at 10:58 a.m. with CNA X, CNA X verified she did not assist Resident 192 when she entered the room and turned off the call light. During an interview on 4/17/25 at 9:37 a.m. with Case Manager (CM) N, CM N stated they have to ask the residents if they need help before turning off the call light and then assist the residents. During an interview on 4/17/25 at 4:04 p.m. with the Director of Nursing…

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

Based on observation, interview and record review the facility failed to post direct care staffing numbers, and nursing staff responsible for direct care to residents in a prominent place in each of four nursing stations of the facility. This failure had the potential for residents and visitors not knowing the accurate number of hours of staff working and which staff were scheduled and available to care for their needs. Findings: During an observation on 4/16/25 at 10:00 a.m., in Hallway 2, no staff schedule or direct patient care hours were posted and accessible to residents. During an observation on 4/16/25 at 10:05 a.m., in Hallway 3, no staff schedule or direct patient care hours were posted and accessible to residents. During an observation on 4/16/25 at 10:10 a.m., in Hallway 4, no staff schedule or direct patient care hours were posted and accessible to residents. During an observation on 4/16/24 at 10:15 a.m., in Hallway 5, no staff schedule or direct patient care hours were posted and accessible to residents. During an observation and interview on 4/17/25 at 2:10 p.m. with…

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

Based on interview and record review, the facility failed to ensure the accurate accountability of controlled medications (medication with a high potential for abuse and addiction) when: 1. Controlled medications were signed out of the Controlled Drug Record (CDR, an inventory or count sheet) but not documented on the medication administration record (MAR) as administered for four out of five residents (Residents 15, 61, 81, and 114). 2. Records of wasted controlled medications did not contain the co-signature from another nurse for four randomly selected residents (Resident 81, 294, 295, and 296) as per facility policy and procedures. These failures had the potential result to the misuse and abuse of controlled substance medications. Findings: 1. During the survey, the CDRs for five random residents receiving as-needed controlled medications were selected for review. During the interview on 4/16/25 at 10:48 a.m., the Assistant Director of Nursing (ADON) C explained the process of administering a controlled medication. The steps included assessing the resident for pain, checking 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.

During an interview on 4/14/25 at 10:55 a.m. with Resident 192, Resident 192 stated food was terrible, and vegetables were mushy. During an interview on 4/15/25 at 9:34 a.m. with Resident 61, Resident 61 stated food did not taste good. During a concurrent dining observation and interview on 4/15/25 at 12:13 p.m. with Resident 192, Resident 192 stated carrot was mushy. Resident 192 did not eat all the carrots on her plate. During a concurrent dining observation and interview on 4/15/25 at 1:00 p.m. with Resident 25 stated food lacked flavor. Resident 25 also stated carrots were overcooked. Resident 25 pressed his fork on the carrots on his plate and were easily mashed. During a lunch test tray conducted on 4/16/25 at 1:32 p.m. with the Dietary Manager (DM), Dietary Director (DD), Registered Dietician (RD) S, and Registered Dietician (RD) L, Regular Diet and Pureed Diet lunch trays were presented and both had mashed potato. DM and DD verified mashed potato lacked flavor. A review of facility's ordered diet list indicated 105 residents were on Regular diet, including pureed texture. A…

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

Based on observations, interviews, and record reviews, the facility failed to ensure evening snacks were offered to all residents. This failure had the potential to affect the nutritional and psychosocial wellbeing of residents who may receive snacks at the facility. Findings: During the Resident Council Meeting on 4/16/25, the Residents attending stated they have never have received snacks, the kitchen is closed after 7pm. 1a. During an interview on 4/17/25 at 1:33 p.m. with Resident 17, Resident 17 stated, Dinner comes about 6 p.m. and breakfast comes about 9 a.m., sometimes I want a snack at night, when I ask for one, they do not provide it. 1b. During an interview on 4/18/25 at 7:49 a.m. with Registered Nurse (RN) T, RN T stated, Residents do not ask for snacks, if needed we can get an order. There are no snacks available at night. 1c. During an interview on 04/18/25 at 2:34 p.m. with Resident 83, Resident 83 stated, I request snacks, and they are not provided. 2. During an interview with Resident 400 on 4/14/2025 at 11:07 a.m., Resident 400 stated she was not getting any…

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 and sanitary conditions were maintained in the kitchen for food preparation and food storage methods, according to standards of practice and facility policy when: 1. Frozen [NAME] (a type of fish) was stored in the freezer without use by date and opened cereals without open and used by dates. 2. Metal container was stored wet. 3. Pureed food was prepared in a sink These failures had the potential to expose residents to contaminants that could cause foodborne illness. Findings: 1a. During the initial kitchen observation on 4/14/25 at 9:11 a.m. with the Dietary Manager (DM), an opened box of frozen [NAME] was found in the freezer without use by date. The DM stated the [NAME] can be used for six months and must be labeled with the use by date. 1b. During an initial kitchen observation on 4/14/25 at 9:22 a.m. with the DM, DM verified two opened cereals in plastic bags without labels for open and use by dates were found in the dry…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain an accurate and systematically organized documentation in accordance with accepted professional standards and practices for one of five sampled residents (residents with peek-a-boo mittens [a type of mitten, often used in healthcare settings, that have a flap on the top that allows for easy inspection of the hand without removing the mitten and designed to prevent patients from removing medical equipment attached to them]) when Resident 23's used of peek-a-boo mitten was not documented in all her weekly summaries (a concise report that provides an overview of a resident's care and progress over the past week). This failure resulted an inaccurate and inappropriate documentation of Resident 23's weekly summaries. Findings: Review Resident 23's clinical record titled, admission Record, dated 4/16/2025, it indicated Resident 23 was admitted to the facility on [DATE] with diagnoses including obstructive hydrocephalus (a condition…

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

Based on observation, interview, and facility's document review, the facility failed to maintain resident's rights to privacy and confidentiality to one of 36 sampled residents (Residents 23) and one unsampled resident (Resident 397) when Resident 23 and Resident 397's personal information and care instructions were posted in the room visible to roommate's visitors. This failure had the potential to compromise resident's rights. Findings: 1. During an observation on 4/14/2025 at 10:08 a.m., inside Resident 23's room, Resident 23 was in bed, with right hand mitten in placed, half naked with upper chest exposed and with caregiver at bedside. Two care instructions were observed posted above Resident 23's head of bed's wall. The first care instruction post indicated, Head of bed elevated at least 40 degrees during feeding. The second care instruction post indicated, -LEFT SIDE WEAKNESS -KEEP LEFT ARM ELEVATED - TURN AND REPOSITION EVERY 2 HOURS. During a concurrent observation and interview with assistant director of nursing I (ADON I) on 4/15/2025 at 9:08 a.m., inside Resident 23's…

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

Based on interview and record review, the facility failed to ensure a pre-admission screening and resident review (PASARR, a federal requirement to help ensure that individuals who have mental disorder or intellectual disabilities are placed in facilities that can provide the appropriate care) was accurately completed for one of 36 sampled residents (Resident 28). This failure had the potential for inaccurate care and services provided to residents with a mental disorder, intellectual disability, or related conditions. Findings: Review of Resident 28's clinical record titled, admission Record, indicated Resident 28 was admitted to the facility with diagnoses including acute respiratory failure (lungs are unable to adequately deliver oxygen to the blood) with hypoxia (a condition where there is an insufficient amount of oxygen in the body's tissues or organs), influenza (a highly contagious respiratory illness caused by influenza viruses), emphysema (a chronic lung disease), and schizotypal disorder (a mental health condition characterized by unusual thoughts and behaviors,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to develop and implement individualized, resident-centered care plan for one of 36 sampled residents (Resident 23) when a care plan for Resident 23's behavior of pulling off her clothes or facility gown was not developed and implemented. This failure had the potential to result in not having to identify the specific care and services necessary to meet Resident 23's needs. Findings: Review Resident 23's clinical record titled, admission Record, dated 4/16/2025, it indicated Resident 23 was admitted to the facility with diagnoses including obstructive hydrocephalus (a condition where the normal flow of cerebrospinal fluid [CSF - a clear, colorless liquid that surrounds and cushions the brain and spinal cord] is blocked within the ventricles [fluid-filled spaces] of the brain), benign neoplasm (a non-cancerous growth of cells) of spinal cord, other specified disorders of brain, dysphagia (difficulty swallowing) , and encounter for attention to…

