White Point Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure residents were free of a medication error rate of 5% or greater. During a medication administration pass on 6/23/26, one licensed nurse failed to administer three prescribed medications Rena Vite (supplement), vitamin c (supplement) and zinc sulfate (supplement) to Resident (68).This resulted in a 10.34% medication error rate, based on three medication errors observed out of 29 medication opportunities.Findings:During an observation on 6/23/26 at 8:45 a.m. in Resident 68's room with licensed vocational Nurse 3, (LVN 3) was observed administering Resident 68 her 9:00 a.m. medications. LVN 3 was observed to not give Resident 68's prescribed Rena Vite, vitamin c and zinc sulfate during Resident 68's 9:00 a.m. medication administration pass.During a review of Resident 68's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 5/19/26, the MDS indicated, Resident 68's cognition (memory) was intact. The MDS…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to follow up necessary dental services for one of four sampled residents (Residen16). This failure put Resident 16 at risk for development of tooth decay and weight loss. Findings: During a review of Resident 16's admission Record, the admission Record indicated Resident 16 was admitted on [DATE] to the facility with diagnoses including cardiomegaly(enlarged heart), enthesopathy( any disease or injury that affects where the tendons and ligaments connect in the bones), hypertension(HTN- high blood pressure), and congestive heart failure(CHF-a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling).During a review of Resident 16's Minimum Data Set (MDS- a resident assessment tool) dated 4/8/2026, the MDS indicated Resident 16 had moderately impaired cognitive (ability to make decisions of daily living) skills and required supervision or touching assistance (helper provides verbal cues 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 ensure the terms and condition of the arbitration agreement (legally binding contract in which parties agree to resolve any future or current disputes out of court) was clearly explained to the resident/ resident representative for one of three sampled residents (Resident 90).This failure had the potential to result in Resident 90 unknowingly giving up the right to resolve any disputes with the facility through a court of law before a jury.Findings:During a review of Resident 90's admission Record, the admission Record indicated the facility initially admitted Resident 90 on 9/2/2024 and readmitted on [DATE] with diagnoses including Parkinson's disease(a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), unspecified dementia(a progressive state of decline in mental abilities), anxiety disorder and diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor…

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

Based on interview and record review, the facility failed to ensure all Certified Nursing Aides (CNA's) received the mandatory five-hour annual dementia management training.This deficient practice had the potential to effect all residents residing in the facility specifically those with dementia by placing them at risk for receiving care from staff who lack current, mandatory competency in managing behavioral expressions and cognitive (memory) decline.Findings:During a concurrent interview and record review on 6/25/26 at 9:42 a.m. with the Director of Staff Development (DSD), CNA trainings and the annual (2026) mandatory in service calendar were reviewed. The DSD stated staff are to be provided with five hours of dementia training annually. The DSD stated one hour of dementia training was provided within the last year. The DSD stated dementia training was important, to ensure staff are equipped with the knowledge and skills needed to take care of residents with cognitive concerns. The DSD stated there was a potential for the residents to receive poor care if the staff 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.

Based on interview and record review, the facility failed to ensure two out of two resident council meetings held on 10/15/2025 and 12/17/2025, where concerns regarding timely toileting assistance on were mentioned on 10/15/2025 and delayed call light response on 12/17/2025, were documented on the Resident Council Response Form (document used by the facility to formally record and respond to concerns). This deficient practice had the potential in delaying tracking issues mentioned during the resident council meetings, resolving resident concerns, and notifying the Quality Assurance/Quality Assurance and Performance Improvement ([QA/QAPI] a data driven proactive approach to improvement used to ensure services are meeting quality standards) committee in a timely manner to address ongoing problems. Findings: During a review of the facility's Resident Council Minutes, dated 10/15/2026, the minutes indicated the residents' concerns included the nurses should regularly check on residents who use the restroom often at least every two hours.During a review of the facility's Resident Council…

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 necessary care and services for one (1) of two (2) sampled residents (Resident 4). The facility failed to: 1.Reassess Resident 4 after a low blood pressure reading of 90/42 millimeter of mercury (mm/Hg unit of pressure) on 10/15/2025 at 8:29 a.m. and failing to recheck vital signs (measure the basic functions of the body which include temperature, blood pressure, pulse and respiratory [breathing] rate) prior to sending the resident to dialysis at approximately 11 a.m., on 10/15/2025.2.Notify the physician of a foul-smelling odor observed from Resident 4's right Achilles wound during wound care treatment on 10/14/2025.These failures had the potential to delay necessary care and treatment and increased the risk of hospitalization for Resident 4.Findings:During a review of Resident 4's admission Record, the admission Record indicated Resident 4 was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses including…

