San Pablo Healthcare & Wellness Center

Based on observation, interview, and record review, the facility failed to provide appropriate care and services related to enteral feeding (also referred to as tube feeding, is the delivery of nutrients through a feeding tube directly into the stomach, duodenum, or jejunum) nutrition for one sampled resident (Resident 252) on a feeding tube when Resident 252 did not receive the calculated amount of tube feeding formula (designed to provide nutrition to individuals who cannot consume adequate food orally) per physician's order. This failure had the potential to cause dehydration, weight loss, and gastrointestinal (GI, relating to stomach and intestines) problems such as abdominal pain and diarrhea. Findings: During a record review of Resident 252's admission Record (AR), printed on 6/25/25, the AR indicated Resident 252 was admitted to the facility in April 2025 with diagnoses of traumatic subarachnoid hemorrhage (bleeding into the space surrounding the brain caused by head trauma) and gastrostomy status (refers to the presence of a gastrostomy tube, a surgically placed tube into…

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 two out of six residents (Resident 1 and Resident 3) were free from physical abuse when: 1) Resident 1 was hit in the head by Resident 2, 2) Resident 3 had lemonade thrown at her by Resident 4. This failure resulted in Resident 1 and Resident 3 being the recipient of physical abuse which affected their physical and psychosocial well-being. Findings: 1) A review of Resident 1 ' s Face Sheet, printed 3/4/25, indicated Resident 1 ' s diagnoses of heart failure (heart not able to pump enough blood to meet body ' s needs) and generalized weakness. A review of Change in Condition Evaluation, written on 12/8/24 at 9:42 a.m., the Change in Condition Evaluation noted Resident 1 was in the room waiting for Resident 2 to come out of the bathroom. Resident 1 stated when Resident 2 came out of the bathroom, Resident 2 hit her twice in the head. In the Pain Assessment section, Resident 1 reported a pain level of 4 (0 being the lowest pain level and 10 being the highest pain level). During an interview on 3/4/25, at…

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

Based on interview and record review, the facility failed to implement their policy and procedure to thoroughly investigate an allegation of abuse for one (Resident 1) of three sampled residents. Resident 1 alleged that a Certified Nursing Assistant (CNA1) hit him on the right leg because he refused to wear a sock. Facility designee/Director of Nursing (DON) did not interview alleged CNA, staff member assigned to provide care for Resident 1 and/or implement care plan to suspend alleged abuser while incident was under investigation. This failure had the potential to place Resident 1 at risk for emotional distress, mistreatment, or abuse. Findings: During a review of Resident 1's Minimum Data Set (MDS - a federally mandated resident assessment and care guide tool), dated 3/11/25, the MDS indicated Resident 1's Basic Interview of Mental status (BIMS, a scoring system used to determine the resident's cognitive status regarding attention, orientation, and ability to register and recall information. A BIMS score of thirteen to fifteen is an indication of intact cognitive status.) Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure necessary treatment and care services was provided for one (Resident 2) of three sampled residents in accordance with professional standards of practice when, rehabilitation referral for restorative nursing (RNA) for Resident 1 was not followed up. This failure had the potential for Resident 1 to not receive the necessary care and services to ensure mobility and muscle strength. Findings: During a review of Resident 2's Minimum Data Set (MDS - Resident assessment and care guide tool), dated 2/26/25, the MDS indicated Resident 2's Basic Interview of Mental Status (BIMS, a scoring system used to determine the resident's cognitive status regarding attention, orientation, and ability to register and recall information. A BIMS score of thirteen to fifteen is an indication of intact cognitive status.) score was 15 and indicated intact mental status. The MDS indicated Resident 2 was able to recall the correct year, month, and day of the…