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

Based on interview and record review, the facility failed to ensure one (Resident 241) out of one sampled resident received treatment and care in accordance with professional standards of practice when Resident 241's vital signs were not checked and due medications were not given. This failure had the potential to compromise Resident 241's physical health condition. Findings: A review of Resident 241's medical record indicated diagnoses of, Paroxysmal Atrial Fibrillation (an irregular, fast heartbeat that comes and goes), Acute on chronic combined systolic and diastolic heart failure (a sudden worsening of a long-standing heart condition where the heart muscle has both problems contracting [systolic] and relaxing [diastolic] properly). A review of Resident 241's Physician Orders indicated, Diltiazem Hcl Oral Tablet 30 MG [milligram, unit of measurement] give 1 tablet by mouth three times a day for HTN [hypertension, high blood pressure]. Hold if SBP [systolic blood pressure, the top number in a blood pressure reading, representing the pressure in the arteries when the heart beats…

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

Based on observation, interview, and record review, the facility failed to provide necessary podiatry services for one of 36 sampled residents (Resident 215) when the toenails were longer than Resident preferred causing pain and concern for ingrown toenails or infection. This failure had the potential to affect the resident's foot health and contribute to injury and/or infection. Review of Resident 215's clinical records indicated Resident 215 had multiple diagnoses including hemiplegia (a symptom that involves the loss of the ability to move on one-side of body) and hemiparesis (one-sided weakness), and diabetes (high blood sugar). Resident 215's cognitive function is intact Review of Resident 215's order summary, dated 11/14/24, indicated Resident 215 may have Podiatry evaluation, Tx, and follow up every 61 days and prn (as needed). During an interview on 4/14/25 at 9:40 a.m. with Resident 215, Resident 215 stated, she requested to see the podiatrist, they showed her a paper stating saying the podiatrist saw her, but he never did. During a concurrent observation Resident 215's…

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

Based on interview and record review, the facility failed to ensure 1 out of 36 sampled residents (Residents 105) was free from unnecessary medications when there was inadequate monitoring for the resident's vitamin B12 (a supplement to treat vitamin B12 deficiency) and vitamin D (an essential vitamin that your body uses for normal bone development and maintenance) level as ordered. This resulted in inadequate monitoring related to medication management for the resident. Findings: A review of record of Resident 105's admission Record, dated 4/17/25, indicated the resident was admitted with diagnoses including deficiency of other specified B group Vitamins and history of falls. A review of Resident 105's clinical record indicated the following physician's orders: - Cyanocobalamin (vitamin B12) tablet 1,000 micrograms (mcg, unit of measurement) PO once a day for vitamin B12 deficiency, order dated 3/20/22; - Vitamin D3 tablet, 2,000 units by mouth one time a day, dated 3/20/22; - Vitamin D Level every 6 months in April and October of each year, dated 4/12/23. 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 ensure safe and orderly discharge for one (Resident 1) out of 2 residents when Resident 1 was discharged without established home health as ordered by the physician. This failure had the potential to put Resident 1 in danger upon returning to his home without a proper care and treatment. Findings: A review of Resident 1's medical records indicated, admission date of 1/7/24 and discharged date of 1/1/25. A review of Resident 1's diagnoses included hearing loss, gastrostomy (a surgical procedure where a tube is inserted through a small opening in the abdomen directly into the stomach) and malignant neoplasm of larynx (a cancerous tumor that forms in the voice box). A review of Resident 1's Interdisciplinary Discharge summary dated [DATE] indicated, .Transportation: Private, pick up by friend .Diet Order and Texture: three times a day enteral bolus feeding via GT [gastrostomy tube] . A review of Resident 1's Physician Orders indicated, May D/C [discharge]…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide services according to professional standards for one of three sampled residents (Resident1) when: 1. Resident 1's baseline care plan (a basic initial care plan created for a patient upon admission to a healthcare facility, outlining the most essential care needs and instructions until a more comprehensive care plan can be developed) related to dysphagia (difficulty in swallowing) and tube feeding (a flexible tube inserted through nose or belly to provide nutrients) were not developed in a timely manner; 2. Nurses did not notify dietitian or the attending physician when Resident 1 was admitted with tube feeding formula not in facility stocks; and 3. Licensed vocational nurse A (LVN A) signed the IV ATB administered by a registered nurse (RN) for Resident 1. These failures had the potential to compromise Resident 1's quality of care. Findings: 1. Review of Resident 1's clinical record titled, admission Record, indicated 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 interview and record review, the facility failed to provide the pharmaceutical services to meet the needs of residents when: 1. Licensed nurses did not administer the ordered intravenous (IV, to deliver a medication into a vein) antibiotic (ATB, a medicine that inhibits the growth of or destroys bacteria) in a timely manner as documented for three of three sampled residents (Residents 1, 2 and 3); and 2. Licensed nurse used other resident's normal saline (NS - a sterile solution containing 0.9% sodium chloride [salt] in water) to mix the Vancomycin for one of three sampled residents (Resident 1). These failures resulted in medication not given to Resident's 1, 2, and 3 as per their scheduled time and had a potential to affect their health and safety. Findings: 1a. Review of Resident 1's clinical record titled, admission Record, indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including malignant neoplasm (primary cancer) of esophagus (a muscular tube that moves food from 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 notify the physician promptly for one of one resident (Resident 1) when Physical Therapist (PT, who promote, maintain, or restore health through patient education, physical intervention, disease prevention, and health promotion) A did not communicate with Resident 1's charge nurse when the resident fell during her physical therapy session and sustained minor injuries. This failure had the potential to result in a delay of assessment and possible treatment to Resident 1. Findings: Review of Resident 1's face sheet (a document that gives a resident's information at a quick glance) dated 6/11/24 indicated, Resident 1 was admitted to the facility on [DATE] with diagnoses of oral surgical aftercare, cancer, reduced mobility. Review of Resident 1's SBAR & INITIAL COC/ALERT CHARTING & SKILLED DOCUMENTATION (a documentation for change of a resident's conditions) dated 4/24/24 at 3:53 p.m. indicated, Date & Time Problem or Symptom Started: 04/24/2024 12:00…

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 promote respect and dignity for one of one resident (Resident 1) when Social Services (SS) A told Resident 1 she would call 911 (a telephone number for emergencies) for a 5150 (the number of the section of the Welfare and Institutions Code, which allows an adult who is experiencing a mental health crisis to be involuntarily detained for a 72- hour psychiatric hospitalization when evaluated to be a danger to others, or to himself or herself, or gravely disabled) assessment when the resident was trying to advocate for her roommate. This failure had the potential to negatively affect the resident's dignity and psychosocial well-being. Findings: Review of Resident 1's face sheet (a document that gives a resident's information at a quick glance) indicated Resident 1 was admitted to the facility on [DATE] with diagnoses of type 1 diabetes (a lifelong condition where the pancreas makes little or no insulin, which leads to high blood sugar levels), major…