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 ensure a safe environment and provide adequate supervision to prevent accident for one of three sampled residents (Resident 1). The facility failed to:1.Supervise Resident 1 and Resident 2 on 10/11/2025 at approximately 7:00 p.m., while they were smoking on the patio according to Resident 1 and 2's Smoking Assessment Forms.2.Secure the door leading to the smoking patio after the last scheduled smoking time at 6 p.m.3.Ensure Certified Nursing Assistants (CNA) 2 redirect Resident 2 to the resident's room instead of leaving Resident 2 unattended in the smoking patio on 10/11/2025. 4.Ensure CNA 1 was aware of Resident 1's whereabout on 10/11/2025 at 7 p.m.These failures resulted in Resident 2 throwing a plastic coffee mug at the right side of Resident 1's head. Resident 1 sustained a bump on the right side of the head and complained of a headache rated of 3 out of 10 on a 0 to 10 numeric pain scale (0 = no pain, 1 to 3 = mild pain, 4 to 6 = moderate pain…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to report a COVID - 19 (a potentially severe illness caused by a coronavirus and characterized by fever, cough, and shortness of breath) outbreak to the California Department of Public Health (CDPH) when three residents (Residents 6, 7, and 8) tested positive for COVID-19 indicative of a facility outbreak.Findings:a. During a review of Resident 6's admission Record (Face Sheet), the Face Sheet indicated Resident 6 was admitted to the facility on [DATE] with diagnoses including arthrogryposis multiplex congenita (a rare, non-progressive condition present at birth, characterized by multiple, stiff, contracted joints (contractures) and muscle weakness).During a review of Resident 6's Minimum Data Set (MDS - a resident assessment tool) dated 7/7/2025, the MDS indicated Resident 6's cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) was intact and required substantial/maximal assistance…

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. Ensure administration of metoprolol succinate (a medication used to treat hypertension [high blood pressure] and heart conditions) extended release (ER) within 60 minutes of its scheduled time as per facility's policy and procedure (P&P) titled, Medication Administration - General Guidelines, dated 05/2022, affecting one of seven sampled residents during medication administration (Resident 27). 2. Clarify and discontinue Resident 27's duplicate orders for Voltaren ([generic name - diclofenac] a medication used topically to treat osteoarthritis [pain and inflammation of joints]) topical gel, affecting one of seven sampled residents during medication administration (Resident 27). 3. Maintain accurate medication administration records as per facility's P&P titled, Medication Administration - General Guidelines, dated 05/2022, affecting one of seven sampled residents during medication administration (Resident 27). 4. Ensure availability…

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 a medication error rate of less than 5% (percent) during medication pass for two of seven sampled residents (Residents 27 and 65). The facility failed to: a. Administer Resident 27's metoprolol succinate (a medication used to treat hypertension [high blood pressure] and heart conditions) extended release (ER) within 60 minutes of its scheduled time as per facility's policy and procedure (P&P) titled, Medication Administration - General Guidelines, dated 05/2022, and 2.Administer Resident 27's timolol ophthalmic solution (a medication used to treat glaucoma [progressive eye disease that damages optic nerve potentially leading to vision loss and blindness] and high eye pressure]), Alphagan P ophthalmic solution ([generic name - brimonidine] a medication used to treat glaucoma and high eye pressure), dorzolamide hydrochloride ophthalmic solution (a medication used to treat glaucoma and high eye pressure) and artificial tears eye…