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

Based on observation, interview and record review, the facility failed to provide choice based on resident preferences for one of two sampled residents (Resident 1) when Resident 1 was not changed to his hospital gown upon request and was left in street clothes overnight. This failure had the potential to cause physical discomfort and emotional distress to Resident 1. Findings: During a record review of Resident 1 ' s admission Record, printed 12/31/24, the admission Record indicated Resident 1 was admitted to the facility in May 2024 with multiple diagnoses that included congestive heart failure (a chronic condition where the heart can't pump blood efficiently) and type 2 diabetes (a long-term disease in which the body cannot regulate the amount of sugar in the blood). During a record review of Resident 1 ' s Care Plan, dated 1/26/24, the Care Plan indicated Resident 1 had decreased ability to perform self-care related to impaired activity tolerance, impaired balance/safety, pain limiting function, weakness . During an observation and interview on 12/27/24, at 8:55 a.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 observation, interview and record review, the facility failed to provide treatment and care in accordance with professional standards of practice for one of two sampled residents (Resident 1) when Resident 1 ' s call light was not answered in a timely manner. This failure had the potential to cause physical discomfort and emotional distress to Resident 1. Findings: During a record review of Resident 1 ' s admission Record, printed 12/31/24, the admission Record indicated Resident 1 was admitted to the facility in May 2024 with multiple diagnoses that included congestive heart failure (a chronic condition where the heart can't pump blood efficiently) and type 2 diabetes (a long-term disease in which the body cannot regulate the amount of sugar in the blood). During a record review of Resident 1 ' s Care Plan, dated 1/26/24, the Care Plan indicated Resident 1 had decreased ability to perform self-care related to impaired activity tolerance, impaired balance/safety, pain limiting function, weakness . During an observation and interview on 12/27/24, at 9:00 a.m., with Resident…

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

Based on observation, interview, and record review, the facility failed to maintain a clean and sanitary environment for one of two sampled residents (Resident 1) when Resident 1 ' s room had: 1. Uncovered trash bin which contained an overflow of soiled diapers and dirty gloves. 2. Resident 1 ' s clothing stored in a mesh bag which was on the floor right next to the overflowing trash. This deficient practice had the potential to cause an unsanitary environment and spread of infection. Findings: During a record review of Resident 1 ' s admission Record, printed on 12/31/24, the admission Record indicated Resident 1 was admitted to the facility in May 2024 with multiple diagnoses that included congestive heart failure (a chronic condition where the heart can't pump blood efficiently) and type 2 diabetes (a long-term disease in which the body cannot regulate the amount of sugar in the blood). During an observation and interview on 12/27/24, at 8:55 a.m., with Resident 1, Resident 1 was sitting on his bed. Under Resident 1 ' s edge of the bed, there was a small trash bin with 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 Based on interview and record review, the facility failed to ensure two of three sampled residents (Resident 1 and Resident 3), received the necessary services to maintain good grooming, and personal hygiene when they were not receiving showers consistently and as scheduled. This failure resulted in these residents being unhappy and facility not meeting their physical, mental, and psychological needs. Findings: During a review of Resident 1's face sheet, the face sheet indicated, Resident 1 was admitted to the facility with diagnoses that included Diabetes (a long-term (chronic) disease in which the body cannot regulate the amount of sugar in the blood), severe obesity, generalized weakness, and depression. During a review of Resident 1's Minimum Data Set (MDS, an assessment tool used to guide care), dated 7/21/24, the MDS indicated, a Brief Interview Mental Status (BIMS, a brief scanner to help detect cognitive impairment) score of 15 indicating no cognitive impairment. The MDS also 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.

Based on observation, interview and record review, the facility failed to maintain the physical environment in accordance with standards of practice, when one resident room and the bathroom used by five residents was not clean. This failure did not ensure residents were provided with a clean, sanitary, and comfortable environment. Findings: During an observation on 10/9/24 at 11 a.m., in Resident 1 and 3 ' s bathroom, the bathroom appeared dirty. Over the toilet bowl a raised toilet seat with arms was placed. Inside the toilet bowl, there were dried scattered brown/black substance around its upper surface and some around the raised toilet seat over it. The toilet bowl had yellowish liquid inside which appeared like urine still sitting there not flushed. There was trash can with no trash liner and looked dirty inside. The bathroom floor appeared dirty. During an interview on 10/9/24 at 11:05 a.m., with Resident 2, Resident 2 stated, they don ' t clean the bathroom unless you call them. Resident 2 stated the bathroom is always like that unless they call the housekeeping to clean it.…