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 services provided met professional standards of practice when a licensed nurse (LN) did not ensure medications were taken for one of one sampled resident (Resident 1). For Resident 1 LN did not observe medications were taken after giving the medications to the Resident. This finding had the potential to compromise Resident 1's health and safety. Review of Resident 1's Face Sheet (document that contains a summary of personal and demographic information), indicated Resident 1 was admitted to the facility on [DATE] with diagnoses of unspecified fracture (break in a bone) of the upper end of the right humerus (upper end of the arm bone) and superior rim of the right pubis (bone that forms the front of the pelvis), wedge compression fracture of the third lumbar vertebra (bones located in the middle of the spine), Hyperlipidemia (elevated levels of fats in the blood), Hypertensive Heart Disease (changes in the heart as a result of chronic high 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 interviews and record review facility failed to maintain respect and dignity for one out of five sampled Residents (Resident 2) when staff tried to interfere on his right to use his power wheelchair. This failure resulted in psychosocial distress to Resident 2 and his family. Findings: Review of Resident 2 ' s admission Record printed 12/5/23 indicated Resident 2 was originally admitted to the facility on [DATE], readmitted [DATE] with diagnoses including Traumatic Subdural Hemorrhage (pool of blood between the brain and its outermost covering) without loss of consciousness subsequent encounter; Type 2 Diabetes Mellitus (problem with the way the body uses and regulates sugar) with diabetic polyneuropathy (simultaneous malfunction of peripheral nerves throughout the body), generalized muscle weakness, and restless leg syndrome. Review of Resident 2 ' s Minimum Data Set (MDS, an assessment tool) dated 10/27/23 indicated Resident 2 had a Brief Interview for Mental Status (BIMS, a cognitive assessment)…

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 to provide a safe, functional, and comfortable environment for residents and staff when: 1. Room (RM) A and B TV cables were dangling; 2. RM B ' s bathroom light fixture was without cover; 3. RM B and C ' s baseboards were missing paint and dusty; 4. RM D and E ' s dresser (furniture with several drawers used to store clothes) drawer handles were broken; and 5. RM F, G, H, I, J, and K ' s dresser drawers were peeling with plastic layer hanging. This failure had the potential to affect the safety of the staff and the comfort of the residents. Findings: During an observation on 1/31/24 at 10:20 a.m. in Room (RM) A and B, the television (TV) cables were exposed and dangling from the ceiling. During an observation on 1/31/24 at 10:25 a.m. in RM B ' s bathroom, the light fixture above the sink was exposed without a cover. During an observation on 1/31/24 at 10:30 a.m. in RM B and C, the baseboards were unkept with missing paint and dusty. During an observation on 1/31/24 at 10:35 a.m. in RM D and E, 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 follow their bed rails (side rails, safety rails and grab/assist bars) policy for 34 of 35 sampled residents (Residents 117, 121, 159, 104, 89, 65, 134, 175, 99, 3, 125, 49, 43, 101, 26, 53, 81, 131, 11, 78, 105, 149, 617, 618, 6, 9, 32, 172, 154, 206, 1016, 35, 193, and 79). The survey team expanded the sample and identified that a total of 198 residents had bed rails. The facility failed to follow their bed rails policy when: 1. There was no documentation that alternatives were attempted prior to installing bed rails for 198 of 198 residents; 2. There was no documentation that risks and benefits were explained to the residents or responsible parties (RP, individuals designated to make decisions on behalf of the residents) prior to installing bed rails for 198 of 198 residents; 3. There was no documentation that the facility assessed for risk of entrapment (becoming trapped between the bed rail and mattress) prior to installing bed rails…

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

Based on observations, interviews, and record reviews the facility failed to ensure: 1. Resident 35 with a wheat allergy received nourishing and palatable meals to meet their needs; 2. The overall day-to-day food and nutrition services operations were carried out in a safe and sanitary manner for food service, preparation, storage, and delivery; equipment sanitation; kitchen staff competency; ineffective pest control; and acceptable parameters of nutrition care to prevent significant and severe resident weight loss for two sampled residents (Residents 104 and 175), according to standards of practice and facility policy. These deficient practices led to 231 residents being exposed to these improper conditions, specifically 197 residents who consume food from the kitchen. Cross reference F692, F802, F804, F812, F813, F908, and F925 Findings: 1. During an observation and interview on 11/13/23 at 1:10 p.m. with Resident 35, the resident stated they were served wheat products yesterday including wheat bread and cream of wheat for breakfast. Resident 35 stated, I get a rash and wheezing…

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

Based on observations, interviews, and record reviews the facility failed to ensure the kitchen staff had the competencies and training to perform their job duties and tasks according to standards of practice and facility policy when: 1. A Dietary Aide did not safely store milk on the trayline served to residents. 2. Two Dietary Aides did not know how to correctly test the sanitizer in the three-compartment sink. These failures had the potential to expose 197 residents who receive food from the kitchen to contamination from food and chemicals that may harm their health and nutrition status. Findings: 1. During the initial kitchen tour on 11/13/23 at 8:03 a.m., Dietary Aide K (DA K) was observed on the trayline adding 8-ounce milk cartons and cold drinks to the breakfast meal trays. There was a food utility cart with two gray milk crates half full of fat-free 8-ounce milk cartons on top and a large rectangle sized tan colored rubber bin on the middle shelf with 4-ounce strawberry protein shakes, and other flavors. The milk crates and rubber bins did not have ice in them or around 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 observations, interviews, and record reviews the facility failed to ensure the recipes were followed, and food was served at a safe and palatable temperature according to facility policy and resident complaints. These failures had the potential to negatively affect the nutritional status due to poor food intake of 197 residents on a therapeutic diet and who may consume a snack from the kitchen. Cross reference F800 Findings: 1. During the initial kitchen tour on 11/13/23 at 8:03 a.m., an observation of an extra-large metal pot was on the stove with meat sauce, uncovered without a lid. The stove was turned off. During an observation and interview on 11/13/23 at 10:14 a.m. with [NAME] D, [NAME] D was preparing the meatballs for the meatball sandwich lunch entrée. [NAME] D placed several frozen pre-made meatballs from a large box on an extra-large baking sheet. [NAME] D stated she was cooking the meatballs for the lunch meal meatball sandwich. She stated she would use the frozen meatballs for the regular diet meals and the meat sauce she prepared earlier in the large pot, for…

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

Based on observation, interview, and facility document review, the facility failed to store, prepare, and serve food in accordance with professional standards for food service safety when: 1. Food preparation equipment and utensils were not maintained clean and/or in good condition including: a. Two of three ice machines; b. Pans, pitchers, mixing bowls; c. A meat slicer; d. An industrial can opener; e. Cutting boards; f. Knives; and g. A microwave. 2. Kitchen storage equipment were not clean and/or in good repair including: a. Food storage racks in the walk-in refrigerator were rusty; b. Drawers holding food preparation/serving utensils; c. A rack holding food preparation equipment/utensils; d. A cart holding items such as cooking oil and gloves; and e. A cart holding clean cutlery. 3. Floor drains were not maintained clean; 4. Kitchen floors were not clean and were not maintained in good repair; 5. Walls were not maintained clean and in good repair in the kitchen and in the dry food storeroom; 6. Non-food contact equipment in the kitchen was not maintained clean including; 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 observations, interviews, and record reviews the facility failed to have a policy pertaining to the safe storage of resident food brought in from the outside. This failure had the potential to expose 197 residents who consume food, to contamination from the unsafe storage of the resident's food from outside stored in three facility refrigerators, including an employee refrigerator where resident and employee food were comingled. Findings: During an interview on 11/14/23 at 4:08 p.m., with Certified Nurse Assistant U (CNA U), CNA U stated residents can bring food in from outside and the food is stored in the refrigerator inside the staff breakroom in Station C. CNA U stated the CNAs would label the resident's food with their name and room number before it is placed in the refrigerator. During an interview on 11/14/23 at 4:10 p.m. with Certified Nurse Assistant H (CNA H), CNA H stated there were two residents he knew of that had food brought in by visitors. CNA H further stated he thought food like…