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. Ensure the dose on Resident 59's Lantus Solostar's ([generic name - insulin glargine] a type of insulin [a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication] used to treat high blood sugar) pharmacy label matched with the physician order in electronic medical health record (eMHR), and was labeled with an open date in accordance with manufacturer specifications, and as per facility's policy and procedure (P&P) titled, Medication Labeling and Storage, dated 2/2023, affecting one of seven sampled residents during medication administration. 2. Ensure removal of Resident 25's discontinued Humalog ([generic name - insulin lispro] a type of insulin used to treat high blood sugar) vial from Station 1 Medication Room Refrigerator, affecting one of one medication rooms inspected (Station 1 Medication Room). 3. Ensure Resident 27's medications including dorzolamide (a medication…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure three of three sampled residents (Resident 82, Resident 48, and Resident 41) was served food that was appetizing, not bland and tasteless. This failure had the potential for Resident 82, Resident 48, and Resident 41) to lose weight. Findings: During a review of Resident 82's admission Record (Face Sheet), the Face Sheet indicated Resident 82 was admitted to facility on 12/28/2024 with diagnoses of diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), hypertension(HTN-high blood pressure) and hyperlipidemia(elevated levels of cholesterol). During a review of Resident 82's Minimum Data Set (MDS-), dated 1/6/2025, the MDS indicated, Resident 82 had the ability to understand others. The MDS indicated Resident 82 had the ability to express ideas and wants. During a review of Resident 82's Physician Orders, dated 12/28/2024, the Physician Orders indicated, Resident 82 had an order 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 interview and record review the facility's Quality Assessment and Assurance (QAA committees established for the purpose of improving the safety and quality of health services) and Quality Assurance Performance Improvement (QAPI- approach to maintain and improve safety and quality in nursing homes) committee failed to implement corrective action to the potential systemic problems identified: 1.Maintain a system to ensure call lights are answered timely. 2.Maintain a system to ensure activities of daily living are implemented. 3.Maintain a system to ensure accurate pharmaceutical services and procedures. 4.Maintain a system to ensure accurate pharmaceutical services and procedures. 5.Maintain a system free of significant medication error. 6.Maintain a system to ensure the storage and labeling of biological and medications. 7.Maintain a system to ensure food is stored in a sanitary manor. 8.Maintain clinical records in accordance with accepted professional standards and practices. These deficient practices had the potential to result in the residents residing 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 interview and record review the facility failed to ensure one of one sampled resident (Resident 82) Minimum Data Set (MDS - a resident assessment tool) section H was coded accurately to reflect Resident 82 was not incontinent (experiencing the involuntary loss of urine or stool). This failure resulted in Resident 82's MDS being coded incorrectly and had the potential to result in a loss of dignity for Resident 82. Findings: During a review of Resident 82's admission Record (Face Sheet), the Face Sheet indicated Resident 82 was admitted to the facility on [DATE] with diagnoses of but not limited to diabetes mellitus(DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), myocardial infarction(MI-heart attack), broken left arm and hypertension(HTN-high blood pressure). During a review of Resident 82's Interdisciplinary Team (a group of professional from different disciplines or fields who work together towards a common goal)-Plan of Care Meeting Notes, dated 1/3/2025, the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for one of three sampled residents (Resident 78) by failing to: 1.Develop a comprehensive person-centered care plan to address Resident 78's toe infection. This failure had the potential to negatively affect the delivery of care and services to Resident 78. Findings: During a review of Resident 78's admission Record, the admission Record indicated Resident 78 was admitted to the facility on [DATE] with diagnoses including hypertension (HTN- high blood pressure) and Diabetes Mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 78's Minimum Data Set (MDS- a resident assessment tool) dated 2/28/2025, the MDS indicated Resident 78's cognition (ability to think, understand, learn, and remember) was severely impaired and required supervision with toileting and dressing. During a review of Resident 78's Order Summary…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure Resident 9's Ciprodex otic (ear) ([generic name - ciprofloxacin and dexamethasone] a medication used to treat ear infection and inflammation) suspension was administered per professional standards of practice and as per facility's policy and procedure (P&P) titled, Specific Medication Administration Procedures - Ear Drop Administration, dated 05/2022, for one of seven sampled residents during medication administration (Resident 9). This failure had the potential to result in Resident 9's discomfort and untreated ear infection. Findings: During a review of Resident 9's admission Record (a document containing demographic and diagnostic information), dated 5/8/2025, the admission Record indicated Resident 9 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including type 2 diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) with diabetic…

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 pressure ulcer treatment for left buttock Stage 4 pressure ulcer (wound that penetrate all layers of skin exposing muscles, tendons [tissue that unites a muscle with a bone] cartilage {tissue that lines a joint}, and bones caused by prolonged pressure on the skin) on 5/8/2025, as indicated in the resident's physician orders for one of one sampled residents (Resident 1) . This deficiency had the potential for Resident 1's left buttock Stage 4 pressure ulcer to worsen, to develop new pressure injury, and had the potential to develop infection. Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses including anoxic brain injury (occurs when the brain receives no oxygen at all and causes brain damage), functional quadriplegia (a severe medical condition characterized by the partial or total loss…

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 residents were free from significant medication errors for one (Resident 27) of seven sampled residents during medication administration. The facility failed to: 1. Administer Resident 27's metoprolol succinate (a medication used to treat hypertension [high blood pressure] and heart conditions) extended release (ER) within 60 minutes of its scheduled time of administration as per facility's policy and procedure (P&P) titled, Medication Administration - General Guidelines, dated 05/2022. This deficient practice failed to provide medication in accordance with the physician's orders or professional standards of practice and had the potential to result in hypertension, stroke (loss of blood flow to a part of the brain) and hospitalization for Resident 27. Findings: During a review of Resident 27's admission Record (a document containing demographic and diagnostic information), dated 5/8/2025, the admission record indicated, Resident 27…

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 the facility failed to ensure one of one sampled resident (Resident 85), food likes, and cultural preferences were met and honored. This failure resulted in Resident 85's not receiving food items from Resident 85's choice and preference. Findings: During a review of Resident 85's admission Record (Face Sheet), the Face Sheet indicated Resident 85 was admitted to the facility on [DATE] with diagnoses of but not limited to Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), low back pain, muscle weakness and dementia(a progressive state of decline in mental abilities). During a review of Resident 85's History and Physical (H&P), dated 4/3/2025, the H&P indicated, Resident 85 did not have the capacity to make decisions. The H&P indicated Resident 85 was alert to his name only. During a review of Resident 85's Minimum Data Set (MDS-), dated 3/31/2025, the MDS indicated Resident 85 usually had the ability…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure licensed staff did not falsify medication administration record ([MAR] a record of all medications administered to a resident) entries as administered for medications listed below that were not available in facility, not administered or not observed as self-administered for one of seven sampled residents (Resident 27). For Resident 27, the facility nurses documented on the MAR for timolol ophthalmic solution (a medication used to treat glaucoma [progressive eye disease that damages optic nerve potentially leading to vision loss and blindness] and high eye pressure]), Alphagan P ophthalmic solution ([generic name - brimonidine] a medication used to treat glaucoma and high eye pressure), dorzolamide hydrochloride ophthalmic solution (a medication used to treat glaucoma and high eye pressure) and artificial tears eye solution (eye drops used to treat dry eyes) as administered for different scheduled times. This deficient practice 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.