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

Based on observation, interview and record review, the facility failed to ensure two of four sampled residents (Resident 1 and Resident 2), were free from physical abuse when Resident 1 hit Resident 2 on his left lower leg while Resident 2 was sleeping and Resident 2 punched Resident 1 on the chest during a second altercation few hours later. This failure placed Resident 1 and Resident 2 at significant risk for physical and emotional harm. Findings: During a record review of Resident 1's admission Record (AR), dated 10/4/24, the AR indicated, Resident 1 was initially admitted to the facility in August 2024. During a record review of Resident 1 ' s Minimum Data Set (MDS, a resident assessment instrument used to identify resident care problems to be addressed in an individualized care plan.), dated 9/18/24, Resident 1 had diagnoses of Chronic Obstructive Pulmonary Disease (COPD, refers to a group of diseases that cause airflow blockage and breathing-related problems. It includes emphysema and chronic bronchitis), major depressive disorder (a mental health condition that causes 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 observation, interview and record review, the facility failed to follow their policies and procedures to mitigate the spread of COVID-19 (a respiratory virus that can cause mild to severe respiratory illness) when: 1. Resident room doors in the COVID-19 positive wing were left open. 2. The portable air conditioning unit filters were not cleaned per manufacturer's recommendation. 3. The portable air conditioning unit in the COVID-19 positive wing was turned off. Findings: During an interview on 7/2/24 at 1:57 p.m. with Infection Preventionist (IP), IP stated there were 36 active cases of COVID-19 as of 7/2/24. During an interview and concurrent record review on 7/2/24 at 2:04 p.m. with IP, facility map and list of COVID-19 residents were reviewed. IP stated on 6/20/24, there were four residents that tested positive for COVID-19. IP stated on 6/24/24, a total of 20 residents also tested positive for COVID-19, followed by four more residents on 6/28/24. IP stated the facility transferred all residents that tested positive for COVID-19 to a COVID-designated area (Station 2).…

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 that all registry employees were screened for background check and trained on abuse prevention when one registry Certified Nurse Assistant (CNA) 1 did not have a background check or abuse prevention training prior to taking care of residents in the facility. This failure had the potential to put residents at risk for injury or harm. Findings: During an interview on 6/20/24 at 10:40 a.m. with the Director of Nursing (DON), DON stated the staff that was involved in an alleged employee to resident abuse incident of Resident 1 on 4/6/24. The staff was a registry CNA (CNA 1). A request was made for the abuse prevention training and CNA certification for the CNA 1. During an interview on 6/20/24 at 1:10 p.m. with DON, DON stated the Staffing Coordinator (SC) was the one responsible for screening and checking the documents of registry staff. The facility did not produce the CNA certification or abuse training for CNA 1. During a telephone interview on 6/21/24 at 9:25 a.m. with SC, SC confirmed that she was the one in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, for one of three sampled residents (Resident 1), the facility failed to provide pain management to Resident 1 consistent with comprehensive person-centered plan of care and resident's goals when Resident 1 was not administered pain medication (hydromorphone, an opioid analgesic to treat moderate to severe pain) as ordered. This failure resulted in Resident 1's pain not being control resulting in increased agitation and verbal aggression. Findings: During a review of Resident 1's admission Record, dated 4/24/24, the admission Record indicated Resident 1 was admitted to the facility in January 2024 with diagnoses that included peripheral vascular disease (circulatory condition in which narrowed blood vessels reduce blood flow to the limbs), chronic kidney disease (a condition in which the kidneys are damaged and cannot filter blood as well as they should), polyneuropathy (condition in which a person's peripheral nerves are damaged, affecting the nerves in the skin, muscles,…

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, for one of three sampled residents (Resident 1), the facility failed to provide pharmaceutical services and procedures that assure accurate dispensing and administration of controlled drugs when administration of hydromorphone (a controlled opioid medication to treat pain) was not accurately recorded in the Medication Administration Record (MAR). This failure had the potential to result in confusion in dosing administration and drug diversion. Findings: During a review of Resident 1's admission Record, dated 4/24/24, the admission Record indicated Resident 1 was admitted to the facility in January 2024 with diagnoses that included peripheral vascular disease (circulatory condition in which narrowed blood vessels reduce blood flow to the limbs), chronic kidney disease (a condition in which the kidneys are damaged and cannot filter blood as well as they should), polyneuropathy (condition in which a person's peripheral nerves are damaged, affecting the nerves in the skin, muscles, and organs), cellulitis (common bacterial skin infection that causes…