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 3. Review of Resident 177's admission Record indicated he was admitted to the facility on [DATE]. During an observation and interview with Certified Nursing Assistant II (CNA II) on 11/13/23 at 12:20 p.m., Resident 177 had two urinals on his bed side table; they were dirty and had dry yellow residue around their necks. CNA II stated Resident 177 used the two urinals and confirmed they were dirty. CNA II stated the urinal should be washed every two hours and changed if it was dirty. During an interview with the Infection Preventionist (IP) on 11/17/23 at 8:59 a.m., he stated the urinal should be washed after it was used. The resident's urinal should be kept clean and changed if it was dirty. Review of the facility's policy, Cleaning and Disinfecting Non-Critical Resident-Care Items, dated 6/2011, indicated . Steps in the Procedure: . Measuring Graduates/Urinals: 1. Rinse measuring graduate/urinal with warm water after each use. 2. Disinfect measuring graduates/urinals weekly using EPA-registered and facility…

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

Based on observation, interview, and facility document review, the facility failed to maintain kitchen equipment in safe operating condition when: 1. Water was dripping onto the floor from the dish machine; 2. A sink/garbage disposal drain was leaking; and 3. A three-compartment sink did not have appropriate drain plugs to allow the sinks to be filled with water. The failure to maintain the equipment working in the way intended had the potential to lead to contamination of food, utensils, and equipment for 197 residents who received food from the kitchen. Findings: Review of the policy and procedure titled, Sanitation dated 2023, showed in the Food and Nutrition Services (FNS) Department, all equipment shall be maintained as necessary and kept in working order. In addition, employees are to alert the FNS Director immediately to any equipment needing repair. Also, the FNS Director will report any equipment needing repair to the maintenance man. The Maintenance Department will assist FNS as necessary in maintaining equipment. 1. An observation and interview 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 facility document review, the facility failed to maintain the facility: 1. Free of flies; and 2. In a manner to keep pests from entering the kitchen. This failure had the potential to result in pest transferred disease to residents for a census of 231. Findings: Review of the Policy and Procedure titled Pest Control dated 2001, showed the facility shall maintain and effective pest control program. Review of the Policy and Procedure titled Sanitation dated 2023, showed on a monthly basis, a pest control company will inspect and service the Food and Nutrition Services Department. If at any time additional servicing is needed, the pest control company will be notified. According to the 2022 Federal Food Code, perimeter walls of a food establishment shall effectively protect the establishment from the entry of insects, rodents, and other animals. In addition, the premises is to be maintained free of insects, rodents, and other pests. 1. On 11/13/23 at 9:39 a.m., a small fly was observed in the kitchen preparation area. On 11/13/23 at 10:40 a.m., five…

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 Review of Resident 9's clinical record indicated she was admitted to the facility on [DATE] with diagnoses including spondylosis (condition caused by aging and wear and tear on the spine) and diabetes. Review of Resident 9's POLST, dated 6/6/22 indicated the section regarding advance directives was left blank. There was no documented evidence that indicated Resident 9 had an advance directive or that advance directives were discussed with the resident.Based on interview and record review, the facility failed to ensure advance directives (written statement of a person's wishes regarding medical treatment should the person be unable to communicate them to a doctor and also allow residents to appoint a health care agent who will have legal authority to make health care decisions in the event that the resident is incapacitated) were discussed with the residents and/or responsible parties for nine of 35 sampled residents (Residents 3, 9, 11, 105, 134, 149, 175, 176, and 618). This failure violated the residents'…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide care and services in accordance with professional standards of practice for 11 of 35 sampled residents (Residents 265, 32, 172, 175, 99, 195, 159, 617, 11, 618, and 105) when: 1. For Resident 265, a speech therapy consult was not done per physician order; 2. For Resident 32, staff provided the resident with salt while she was on a physician ordered no added salt diet; 3. For Resident 172, a licensed nurse failed to properly administer the resident's tube feeding and there was no order or documented assessments for the use of peek a boo hand mittens; 4. For Resident 175, there was no documented assessments or care plan for the use of peek a boo hand mittens and order for use of peek a boo mittens was not followed as indicated. 5. For Resident 99, there was no documented order, assessments or care plans for the use of peek a boo hand mittens. 6. For Resident 195, staff failed to safely administer medications when a medication 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to: 1. Provide parameters to maintain acceptable nutrition status for a planned weight loss regimen for one sampled resident (Resident 175) with severe weight loss; and 2. Complete a nutrition assessment for one of six sampled residents (Residents 104) with significant weight loss. These failures had the potential to result in undesirable and/or avoidable weight loss for two out of six sampled residents with facility reported significant weight loss. Cross reference F800 Findings: 1. Per the facility's admission Record, Resident 175 was admitted on [DATE] with diagnoses that included cerebral infarction (restricted blood and oxygen to the brain), encephalitis (inflammation of the brain), dysphagia (difficulty swallowing), type 2 diabetes (inability to manage blood sugar), and autoimmune thyroiditis (when the body makes substances to attack it's thyroid gland). Resident 175 experienced a 12.3% weight loss in six months from May 2023 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 controlled substance medications (medication with a high potential for abuse and addiction) were accurately accounted for on the Medication Administration Record (MAR) and the Controlled Drug Record (CDR) for seven of eight randomly selected residents (Residents 94, 111, 131, 168, 184, 189 and 193). Two of two randomly selected medication cart controlled drug sign-in/sign-out sheets (a sheet used to reconcile inventory of controlled medications in the medication cart by the outgoing and incoming nurse during a shift change) were missing signatures of the outgoing and incoming nursing shift. Medications for disposal in the medication storage room and one medication cart were not rendered unusable and irretrievable. Five of 13 emergency kits (e-kit; a kit/box containing medications and supplies for immediate use during a medical emergency) were not replaced timely after being opened or expired. These failures resulted in the facility…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure opened multi-dose medications and biologicals were dated with an open and discard date to ensure they were not used beyond the discard date, expired medications were not available for resident use, single resident over-the-counter (OTC) products were appropriately labeled with a pharmacy label or name to correctly identify which resident they were for, vaccine refrigerator temperatures were monitored daily, labeling of pharmacy-dispensed gabapentin with an expiration date, and storage of medication separate from resident food items. The deficient practices had the potential for residents to receive medications with unsafe and reduced potency from being used past their discard date, incorrect medications from inadequate labeling, and unsafe or ineffective medications or biologicals from inadequate temperature monitoring and storage. Findings: 1. During a concurrent observation and interview on 11/13/23 at 10:18 a.m. with Assistant…

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 treat residents with respect and dignity for four of 35 residents (28, 53, 104, and 162) when 1. Certified Nursing Assistant W (CNA W) and Certified Nursing Assistant X (CNA X) did not maintain privacy when providing care for Resident 28 and 53; and 2. Certified Nursing Assistant Z (CNA Z) and Certified Nursing Assistant CC (CNA CC) were standing while feeding Resident 162 and Resident 104. These failures had the potential to cause embarrassment and feeling low self-esteem for the residents. Findings: 1a. Review of Resident 28's admission Record indicated she was admitted to the facility on [DATE]. During an observation on 11/13/23 at 8:18 a.m., Resident 28 was sitting on the wheelchair in her room and facing the room door. CNA W was changing her without closing the door or the curtain. Resident 28 was naked from the waist up and could be seen from the hallway. During a concurrent interview with CNA W, she stated she should close the door…