Based on observation, interview, and record review, the facility failed to implement and maintain infection control procedures when Licensed Vocational Nurse (LVN) 3 failed to perform hand hygiene between resident's care and prior to entering and exiting the resident room. This deficient practice had the potential to result in cross contamination (physical movement or transfer of harmful bacteria from one person, object, or place to another) and spread of diseases and infection to the facility staff, residents, and visitors. Findings: During an observation on 5/8/2025 at 11:04 a.m., LVN 3 was observed not performing hand hygiene between resident care or when entering and exiting a resident room. During an interview on 5/8/2025 at 11:12 a.m., LVN 3 stated she should have performed hand hygiene to prevent the spread of germs and infection. During an interview on 5/9/2025 at 1:38 p.m., with the Director of Nursing (DON), the DON stated the number one way to prevent the spread of infection was through hand hygiene. The DON stated the staff should perform hand hygiene between 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 implement their protocol for Antibiotic Stewardship (refers to a set of commitments actions designed to optimize the treatments of infections while reducing the adverse events associated with antibiotic use) for one of three sampled residents (Resident 78) by prescribing an antibiotic medication (a substance used to kill bacteria and treat infections) without meeting the criteria, before being treated for toe cellulitis (a skin infection that causes swelling and redness). This failure had the potential for Resident 78 to develop antibiotic resistance (not effective to treat infection) from inappropriate antibiotic use. Findings: During a review of Resident 78's admission Record, the admission Record indicated Resident 78 was admitted to the facility on [DATE] with diagnoses including hypertension (HTN- high blood pressure) and diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing). 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 ensure one of the sampled residents (Resident 82) was provided with a home-like environment, Resident 82 had a large hole in his sliding screen door. This failure had the potential to have unwanted pest entering Resident 82's room . Findings: During a review of Resident 82's admission Record (Face Sheet), the admission Record indicated Resident 82 was admitted to facility on 12/28/2024 with diagnoses of diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), hypertension(HTN-high blood pressure) and hyperlipidemia (elevated levels of cholesterol). During a review of Resident 82's Minimum Data Set (MDS-), dated 1/6/2025, the MDS indicated Resident 82 had the ability to understand others. The MDS indicated Resident 82 had the ability to express ideas and wants. During a concurrent observation and interview on 5/6/2025 at 2:06 PM with Resident 82, Resident 82 pointed to his screen door and stated the hole has been there for four months. Resident 82 stated the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure residents room temperature was comfortable and safe temperatures (71-81 degrees Fahrenheit [°F unit of measurement that is used to measure temperature ]) for one of three sampled residents. This failure had the potential to increase the risk of adverse health effects from an uncomfortable environment for the residents (Resident 3). Findings: During a review of Resident 3 ' s admission Record, the admission Record indicated Resident 3 was admitted to the facility on [DATE] with diagnoses including hypertension (HTN- high blood pressure) and immunodeficiency (decreased ability of the body to fight infections and other diseases). During a review of Resident 3 ' s Minimum Data Set (MDS- resident assessment tool dated 1/3/2025, the MDS indicated Resident 3 was cognitively intact (a person ' s mental abilities, like thinking, remembering, and reasoning, are fully functional and not significantly impaired). The MDS indicated Resident 3 required…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to protect the residents ' right to be free from physical abuse for one of three sampled residents (Resident 1) when Resident 2 slapped and punched Resident 1 in the face repeatedly on 1/17/2025. The facility failed to: 1. Developed a plan of care for Resident 2 who verbalized to staff that he does not want to have roommates, does not like noise and preferred to be alone in his room when Resident 1 was transferred to Resident 2 ' s room (unknown date). 2. The facility failed to follow policy and procedures titled Identifying Types of Abuse, revised 9/2022, which indicated, Abuse of any kind against residents is strictly prohibited. These failures resulted in Resident 2 slapped and punched Resident 1 in the face repeatedly on 1/17/2025. Resident 1 sustained scattered facial redness on bilateral (both) cheeks, forehead, and nose with complained of pain level three out of 10 on a pain rating scale from zero to ten (a numeric pain scale with zero represents…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement residents' care plan interventions for one of three sampled residents (Residents 1), who had wandering (walking around slowly in a relaxed way or without any clear purpose or direction) behavior to monitor Resident 1's whereabouts. This failure resulted in Resident 1 entering her previous room after Resident 1 had alleged physical altercation (a dispute between individuals in which one or more persons sustain bodily injury arising out of the dispute) with her previous roommate. Findings: During a review of Resident 1's admission Record, the admission Record indicated, Resident 1 was initially admitted to the facility on [DATE] and last re-admission was 4/16/2024 with diagnoses including dementia (a progressive state of decline in mental abilities), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and repeated falls. During a review of Resident 1's History and Physical…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide a copy of medical records upon written request from an authorized legal representative ([LR] a person who is legally authorized to act on behalf of another) for one of three sampled residents (Resident 1) within two working days per the facility's policy and procedure (P&P) titled, Release of Information. This deficient practice violated Resident 1 and the LR's rights to obtain a copy of the resident's medical record. Findings: During a review of Resident 1 ' s admission Record (Face Sheet), the face sheet indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including severe sepsis (a life-threatening condition that occurs when an infection causes organ damage) with septic shock (a life-threatening condition that occurs when a body-wide infection causes dangerously low blood pressure and organ failure), and vascular dementia (a chronic condition that affects the brain ' s ability to think, remember, and behave due to poor…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide a copy of medical records upon written request from an authorized legal representative ([LR] a person who is legally authorized to act on behalf of another) for one of three sampled residents (Resident 4) within two working days per the facility's policy and procedure (P/P) titled, Release of Information. This deficient practice violated Resident 4 and the LR's rights to obtain a copy of the resident's medical record. Findings: During a review of Resident 4's admission Record (Face Sheet), the Face Sheet indicated Resident 4 was admitted to the facility on [DATE] with diagnoses including severe sepsis (a life-threatening condition which occurs when an infection [germ] causes organ damage) with septic shock (a life-threatening condition which occurs when a body-wide infection causes dangerously low blood pressure and organ failure), acute pyelonephritis (a bacterial infection of the kidneys which can be life-threatening and cause organ damage),…