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, for one of three sampled residents (Resident 1), the facility failed to ensure allegation of a missing wallet was investigated thoroughly. This failure had the potential to result in further potential misappropriation of Resident 1's personal property. Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility in July 2023 with diagnoses that included essential hypertension (abnormally elevated blood pressure), chronic atrial fibrillation (irregular and often very rapid heart rhythm) and primary open angle glaucoma (happens when the eye's drainage canals become clogged over time, can cause gradual vision loss). During a review of Resident 1's Minimum Data Set (MDS, an assessment tool used to direct resident care) dated 2/12/24, the MDS indicated a Brief Interview for Mental Status (BIMS, is a scoring system used to determine the resident's cognitive status in regard to attention, orientation, and ability to register and recall information) score of 15 (A BIMS…

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, record reviews, and facility policy review, the facility failed to ensure residents who had medication in their room and self-administered medications had a physician's order to do so and were assessed as safe to self-administer medication(s). The deficiency affected 4 (Residents #18, #28, #49, and #82) of the 21 sampled residents. Findings included: A review of the facility policy titled, Medication - Self Administration, revised on 01/01/2012, revealed The Facility will allow a resident to self-administer medications when determined capable to do so by the IDT [interdisciplinary team] and the resident's Attending Physician. Per the policy, II. If a resident wants to self-administer medication, the IDT will assess the resident's cognitive, physical, and visual ability to carry out this responsibility based on a review of an assessment by a Licensed Nurse. 1. A review of Resident #28's admission Record revealed the facility most recently admitted the resident on 02/24/2022,…

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 record review, interviews, and facility policy review, the facility failed to ensure that 1 (Resident #6) of 2 sampled residents reviewed for advance directives had an order in their electronic health record (EHR) that was consistent with the resident's wishes for no cardiopulmonary resuscitation (CPR). Findings included: A review of a facility policy titled Advance Directives, revised in [DATE], indicated that the purpose of the policy was To ensure that the Facility respects advance directives. The policy revealed, The facility will respect a resident's advance directive and will comply with the resident's wishes expressed in an advance directive. The policy revealed, Do Not Resuscitate - Indicates that, in case of respiratory or cardiac failure, the resident, legal guardian, health care proxy, or representative (sponsor) has directed that no cardiopulmonary resuscitation (CPR) or other life-saving methods are used. A review of Resident #6's admission Record revealed the facility admitted the resident…

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

Based on interviews, record review, and facility policy review, the facility failed to ensure that allegations of abuse were reported to facility administration immediately for 1 (Resident #6) of 2 sampled residents reviewed for abuse. Specifically, Resident #6 made an allegation of abuse to a charge nurse that was not immediately reported to the Administrator. Findings included: A review of a facility policy titled Abuse- Reporting & Investigations, revised in March 2018, revealed, Allegations of abuse, neglect, mistreatment, exploitation or reasonable suspicion of a crime to be [sic] reported to the Administrator or designated representative immediately. A review of Resident #6's admission Record revealed the facility admitted Resident #6 on 02/01/2021. According to the admission Record, the resident had a medical history that included diagnoses of unspecified injury at the C2 level of the cervical spinal cord, chronic pain syndrome, and adjustment disorder with mixed anxiety and depressed mood. A review of Resident #6's annual Minimum Data Set (MDS), with an Assessment Reference…

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

Based on interviews, record reviews, and facility policy review, the facility failed to schedule and complete a quarterly care plan review for 3 (Residents #8, #28, and #82) of 4 sampled residents reviewed for care planning. Findings included: A review of the facility policy titled Comprehensive Person-Centered Care Planning, revised in November 2018, revealed f. Each resident and/or resident representative will actively remain engaged in his or her care planning process through the resident's rights to participate in the development of, and be informed in advance of changes in the plan of care. The policy specified, c. The comprehensive care plan will be periodically reviewed and revised by IDT [interdisciplinary team] after each assessment which means after each MDS [Minimum Data Set] assessment as required, except discharge assessments. 1. A review of Resident #28's admission Record revealed the facility admitted the resident on 02/24/2022, with diagnoses that included end stage renal disease and dependence on renal dialysis. A review of Resident #28's quarterly Minimum Data Set…