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 complete a quarterly Minimum Data Set (MDS, an assessment tool) for one of three residents (Resident 81). Failure to assess had the potential to compromise the facility's ability to provide resident-centered care plan interventions. Findings: Review of Resident 81's medical record indicated he was admitted to the facility on [DATE]. The medical record indicated the facility completed an admission MDS, which was dated 6/19/23. Further review of Resident 81's medical record indicated the facility scheduled a quarterly MDS with a date of 9/15/23. The record indicated this MDS was still In Progress and not Completed. The record further indicated this quarterly MDS was supposed to be completed by 10/3/23 and was 43 days overdue. During an interview and concurrent record review with the Minimum Data Set Coordinator (MDSC) on 11/15/23 at 12:51 p.m., she reviewed Resident 81's medical record and confirmed the facility did not complete the quarterly MDS dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to accurately complete the Minimum Data Set (MDS, an assessment tool) for two of 35 sampled residents (Residents 117 and 121). This failure had the potential to compromise the facility's ability to provide resident-centered care plan interventions. Findings: 1. Review of Resident 117's medical record indicated she was admitted on [DATE] and had the diagnoses of anxiety, dementia (mental disorder caused by brain disease or injury), and epilepsy (a brain disorder that causes seizures). Review of Resident 117's SBAR (Situation, Background, Assessment, Recommendation) documentation, dated 6/12/23, indicated Resident 117 had a witnessed fall. During an interview and concurrent record review with the Minimum Data Set Coordinator (MDSC) on 11/15/23 at 9:56 a.m., she reviewed Resident 117's medical record and confirmed the resident fell on 6/12/23. The MDSC explained this fall should have been coded on the MDS dated [DATE]. The MDSC reviewed Resident 117's 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.

Based on interview, and record review, the facility failed to coordinate the Preadmission Screening and Resident Review (PASARR, is a federal requirement to help ensure that individuals who have a mental disorder or intellectual disabilities are not inappropriately placed in nursing homes for long term care) for one of 35 residents (Resident 32) when a PASARR was not done after Resident 32 had a significant change in condition. This failure resulted in Resident 32 not being evaluated and placed the resident at risk for not receiving the appropriate care or services. Findings: Review of Resident 32's clinical record indicated she was admited to the facility 12/9/20 with diagnoses including dementia (decline in mental capacity affecting daily function) and bipolar disorder (mental disorder characterized by periods of elevated mood and depression, often with poor decision-making). Review of Resident 32's PASSAR, dated 12/11/20, indicated the evaluation was negative. Review of Resident 32's minimum data sets (MDS, an assessment tool), indicated she had a significant change assessment…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to develop and implement interventions to maintain the ability to communicate for one of 35 sampled residents (Resident 104). This failure had the potential to result in Resident 104's needs not being met. Findings: Review of Resident 104's medical record indicated she was admitted on [DATE] and had the diagnoses of dementia (mental disorder caused by brain disease or injury), diabetes (disease that affects the body's ability to control blood sugar), hypertension (high blood pressure) and depression. Review of Resident 104's Minimum Data Set (MDS, an assessment tool), dated 9/27/23, indicated her speech was clear and she was usually able to make herself understood. The MDS indicated Resident 104's preferred language was a foreign language and she needed an interpreter to communicate with health care staff. The MDS further indicated communication was to be addressed in Resident 104's care plan. Further review of Resident 104's medical 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 ensure an activity program was provided to one of 35 sampled residents (Resident 618). This failure had the potential to affect the overall well-being and quality of life of the resident. Findings: A review of Resident 618's clinical record indicated he was admitted on [DATE] and had diagnoses including surgical aftercare following surgery on the genitourinary system and dementia (a decline in mental capacity affecting daily functioning). His minimum data set (MDS, an assessment tool), dated 10/11/23 indicated he was not able to complete the brief interview for mental status. It also indicated Resident 618 felt it was very important to listen to music he liked and somewhat important to have books, newspapers, and magazines to read for him. During a review of Resident 618's activities care plan, the care plan included interventions to offer a la carte activities, magazines and the newspaper; offer 1:1 visit if unable to attend out of room…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 4. Review of Resident 265's clinical record indicated she was admitted to the facility with diagnoses including contracture of muscle (tightening or shortening of the muscle which can result in loss of joint mobility and joint deformity) and dysphagia (difficulty swallowing). Review of Resident 265's Skin Assessment, dated 7/19/23 indicated the resident had two trochanter (a bony prominence on the thigh bone close to the hip) pressure ulcers. The assessment also indicated the MD was notified and received new treatment orders and wound consult. Review of Resident 265's orders, indicated an order, dated 7/19/23, Wound MD consult for L [left] trochanter wound. Review of Resident 265's Skin Assessment, dated 8/4/23 indicated the two small trochanter pressure ulcers merged into one wound. The assessment also indicated, Notified MD. New order for Wound care consult ordered . Documentation of Resident 265's wound consults in August 2023 were requested. There were no August 2023 wound consults provided. 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 one of 35 sampled residents (Resident 618) had and was wearing his hearing aids (small devices placed in the ear to amplify sound). This failure had the potential to compromise the residents' health, ability to relate to others, and psychosocial well-being. Findings: A review of Resident 618's clinical record indicated he was admitted on [DATE] and had diagnoses including surgical aftercare following surgery on the genitourinary system and dementia (a decline in mental capacity affecting daily functioning). His Minimum Data Set (MDS, an assessment tool), dated 10/11/23 indicated he was not able to complete the brief interview for mental status and had adequate hearing with hearing aids. During an observation and interview from 11/13/23 to 11/14/23 in Resident 618's room, he did not respond to greetings but just stared. During an interview on 11/15/23 at 3:31 p.m. with Resident 618's family member, she stated Resident 618 could not…

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 of 35 sampled residents (Residents 265, 65, 149) with limited mobility were provided appropriate treatment and services: 1. For Resident 265 and 65, there was no documentation that restorative nursing services (RNA, restorative care for individuals recovering from illnesses or injuries) were provided as ordered; 2. For Resident 149, there was no care plan or interventions developed to address her arthritis (inflammation or swelling in one or more joints that can result in stiffness and pain). These failures had the potential to result in decreases in mobility and complications for residents. Findings: 1a. Review of Resident 265's clinical record indicated she was admitted to the facility with diagnoses including contracture of muscle (tightening or shortening of the muscle which can result in loss of joint mobility and joint deformity). Review of Resident 265's RNA - Weekly Summary, date 6/9/23 indicated the resident 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 ensure one of 35 residents (Resident 175), with an indwelling catheter (a small, flexible tube that can inserted through the bladder to drain into a urine bag) received care consistent with professional standards when there was no evidence of an order for a indwelling catheter, there was no evidence of catheter care, and there was no evidence of a care plan a indwelling catheter. These failures had the potential to put Resident 175 at risk of not receiving the interventions necessary to maintain their highest level of well-being and at risk of a urinary infection. Findings: Review of Resident 175's clinical record indicated she was admitted to the facility with multiple diagnoses including cerebral infarction (a life-threatening condition that happens when part of the brain doesn't have enough blood flow) and neuromuscular dysfunction of the bladder (lack of bladder control). During an observation on 11/13/23 at 10:45 a.m. in Resident 175's room, Resident 175 was in her bed sleeping, an indwelling catheter…