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 pressure sores (a wound caused by localized area of damaged skin or tissue that can occur when prolonged pressure is applied to an area of the body) were measured and appropriate interventions were provided for a resident (Resident 1) who was a high risk for skin break down for one out of three residents. These deficient practices had the potential to cause complications of Resident 1 ' s current wounds and had the potential for Resident 1 to sustain new wounds. Findings: During a review of Resident 1 ' s admission Record (Face Sheet), the Face Sheet indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses including diabetes mellitus (DM) type 2 [a chronic condition characterized by elevated levels of blood glucose (or blood sugar) in a bloodstream], hemiplegia (paralysis or weakness of one side of the body) and hemiparesis (weakness or inability to move one side…

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 include the resident representative in the plan of care for one of three residents (Resident 1) when Resident 1 ' s representative was not informed of Resident 1 ' s change of condition which resulted in Resident 1 being late to his appointment. This deficient practice had the potential to violate Resident 1's right to have their representative participate in his care. Findings: During a review of Resident 1 ' s admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] with the diagnoses including malignant neoplasm of the bone and articular cartilage (bone cancer) and congestive heart failure (a serious condition that occurs when the heart can't pump enough blood to meet the body's needs). During a review of Resident 1 ' s History and Physical (H&P) dated 8/31/2024, the H &P indicated Resident 1 was awake and alert. During a review of Resident 1 ' s Nursing Progress Note dated 9/4/2024, the 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure pain management was provided according to professional standards of practice for one of three residents (Resident 1). The facility failed to: 1. Document the administration of seven doses of Norco [a narcotic (a drug that works in the brain to dull the sense of pain) to relieve moderate to severe pain] from 9/1/2024 through 9/3/2024 on Resident 1 ' s administration record. 2. Assess and document Resident 1 ' s pain using the pain rating scale (a subjective [personal view] measure in which individuals rate their pain on an 11-point scale; 0 = no pain, 1-3 = mild pain, 4-6 =moderate pain, 7 to 9 = severe pain, and 10 = worst possible pain). 3. Assess and document the effectiveness of Norco after administration according to the facility ' s policy and procedure (P/P) titled Pain Assessment and Management. This deficient practice had the potential to result in unrecognized unrelieved pain for Resident 1 and placed Resident 1 at risk to suffer…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one out of three sampled residents, (Resident 3) had floor mats (mat used to reduce fall related trauma if a resident gets out of bed, loses balance, and falls to the floor) at the bedside as indicated in Resident 3's care plan This deficient practice had the potential to result in injury from a fall if Resident 3 suffers a fall by the bed. Findings: During a review of Resident 3's admission record, dated 6/4/2024, the record indicated Resident 3 was admitted on [DATE] with a diagnosis including Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills and eventually the ability to carry out the simplest tasks) and unspecified psychosis (a severe mental disorder in which a person loses the ability to recognize reality or relate to others), unilateral (one side) primary osteoarthritis (happens knee joint breaks down, enabling the bones to rub together), muscle weakness, and unspecified abnormalities of gait 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 develop an individualized care plan and conduct an interdisciplinary (group of professionals from different disciplines) team conference, involving the family member 1 (FM 1), to address one out of nine sampled resident's (Resident 1) refusal of examination and treatment by the podiatrist (foot specialist) and optometrist (health professional that involves examining eyes). This deficient practice resulted in a delay of needed services and had the potential to contribute to further medical problems and contribute to a negative physical wellbeing. Findings: During a review of Resident 1's admission Record, dated 5/23/2024, the admission Record indicated Resident 1 was originally admitted on [DATE] and re-admitted on [DATE] with a diagnosis including dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities) with agitation, bipolar disorder (a serious mental illness that causes extreme mood swings that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to place floor mats (mats used to reduce fall?related trauma if a patient gets up from bed, loses balance, and falls to the floor) on both sides of one out of nine sampled resident's (Resident 1), bed as ordered by the physician and as indicated in the care plan. This deficient practice had the potential to result in severe injury if Resident 1 fell onto the floor from the bed. Findings: During a review of Resident 1's admission Record, dated 5/23/2024, the admission Record indicated Resident 1 was originally admitted on [DATE] and re-admitted on [DATE] with a diagnosis including dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities) with agitation, bipolar disorder (a serious mental illness that causes extreme mood swings that include emotional highs [mania] and lows [depression], and difficulty in walking. During a review of Resident 1's Minimum Data Set (MDS), a standardized…