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, record reviews, and facility policy and document review, the facility failed to follow appropriate infection control procedures during wound care for 2 (Resident #11 and Resident #76) of 3 sampled residents reviewed for pressure ulcer/injury. Findings included: A review of an undated facility Clean Dressing Change Competency/Validation form revealed Competency Description: Dressings are applied using clean technique to promote wound healing and to prevent cross-contamination among and between residents and caregivers. A section titled Procedures revealed, Remove soiled dressing, noting drainage amount and type then discard in the appropriate waste receptacle. Remove old dressings, one layer at a time, if layered. Determine if dressing remains appropriate for treatment. Thoroughly inspect the wound. Remove and discard gloves, perform hand hygiene and apply clean gloves. Cleanse/irrigate wound, including periwound, as ordered. The form revealed, Remove and discard gloves, perform…

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 (Residents 1, 2 and 3) of three sampled residents were served meals in a dignified manner when the residents reported their meals were served in Styrofoam containers and were provided plastic utensils; and one (Resident 1) of three sampled residents was not provided a shower for weeks. These failures did not promote a positive dining experience for Residents 1, 2, and 3; and Resident 1 stated feeling ignored when staff did not honor her request to use an extra-large transfer sling for a shower. Findings: 1. During an observation and interview on 4/18/23 at 9:34 a.m., Resident 1 stated it was about a month the facility served meals in Styrofoam containers and provided plastic utensils and paper cups. Resident 1 stated kitchen service was erratic due to lack of staff, broken equipment, and budget. Resident 1 stated it was unenjoyable to eat this way for weeks. During an interview on 4/18/23 at 10:02 a.m., Resident 2 stated I don…

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 policy regarding discharge planning for three residents (Resident 50, 51 and 75) of 25 sampled residents when the facility did not complete a discharge plan within seven days of admission. This resulted in Residents 50, 51 and 75 not having plans for discharge and causing unnecessary anxiety and frustrations. Findings: 1. During a review on 6/2/21, at 10:30 a.m., the facility Face Sheet indicated, Resident 50 was admitted to the facility on [DATE] with multiple diagnoses including, fracture of the right femur, unsteady on his feet, and drug abuse. During an interview on 6/1/21, at 11:00 a.m., Resident 50 stated he still needed to know when he would be discharged from the facility. Resident 50 stated he was concerned about how he could function in the community and he was anxious. During a review of the Care Conference Summary, dated 4/29/21, it indicated, Resident 50 asked when he would be discharged ? Resident 50 was notified…

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 professional nursing care for three residents (Resident 35, 51 and 52) of 25 sample residents on hemodialysis (an artificial kidney procedure used to clean the patient's blood), when; 1. Staff did not remove the dressing and assess the hemodialysis venous access site per policy post hemodialysis for resident 35. 2. Staff did not assess and monitor the hemodialysis venous access site for Resident 51,. 3. Intake and Output (I&O) was not monitored since admission and dietary recommendations from the Registered Dietician (RD) were not carried out for Resident 52. These failures had the potential for life-threatening complications including severe bleeding for Resident 35 and 51 and severe kidney compromise and fluid overload for Resident 52. Findings: 1. During a review of Resident 35's face sheet, it indicated she was admitted on [DATE] with multiple diagnosis including, End-Stage Renal Disease [(ESRD) - a medical condition in which 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 observation and interview, the facility failed to answer residents call lights in a timely fashion due to a lack of sufficient staff. These failures resulted in Resident 75 having an episode of urinating and defecating in her bed which made her feel hopeless and embarrassed and Resident 243 urinated in the bed waiting for assistance from the staff. Findings: 1. During a review of Face Sheet dated 5/11/21 for Resident 75, the Face Sheet indicated she was admitted with multiple diagnoses including, Morbid Obesity and chronic pain. During a review of Resident 75 Minimum Data Set [(MDS) a health status screening and assessment tool used for all residents of long term care nursing facilities], dated 5/17/21 indicated, Resident 75 cognitive status was intact. Resident 75's Functional status indicated she needed extensive assistance in toileting. During an interview with Resident 75 on 6/2/21, at 10:30 a.m., Resident 75 complained that it took staff 45 minutes to answer her call light. Resident 75 stated she urinated and had a bowel movement in her bed as the staff took too long…