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 respiratory care in accordance with professional standards of practice for three of 35 sampled residents (Residents 209, 617, and 105) when: 1. For Resident 209 and 617, staff failed to ensure oxygen was administered as specified in the physician's order; and 2. For Resident 617, staff administered oxygen without a physician's order. These failures had the potential to compromise the residents' health and safety. Findings: 1.a. Review of Resident 209's clinical record indicated he was admitted on [DATE] and had diagnoses including acute respiratory failure (inability to keep oxygen and carbon dioxide at normal levels) and dependence on supplemental oxygen. Review of Resident 209's physician's order, dated 11/03/17, indicated he was to receive oxygen (O2) at 2 to 3 liters per minute (LPM, rate of oxygen administration) or to keep O2 saturation (sat) above 92% via nasal cannula (flexible tubing placed into the nostrils and connected…

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 observation, interview, and record review, the facility failed to ensure a resident receiving hemodialysis (medical procedure of removing waste products and excess fluid from the blood through an artificial kidney) treatment received care consistent with professional standards for one of 35 sampled residents (Resident 49) when Resident 49's dialysis access site was incorrectly assessed and documented upon Resident 49's return to the facility and the care plan for dialysis was not specific to Resident 49's hemodialysis. This failure had the risk of causing the resident health complications. Findings: During a review of Resident 49's clinical record, the clinical record indicated Resident 49 was admitted to the facility with multiple diagnoses including end-stage renal disease (ESRD, kidney failure that requires dialysis or a kidney transplant to survive). During an observation and interview on 11/13/23 at 9:44 a.m., in Resident 49's room, Resident 49 was in the bed waiting to be transported to hemodialysis (a procedure where a dialysis machine and a special filter called an…

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

Based on interview and record review, the facility failed to act upon the Consultant Pharmacist's (CP) monthly medication regimen reviews (MRR) for two of five sampled residents (Residents 6 and 175). This failure had the potential for unsafe medication use for these residents. Findings: 1. Resident 175 was admitted to the facility in February 2023 with diagnoses which included schizoaffective disorder (a mental disorder in which people interpret reality abnormally in combination with mood disorder) and major depressive disorder. A review of Resident 175's medical record (MR) indicated the following orders for psychotropic medications (drugs that affect brain activities associated with mental processes and behaviors): - Aripiprazole 5 milligrams (mg, a unit of measurement): Give 2 tablets via G-tube (a tube inserted through the belly that brings nutrition directly to the stomach) one time a day for Schizophrenia m/b (manifested by) visual hallucinations, dated 10/12/23; and - Depakote Delayed-Release (DR, a formulation designed to release in the intestine) 250 mg: Give 1 tablet via…

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 of five sampled residents (Resident 6 and 175) were free from unnecessary psychotropic medications (drugs that affect brain activities associated with mental processes and behaviors) when: 1. Resident 6 received carbamazepine (Tegretol, anticonvulsant; medication used to treat seizures, a medical condition in the brain causing stiffness, twitching or limpness), lamotrigine (Lamictal, anticonvulsant medication) and benztropine (anticholinergics, medication to treatment tremors or movement disorder) without clinical indications for use; and there were no specific behavioral symptoms for auditory and visual hallucinations (what the resident sees or hears), no monitoring for auditory hallucinations for use of Abilify (antipsychotic used to treat mental conditions), and inaccurate Abnormal Involuntary Movement Scale (AIMS; a rating scale designed to measure involuntary movements known as tardive dyskinesia [a condition affecting 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 had a medication error rate of 5.71% when four medication errors occurred out of 70 opportunities during the medication administration observation for four out of eight residents (Resident 1016, 206, 103 and 109). The failure resulted in medications not given according to the physician's orders and had the potential for residents not receiving the full therapeutic effects of the medications. Findings: 1. During a concurrent observation and interview on 11/13/23 at 8:08 a.m., with Licensed Vocational Nurse A (LVN A), LVN A was observed preparing six medications for Resident 1016. LVN A stated the resident's furosemide (Lasix, medication used to treat high blood pressure and remove extra fluid in the body) was not available, and pharmacy has been notified. Review of Resident 1016's clinical record indicated a physician order of Lasix (furosemide) 20 milligrams (mg, unit of measurement) give 0.5 tablet by mouth one time a day for ascites (abdominal swelling caused by accumulation of fluid) and urinary retention…

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 serve foods that accommodated residents' food allergies for one of 35 sampled residents (Resident 35). Resident 35, who was allergic to mushrooms and wheat products was served mushrooms and wheat products on two separate occasions. This deficient practice had the potential to cause severe allergic reactions and cause harm to the resident. Findings: During an interview and concurrent record review with Resident 35 on 11/13/23, at 1:10 p.m., while in Resident 35's room. Resident 35, was alert and oriented, and stated she was allergic to wheat products and mushrooms. Resident 35 stated she was served wheat bread and cream of wheat yesterday, and meat with mushroom the other day. Resident 35 further stated that she experienced rash and wheezing from wheat products and mushrooms. Resident 35 stated she already informed the Dietary Manager (DM) about her allergies to wheat and mushrooms, but the incident still occurred. Review of Resident 35's tray ticket indicated, Allergies: LACTOSE INTOLERANT, MUSHROOM, WHEAT PRODUCTS. Review…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure services were provided in accordance with professional standards of practice for one resident (Resident 1) when: 1. There was no documentation that the facility communicated with the dialysis center to check on the resident ' s well-being when the resident did not return as anticipated after dialysis treatment (a treatment for people whose kidneys are failing), and 2. There was no documentation that the facility assisted the resident ' s transportation arrangement when it was cancelled. These failures had the potential to compromise the resident ' s health and well-being. Findings: A review of Resident 1's clinical record indicated he was admitted on [DATE] and had diagnoses including end stage renal disease (ESRD, a medical condition in which a person ' s kidneys cease functioning) and dependence on renal dialysis. During a review of Resident 1 ' s physician's order, dated 8/16/23, the order indicated hemodialysis at [name of the dialysis…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure care and services were provided in accordance with professional standards of practice for one of two residents (Resident 1) when: 1. The facility did not follow their own policy for diabetes (blood sugar higher than normal) management, and 2. The care plan for diabetes was not developed. These failures had the potential to compromise residents' care and well-being. Findings: A review of Resident 1's clinical record indicated Resident 1 was admitted on [DATE] and had diagnoses including type 2 diabetes mellitus. During a review of Resident 1's physician's order, dated 10/04/23, the order indicated Humulin N subcutaneous suspension 100 unit/ml inject 14 unit subcutaneously in the morning for DM, given 30 minutes before breakfast. A further review of Resident 1's order, dated 10/06/23, indicated Check FSBS (finger stick blood sugar) before breakfast and dinner, If BS <70, follow hypoglycemia guideline and notify MD, If BS is 300 and greater, call…

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 services was provided to meet professional standard of practice for Resident 1 when the licensed nurses (LNs) did not initial and document the time, level of pain, and effectiveness of the medication given for pain. This failure may affect the health and safety of Resident 1. Findings: Review of Resident 1's clinical record indicated she was admitted to the facility on [DATE] with diagnoses including multiple fractures of right side of the ribs. Review of Resident 1's physician order dated 8/26/23 indicated give 2.5 milliliter (ml, unit of measurement) Morphine Sulfate oral solution (narcotic pain medication) 10 milligrams/5 milliliters (mg/ml, unit of measurements) orally as needed for pain. Review of Resident 1's controlled drug inventory sheet done on 9/11/23 indicated Morphine Sulfate oral solution were given by licensed vocational nurse A (LVN A) on 8/27/23 at 12 MN; LVN B on 8/30/23 at 12 MN; and LVN C on 9/9/23 at 12:10 a.m. There was no…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility failed to ensure residents were free of accidents and hazards for one of two sampled residents (Resident 1) when: 1. Staff did not develop and/or implement resident-centered interventions to prevent falls, and 2. Care Support Team Members (CSTM) were not supervised by their supervisor during resident care. These failures resulted not prevent further falls for Resident 1. Findings: During a review of Resident 1's clinical record, the record indicated Resident 1 was admitted on [DATE] and had diagnoses including type 2 diabetes (high blood sugar), dementia, restlessness and agitation, hypertension (high blood pressure), and psychotic disorder with hallucination (a perception of having seen, heard, or touched something that was not actually there). During a review of Resident 1's Minimum Data Set (MDS, an assessment tool) dated 6/29/23, the MDS indicated a brief interview for mental status (BIMS, a structured cognitive test) scoring 04 (severe impairment). Resident 1 required limited assistance (staff…