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 in a manner that maintained or enhanced a resident's dignity and respect in full recognition of their individuality for ywo of two sampled residents (Resident 82 and Resident 59. The facility failed to: a. Ensure Resident 82 was dry and clean and provided with privacy while only wearing diaper. This failure had the potential to affect the resident's self-worth and dignity. b. Ensure Resident 59 indwelling urinary catheter ([foley catheter]- a tube that inserted into the bladder, allowing the urine to drain freely into a collection bag, which must be strapped and/ or secured) was enclosed in a privacy bag. This failure has the potential for Resident 59 to feel embarrassed and undignified. Findings: a. During a review of Resident 82's admission Order (Face Sheet), the admission Order indicated Resident 82 was initially admitted to the facility on [DATE] and re-admitted on [DATE], with diagnoses including dysphagia (difficulty 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 call light was within reach for two of three sampled residents (Resident 82 and 67). This failure had the potential for Resident 82 and 67 not able to find the call light to call for assistance when needed, and experienced loss of self-esteem. Findings: a. During a review of Resident 82's admission Order (Face Sheet), the admission Order indicated Resident 82 was initially admitted to the facility on [DATE] and re-admitted on [DATE], with diagnoses including dysphagia (difficulty of swallowing), hemiplegia (complete paralysis and hemiparesis (partial weakness) following cerebral infarction (damage to the brain from interruption of its blood supply), essential hypertension (high blood pressure). During a review of Resident 82's Minimum Data Sheet (MDS- a comprehensive assessment and care screening tool) dated 3/29/24 indicated Resident 82 had moderate cognitive impairment (ability to learn, understand, and make decisions) and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure two of two sampled residents (Resident 20 and Resident 145) was provided their activities of choice (preference). This failure has the potential for Resident 20 and Resident 145 to have no mental and emotional interaction that could negatively impact their quality of life. Findings: a. During a review of Resident 20's admission Record (Face sheet), indicated Resident 20 was admitted to the facility on [DATE] with diagnoses including cerebral infraction (damage to the brain from interruption of its blood supply) with hemiplegia on the left side of the body (paralysis to the left side of the body). During a review of Resident 20's Minimum Data Set ([MDS] a comprehensive assessment and care screening tool) dated 4/23/2024, the MDS indicated Resident 20 was able to speak clearly, hear adequately and usually understands and able to be understood. The MDS indicated Resident 20's preferred activities were reading books, listening to music,…

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 two of two sampled residents (Resident 17 and Resident 47): a. yankauer (an oral suctioning tool used in medical procedures), and suction machine tubing were dated, and b. oxygen tubing was dated and humifying water (sterile water incorporated with oxygen use to prevent irritation of the nasal passages during use of supplemental oxygen) was changed timely. These failures have the potential for the respiratory equipment to lose patency and delay delivery of care and services to Resident 17 and Resident 47. Findings: A. During a review of Resident 17's admission Record (Face sheet), the face sheet indicated Resident 17 was admitted to the facility on [DATE] with diagnosis including acute (urgent) and chronic (long lasting and do not quickly go away) respiratory failure ( a condition I which the lungs have a hard time loading the blood with oxygen {large amount of gas released in the air needed by plants, animals and human beings in order to live}and removing carbon dioxide {a waste…

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 accurate and safe pharmaceutical services and procedures when: a. Medications for two of two residents (Resident 39 and Resident 16), were not disposed from the medication cart after being discontinued. b. Physician's orders for fentanyl (medication to treat pain) transdermal (placed on the skin) patches were not transcribed into the Medication Administration Record (MAR) for one of one resident (Resident 14) c. Medication destruction was not followed according to the Controlled Drug Record instructions for one of one resident (Resident 14). d. Ensure to check blood pressure parameter for a resident (Resident 148) prior to administering antihypertensive medication as ordered. These failures placed the residents at risk for accidental use of discontinued medications, adverse side effects and potential diversion of a medication with a high risk for addiction and dependence. The deficient practice of not checking blood pressure…