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 reviews the facility failed to ensure that two (Resident 52 and 51) of 25 sampled residents medications were not given medications with meals as ordered by their physicians. 1. Resident 52's medication Renvela (lowers phosphorus level in the blood), prescribed for end stage kidney disease, was not given with food as ordered . 2. Resident 51 did not receive Selvelamer (lowers the phosphorus level in the blood), as prescribed for end stage kidney disease. These failures had the potential to increase the residents 52 and 51's phosophorus levels which could cause further kidney damage. Findings: 1. During a review of Resident 52's Facesheet, dated 6/3/2021, the facesheet indicated, Resident 52 was admitted to the facility on [DATE] with multiple diagnoses that included end-stage renal disease (ESRD, a condition in which the kidneys no longer function normally) and was dependent on hemodialysis (artificial means of filtering the blood when the kidneys fail). 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.

Based on observation, interview, and record review, the facility failed to provide an environment that promoted respect and dignity of two residents (Resident 54, 20) in a sample of 25 residents when, the Certified Nursing Assistant (CNA) 4 stood over Resident 54 and resident 20 while assisting them with their meals. This deficient practice had the potential for residents 20 and 54 not feeling respected and a diminishment of their individual dignity. Findings: 1. During an observation on 6/2/21, at 9:17 a.m., Resident 54 was observed in bed left in a high position without staff supervision. In a follow-up interview immediately following the observation, Certified Nursing Assistant (CNA) 4 confirmed she fed Resident 54 and had forgotten to lower the bed after assisting the resident with breakfast. During a concurrent follow-up observation and interview on 6/2/21, at 12:43 p.m., CNA 4 was observed standing next to the bed while assisting Resident 54 with lunch. CNA 4 stated she did not bring a chair in. CNA 4 remained standing while feeding the resident. 2. During another observation…

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 address lost of personal property for two (Resident 51 and 90) of 25 sampled residents when: 1. A personal Hoyer lift sling (a soft material used to support and wrap around part of the patient's body, and attach to patient lifts) for Resident 51 was lost. 2. A wallet containing Identification Cards (ID) and money belonging to Resident 90 was missing. These failures resulted in loss of personal possessions belonging to Residents 51 and 90. Findings: 1. During a review on 6/2/21, at 10:30 a.m., the facility Face Sheet indicated, Resident 51 was admitted on [DATE]. During an interview with Resident 51 on 6/1/21, at 9:45 a.m., Resident 51 complained that the staff lost his personal Hoyer sling few days after he was admitted to the facility. Resident 51 stated the Hoyer sling the staff use on him was hurting his back and shoulder. Resident 51 stated he told the Certified Nurses Aides (CNAs) every time but nothing was done to resolve the issue.…

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 the necessary care to maintain good nutrition and personal hygiene for three Residents (54, 58, and 74) of 42 sampled residents when: 1. Resident 54 was not fed lunch until half hour after the meal was served. This failure had the potential to result in the meal being cold and unpalatable 2. Resident 58, and Resident 74 were not provided the needed assistance with nail care appearing poorly groomed. This failure had the potential to cause emotional distress and physical discomfort. Findings: 1. During a review of Resident 54's Facesheet, dated 6/3/21, the facesheet indicated, Resident 54 was admitted to the facility on [DATE] with multiple diagnoses that included hemiplegia (weakness to one side of the body) following cerebral infarction (stroke), affecting the left non-dominant side, and on palliative (a specialized medical care for people with a serious illness) care. During a review of Resident 54's Minimum Data Set (MDS, an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide an environment free from accidents and hazards for one resident (Resident 54) in a sample of 42 residents, when the bed was not returned to a low position after Resident 54 was assisted with a meal. This failure had the potential to place Resident 54 at risk for injury from fall. Findings: During a review of Resident 54's Facesheet, dated 6/3/21, the facesheet indicated, Resident 54 was admitted to the facility on [DATE] with multiple diagnoses that included hemiplegia (weakness to one side of the body) following cerebral infarction (stroke) affecting the left non-dominant side. During a review of Resident 54's Minimum Data Set (MDS, an assessment tool used to direct care) dated 5/5/21, the MDS indicated, Resident 54 was totally dependent on one person for assistance with eating, transfers, and personal hygiene, and has a severely impaired cognition. During an observation on 6/2/21, at 9:17 a.m., inside the resident's room,…

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