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 physician's orders regarding pressure ulcer order treatment for sacrum (bone in the lower back ), implement the care plan intervention regard pressure ulcer (PU, injury to the skin and the underlying tissue resulting from prolonged pressure on the skin, complete the weekly skin assessment, and conduct interdisciplinary team (IDT, a group of health care professionals with various areas of expertise who work together toward the goals of their residents) meeting to discuss Resident 1's PU condition and progress for one of three sampled residents (1) when: 1. Facility did not follow the acute hospital discharge order for low air loss (LAL, a type of therapy mattress designed to help prevent and treat pressure wounds) and avoiding the use of adult absorbent brief for Resident 1's wound management. 2. Facility did not follow doctor's order for Resident 1's PU treatment, 3. Facility did not implement the PU care plan intervention for LAL mattress 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 store medications in a safe and sanitary condition when: 1. Fifteen of fifteen medication carts (Med Carts 1-15) had multi-colored and sticky substances; medication pills were spilled inside the med carts; med carts stored expired medications; med carts stored unlabeled medications; med carts had improperly stored medications; and 2. Three of five medication rooms (Med Rooms E, D, and B) stored staff's personal items; the medication refrigerator temperatures in two med rooms (Med Rooms D and B) were out of range; and the refrigerator temperature log was incomplete for one med room (Med Room E); These failures had the potential for the residents to receive used, contaminated, and/or deteriorated medications. Findings: 1a. During Med Cart 10 inspection with registered nurse GG (RN GG) on 4/19/21 at 10:33 a.m., observed the following: 1) Pill crusher (device to crush the medication) had black, grey, and white substances. 2) Applesauce (for…

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 staff implemented proper infection control practices when: 1. Nurse staff did not follow infection control practices during medication passes (med pass, nurse administered the medications to residents per physician's order) for four of nine observed residents (Residents 114, 151, 30, and 72). 2. Housekeeping staff did not follow infection control practices when cleaning residents' rooms; 3. An outdated gastric tube (GT, tube inserted through the abdomen into the stomach to deliver nutrition, hydration and medication) syringe (tube with a nozzle and piston used to suck and eject liquid) was not discarded for Resident 126; 4. Surgical masks were not stored properly for Residents 30, 33 and 75; a nasal cannula was not stored properly for Resident 16; screening for signs and symptoms of respiratory illness was not consistently done for Resident 68; 5. Staff failed to perform hand hygiene after touching potentially contaminated objects…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to maintain dignity and privacy for five of 33 sampled residents (Residents 102, 73, 36, 143 and 66) and one non-sampled resident (Resident 72). For Residents 102, 73, 36, 143 and 66, staff provided feeding assistance while standing over the residents. For Resident 72, staff did not provide privacy during the finger stick blood sugar check (FSBG, medical device is used to prick the resident's fingertip to collect a blood sample and test the blood sugar level). These failures to maintain dignity may impact the residents' quality of life and lower residents' self-esteem. Findings: Review of Resident 102's Minimum Data Set (MDS, an assessment tool), dated 2/26/21, indicated cognitive skills for decision-making were severely impaired and the resident was totally dependent on staff with eating. Review of Resident 73's MDS, dated [DATE], indicated she needed assistance from staff with eating. Review of Resident 36's MDS, dated [DATE], 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 8. The clinical record for Resident 100 was reviewed. He was admitted on [DATE] with diagnoses including cerebral edema and acute respiratory failure with hypoxia (absence of enough oxygen in the tissues to sustain bodily functions). His care plan included behavior episodes of undressing self and pulling trach tubing. His physician orders included, Behavior Monitoring: document number of episodes per shift of target behavior (specify) 1. Undressing self, 2. Pulling trach tubing, date started [DATE]. A record review of the behavior monitoring record per the above order for [DATE], indicated the licensed nurses on all shifts were charting YES or NO answers to the record instead of monitoring how many times behavior 1 or 2 occurred. During an interview on [DATE] at 12:55 p.m. RN Z, she reviewed the [DATE] charting for Behavior Monitoring for Resident 100 and stated document number of episodes should specify which behavior 1 or 2 not yes or no; the problem is, it is not marking how many times he is doing 1 or 2. RN…

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

Based on interview and record review, the facility failed to ensure the controlled substance medications (medication with a high potential for abuse and addiction) were accurately accounted on the medication administration record (MAR) and the Controlled Drug Record (CDR) for two randomly selected residents (Residents 6 and 7). The facility failed to ensure the controlled substance was disposed properly for one randomly selected resident (Resident 91). Nurse staff stored Resident 569's opened controlled medication in medication cart 12 (Med cart 12). These failures had the potential to result in residents not getting the controlled medications per physician's order and potential to cause misusing and abusing the controlled medications. Findings: 1. Review of Resident 6's physician order, dated 1/8/21, indicated to administer one tablet of one milligram (mg, measure unit) lorazepam (medication for anxiety) by mouth every 24 hours as needed for anxiety. Review of Resident 6's CDR and MAR from 1/15/21 to 1/26/2020 indicated nurse staff removed one tablet of lorazepam from 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 employ dietary staff with the appropriate competencies and skills to carry out the functions of the food and nutrition service when: 1. Dietary staff did not know how to check the dish machine's sanitizer correctly; 2. Dietary staff did not know how to check the quaternary sanitizer (sanitizer used to clean kitchen counters, tables and surfaces, and used to manually sanitize dishes) at three compartment sinks area (3 sinks used to manually sanitize dishes with quaternary sanitizer); 3. Dietary staff did not know how to calibrate the temperature thermometers correctly; the registered dietitian (RD) did not know how to calibrate the temperature thermometers correctly; and 4. RD was not aware how kitchen function and did not supervise the kitchen or provide in-service to dietary staff. The lack of knowledge of the RD created the potential for dietary staff to be inadequately trained and supervised to carry out their job functions properly; the lack of knowledge of dietary staff had the potential to compromise…

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

Based on observation, interview, and record review, the facility failed to maintain sanitary conditions in the kitchen when: 1. Dietary staff did not cover their hair completely with a hairnet; 2. Toaster had multi-colored substances; 3. Refrigerator (fridge) had multi-colored substance; 4. Electrical pipes on the wall near the kitchen table had black sticky substance; 5. The can opener had multi-colored substances; 6. Multi-colored substance noted on the top of the dish washer; 7. There was no space (air gap) between dish machine (same as dish washer) and food preparation sink drain pipes and floor sink drain; 8. Two of three ice machines (Ice machine B and C) had black substance at the interior and exterior of the ice machines; 9. There was no evidence that the facility identified and addressed the multiple out of range dish machine temperatures (per the dish machine temperature log). These failures had the potential to cause food-borne illness for residents. Findings: 1a. During an initial kitchen tour with the dietary manager (DM) on 4/19/21 at 9:14 a.m., the DM, dietary aides…