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 observation, interview, and record review the facility failed to ensure the refrigerator in the medication storage room was operating at a normal/ expected range of temperature per facility's policy (36-to-46-degree Fahrenheit {a temperature scale in which the freezing point of water is 32 degrees, and the boiling point is 212 degrees}). This failure has the potential for the medications stored in the refrigerator to lose potency (activity of the drug in terms of concentration or amount of the drug required to produce a desired effect) and efficacy (the ability of a drug to produce a desired effect) which could negatively affect the delivery of care and services to the residents. Findings: During an observation on 5/1/2024 at 9:55 a.m., of one of 2 (two) medication storage rooms, the refrigerator in the medication storage had a temperature of 54 degrees Fahrenheit. In the refrigerator were the following unopened and unexpired medications: 1. Lantus Solostar (a long-acting man-made insulin {a hormone that lowers the levels of glucose, or blood sugar} used to control high…

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 store food in a sanitary manner to prevent growth of infectious agents that could cause food borne illness (food poisoning: any illness resulting from the food spoilage or contaminated food) for 93 out of 95 total residents in the facility by failing to: 1. Ensure foods were dated, labeled, and discarded before the used by date (expiration dates). 2. Monitor and document room temperature in dry storage room daily. 3. Ensure three frozen packs of ham was properly thawed in the refrigerator. These failures had the potential to affect residents and result in pathogen (germ) exposure and placed residents at risk for developing food borne illness (food poisoning) with symptoms including upset stomach, stomach cramps, nausea, vomiting, diarrhea, and fever and can lead to other serious medical complications and hospitalization. Findings: 1. During a concurrent observation and interview on 4/30/2024 at 8:32 a.m. with Kitchen Aid (KA), in refrigerator, freezer, and storage room, there were food items that were 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 interview and record review, the facility failed to ensure that the discharge Minimum Data Set (MDS-a comprehensive assessment and care screening tool) Assessment was transmitted to Centers for Medicare and Medicaid Services (CMS) within 14 days' time frame for one of 12 sampled residents (Resident 82). This failure had the potential to the delay in identifying resident care concerns needing individualized care plan, delay in providing residents interventions necessary to provide quality care and delay in the reimbursement process. Findings: During a review of Resident 82's admission Order (Face Sheet), the admission Order indicated Resident 82 was initially admitted to the facility on [DATE] and re-admitted on [DATE], with diagnoses including dysphagia (difficulty of swallowing), hemiplegia (complete paralysis and hemiparesis (partial weakness) following cerebral infarction (damage to the brain from interruption of its blood supply), essential hypertension (high blood pressure). During a review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure one of one sampled resident (Resident 20) fingernails were clean and trimmed. This failure has resulted to Resident 20's right hand fingernails to have irregular edges, accumulation of dark brown substance under the fingernails and had the potential to cause infection and impaired skin integrity. Findings: During a review of Resident 20's admission Record (Face sheet), the face sheet indicated Resident 20 was admitted to the facility on [DATE] with diagnosis including cerebral infarction (stroke- blood flow in the brain is stopped or there is a sudden bleeding in the brain) with hemiplegia on the left side of the body (paralysis to the left side of the body) and diabetes mellitus (a disease that occurs when the blood glucose or blood sugar in the body is too high) and peripheral vascular disease (a disease that is caused by restricted blood flow to the tissues of the body). During a review of Resident 20's Minimum Data Set ([MDS] a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure one of two sampled residents (Resident 20) was provided range of motion exercises by the certified nursing assistant staff during activities of daily living (the routine activities that people do to take care of their basic needs such as eating, bathing, dressing, grooming, toileting, repositioning and transferring). This failure has the potential for Resident 20 to decline with mobility and/ or function and develop and/ or worsen contractures (fixed tightening of the muscles, tendons, ligaments, or skin that prevents normal movement) to her extremities. Findings: During a review of Resident 20's admission Record (Face sheet), the face sheet indicated Resident 20 was admitted to the facility on [DATE] with diagnosis including cerebral infraction (stroke- blood flow in the brain is stopped or there is a sudden bleeding in the brain) with hemiplegia on the left side of the body (paralysis to the left side of the body). 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 ensure one of one sampled resident (Resident 39) was free from unnecessary drugs by: Failing to assessed Resident 39 for infection before starting oral antibiotic ( drug used to treat infections caused by bacteria and other microorganisms) medication. This failure had the potential to result in Resident 39 receiving unnecessary medication. Findings: During a review of Resident 39's admission Order (Face Sheet) indicated Resident 39 was admitted on [DATE] with diagnoses including dysphagia (difficulty of swallowing), pressure ulcer of sacral region stage 4 (damage to an area of the skin caused by constant pressure on the area for a long time), acute cystitis without hematuria (sudden inflammation of the bladder without presenting blood in the urine). During a review of Resident 39's Minimum Data Sheet (MDS- a comprehensive assessment and care screening tool) dated 2/16/24 indicated Resident 39 had moderate cognitive impairment (ability to learn,…