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 document review, the facility failed to maintain sanitary conditions for the dumpsters when four of five dumpsters were overflowed with disposable food plates and utensils, dumspters were not covered with lids, garbage bags were overflowed from the side of the dumpster, and used gloves were on the ground next to the dumpsters. These failures had potential to harbor or feed the pests. Findings: During an observation at the dumpster's area near the parking lot with the maintenance supervisor (MS) on 4/22/21 at 4:50 p.m., two dumpsters were overflowed with disposable food plates and utensils. These two dumpsters were not covered with lids. One dumpster contained cardboard without a lid covering. One dumpster had garbage bags overflowed from the side of the dumpster. Multiple used gloves were noted on the ground next to the dumpsters. During an interview with the MS on 4/22/21 at 4:55 p.m., he stated the dumpsters should be covered with a lid and the dumpsters should not be overflowing. Review of the facility's revised policy, Storage Area,…

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 its policy and resident plan of care for one non-sampled resident (Resident 150) by not ensuring an adaptive device was available for Resident 150. Resident 150's eyeglasses were kept in the social service office instead of by the bedside. This deficient practice had the potential to delay provision of services and could have resulted in the resident's needs not being met. Findings: Review of Resident 150's admission Record indicated he was admitted to the facility with a diagnosis including unspecified glaucoma (a group of eye conditions that can cause blindness). Review of Resident 150's Minimum Data Set (MDS, an assessment tool), dated 1/13/2021, indicated he had a BIMS (Brief interview of mental status) score of eight (8-12 indicates moderate cognitive impairment). Review of Resident 150's care plan, dated 10/10/2018, indicated Resident 150 had altered visual function due to impaired vision, and the interventions indicated to keep eyeglasses clean and within easy reach. Review of Resident 150'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 one of one sampled resident (Resident 140) was free from physical restraints when staff placed both of Resident 140's feet into a single pressure relief boot (device strapped to the foot in order to reduce pressure on the heels). This practice impaired Resident 140's ability to move both lower extremities (feet and legs) and had the potential to negatively affect his physical and psychosocial well-being. Findings: Review of Resident 140's clinical record indicated he was admitted on [DATE] and had the diagnoses of respiratory failure (the body is unable to effectively transfer oxygen and carbon dioxide) and myoclonus (muscle jerks). Review of Resident 140's Minimum Data Set (MDS, an assessment tool), dated 1/6/21, indicated he was totally dependent (staff provide full assistance) and required physical assistance from two or more people for bed mobility (how the resident moves to and from lying position, turns side to side, 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 implement their abuse policy for one of two sampled residents (Resident 25) when they did not report an injury of unknown source to the Ombudsman (an advocate for the residents) and law enforcement. This failure had the potential to delay investigation of the incident in order to rule out abuse. Findings: Review of Resident 25's clinical record indicated she was admitted on [DATE] and had the diagnoses of respiratory failure (the body is unable to effectively transfer oxygen and carbon dioxide), osteoporosis (condition that causes weak and brittle bones) and quadriplegia (both arms and legs are paralyzed). Review of Resident 25's situation, background, assessment, recommendation (SBAR, a communication tool) documentation, dated 2/23/21, indicated she had swelling on the left knee. Review of Resident 25's Interdisciplinary Team (IDT, staff from different disciplines who work together to plan and provide care) Progress Notes, dated 2/24/21, indicated the…

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

Based on observation, interview, and record review, the facility failed to ensure the environment was free of accident hazards when: 1. The patio door in Station A leading to the parking lot was open; and 2. Staff did not keep the bed in its lowest position for one of six sampled residents (Resident 73) as indicated in the care plan. These failures could potentially result in serious injury to the residents in the facility. Findings: 1. During an observation in Station A on 4/19/2021 at 12:15 p.m., Resident 160 was standing near an open automatic door and was attempting to go to the patio. Assistant director of nursing F (ADON F) and licensed vocational nurse EE (LVN EE) were standing next to Resident 160 and redirecting her to go back inside the unit. During a concurrent interview with LVN EE and ADON F, LVN EE stated she saw Resident 160 going to the patio and immediately tried to stop and redirect the resident's behavior. According to ADON F, they had many residents who wandered frequently. During an observation in Station A with ADON F on 4/22/2021 at 10:41 a.m., the patio door…

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

Based on observation, interview and record review, the facility failed to provide respiratory care in accordance with professional standards of practice and facility's policy and procedure for four of 13 sampled residents (Residents 106,111, 36 and 164) when: 1. For Residents 106, 36 and 111, facility staff failed to ensure oxygen was administered as specified in the physician's order. Residents 36 and 111 did not have the oxygen sign posted outside of the room. 2. For Resident 164, facility staff administered oxygen without a physician's order. These failures had the potential to compromise the residents' health and safety. Findings: 1. Review of Resident 106's order summary report, dated 12/20/2020, indicated oxygen at 2 liters/min (liters per minute, LPM, unit of measurement) via nasal cannula (flexible tubing placed into the nostrils and connected to an oxygen source) continuously via concentrator (machine used to deliver oxygen) every shift. During an observation on 4/19/21 at 9:47 a.m., Resident 106 was lying in bed receiving oxygen at 2.5 LPM via nasal cannula. During another…

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 three of eight sampled residents (Residents 5, 74 and 68) were free from unnecessary psychotropic medications (medications that cause changes in mood, feelings or behavior) when: 1. For Residents 5 and 74, staff did not monitor target behaviors (behavior intended to be reduced or eliminated by administering the psychotropic medication); and 2. For Resident 68, staff did not provide non-pharmacological interventions (interventions that do not involve the use of medications) before administering as needed (PRN) psychotropic medication. These failures had the potential to compromise the facility's ability to determine the effectiveness of the psychotropic medications. These failures also had the potential to increase the residents' risk for adverse effects from the medications. Findings: 1. Review of Resident 5's clinical record indicated she had the diagnosis of major depressive disorder (mood disorder that causes a persistent feeling of sadness…

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 had a 19.23% medication error rate with five medication errors during 26 opportunities during the medication passes (med pass, licensed nurses administer medication to residents) for two of nine observed residents (Residents 117 and 118). This failure had the potential to jeopardize the residents' medical condition and health. Findings: 1. During a med pass observation in Resident 118's room on 4/20/21 at 6:04 p.m., licensed vocational nurse KK (LVN KK) administered the mixture of water and famotidine (medication for digestive disease), mixture of water and sennosides (medication for constipation) to Resident 118 via gastrostomy tube (GT, a soft tube surgically inserted from the abdomen area into stomach for medication and nutrition use). After LVN KK finished med pass for Resident 118, white residue particles of famotidine and brown residue particles of Sennosides remained on the bottom and side of the medication cups. Both medications were not completely dissolved with water and Resident 118 did not receive the full…

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 five resident beds (Room F beds a, b and c; Room G bed b and Room H bed c) were in safe operating condition when these five beds were found not locking properly. Two of the five beds were occupied by Residents 18 and 27. This failure can put residents and staff at risk for accidents. Findings: During a dining observation on 4/19/21 at 12:32 p.m., Resident 18 was being served his lunch tray by certified nursing assistant A (CNA A). A clean folded diaper pad was noted under the bed of Resident 18. During a concurrent interview with CNA A, he stated, The diaper is placed under the bed to keep it locked as it moves even when locked, maintenance is fixing the bed. During a concurrent observation and interview on 4/20/21 at 10:32 a.m., CNA A stated, Yesterday I took the (diaper) pad off from [Room F bed a] after you left. I tested it again today and it still moves. CNA A then showed surveyor all beds in Room F (beds a, b and c) were…

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.