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 eight residents (Resident 14) was free from significant medication error by failing to administer fentanyl (medication use to treat severe pain) transdermal (on the skin) patches as ordered by the physician. This deficient practice placed the resident at risk for higher dosage of medication and respiratory depression. Findings: During a review of Resident 14's admission Record (facesheet), indicated resident was admitted to the facility on [DATE] with diagnoses including arthrogryposis multiplex congenita (condition that causes stiffness in the joints), pain due to an internal orthopedic prosthetic (artificial substitute to a part of the body) with history of joint replacement surgery, peripheral vascular disease (narrowed arteries causing reduced blood flow to the arms and legs), gout (inflammation of the joints), difficulty walking and muscle weakness. A review of Resident 14's Electronically Transmitted Prescription orders…

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 clinical records in accordance with accepted professional standards and practices for document Resident 14's records of fentanyl patch that required two signatures of licensed staff accurately and completely. This failure had the potential for non-accountability of medication and drug diversion. Findings: During an interview with the Dispensing Pharmacist (DPh) on 5/2/2024 at 9:59 a.m., the DPh stated nurses should fill out the date and time the fentanyl patches were removed and when removed, two nurses' signatures are required on the form. During an interview on 5/3/2024 at 12:12 p.m. with Director of Nursing (DON), the DON stated that licensed staff signatures was to verify if fentanyl patch was given or removed. DON stated if the patches are not monitored, that can cause overdose and respiratory failure. During a review of Controlled Drug Record dated 2/28/2024 through 3/18/2024, 3/20/2024 through 3/28/2024, 3/30/2024 through 4/7/2024 and 4/11/2024 through/19/2024 indicated when patch is removed,…

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 protocol for Antibiotic Stewardship (refers to a set of commitments and actions designed to optimize the treatment of infections while reducing the adverse events associated with antibiotic use) for one of two sampled residents (Resident 39). Resident 39 was prescribed antibiotic ( drug used to treat infections caused by bacteria and other microorganisms) drug without meeting the criteria and prior to assessing for wound infection. This failure had the potential for resident to develop antibiotic resistance (not effective to treat infection) from unnecessary or inappropriate antibiotic use. Findings: During a review of Resident 39's admission Order (Face Sheet) indicated Resident 39 was admitted on [DATE] with diagnoses including dysphagia (difficulty of swallowing), pressure ulcer of sacral region stage 4 (damage to an area of the skin caused by constant pressure on the area for a long time), acute cystitis without hematuria (sudden…

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 there was a facility Infection Preventionist (specially trained professional who makes sure healthcare workers and residents are doing all the things they should to prevent infections [IP]) as indicated in the facility assessment for ninety of ninety residents. This deficient practice had the potential to result in the increased spread of COVID-19 (a contagious and potentially severe respiratory illness) infection in the facility and the community. Findings: During a review of the facility document Notice to Employee as to Change in relationship (undated), the document indicated Licensed Vocational Nurse 2 (LVN 2), former IP, resigned on 1/12/2024. During an observation on 2/29/2024 at 11:16 a.m., it was noted that there was no Infection Preventionist nurse in the facility. During an interview on 2/29/2024 at 12 p.m. with the director of staff development (DSD), the DSD stated there was no Infection Preventionist now, the previous IP resigned 1/12/2024 as indicated in the resignation form and has 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 gloves and alcohol-based hand sanitizers were available for use in four out of four resident rooms. These failures placed all the residents, staff, and the community at higher risk for cross contamination (transfer of harmful germs from one person, object, or place to another) and increased spread of COVID-19 (a potentially severe respiratory illness) infection in the facility and the community. Findings: During an interview on 2/29/2024 at 10:28 a.m. with the Maintenance Supervisor (MS), the MS stated staff complained about having no gloves two a weeks ago and had to order more. During a concurrent observation and interview with Licensed Vocational Nurse (LVN 1) in four different resident rooms on 2/29/2024 at 11:25 a.m., the in-room alcohol-based hand sanitizers were all empty and there were no gloves available. LVN 1 stated especially because there was an outbreak (at least one resident was positive with Covid-19), staff should have easy access to gloves and hand sanitizers. During an interview on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to determine the call lights were within reach and useable, for two of three sampled residents (Resident 1 and 3): A. Resident 1's call light was observed hanging over the top of lamp. B. Resident 3 ' s call light was found on the floor. These failures had the potential for Residents 1 and 3 not to receive necessary assistance when needed, and experienced loss of self-esteem. Findings: A. During a review of Resident 1's admission Record, the record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease (a disease causes obstructed airflow from the lungs), Parkinsonism (brain conditions that cause slowed movements, stiffness, and tremors), diabetes mellitus (irregular blood sugar). A review of Resident 1's Minimum Data Set (MDS), a standardized assessment and care planning tool, dated 10/15/2023, indicated Resident 1's cognitive (relating to the process of acquiring…

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.