Smith Ranch Skilled Nursing & Rehabilitation Cente

Based on observation and interview, the facility failed to ensure laundry equipment was safely maintained for a census of 71 residents when the inside of one of two laundry dryers was visibly contaminated with debris (pieces of waste). This failure had the potential to expose resident's linens and laundry to unsanitary conditions and damage. During a concurrent observation and interview on 2/11/26 at 12:20 p.m., the Housekeeping Supervisor (HS) removed dry linens from one of two operated laundry dryers. The inside of the dryer cylinder was observed with debris that was melted, hardened, and adhered throughout the inside of the cylinder that was in direct contact with laundry. The HS stated the inside of the dryer cylinder did not get cleaned. The HS further stated the items inside the dryer cylinder appeared to be melted plastic bags and bandages. The HS stated he could not ensure that laundry that came out of the dryer was clean.During an interview on 2/11/26 at 1:51 p.m., the Maintenance Director (MTD) stated it was hard to know what the debris inside the dryer cylinder was. 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 submit Level I Preadmission Screening and Resident Reviews (PASRR) by the 31st day after admission for two of four sampled residents (Residents 4 and 5), who stayed longer than 30 days.This failure had the potential to result in Resident 4 and Resident 5 losing their eligibility for specialized medical services if diagnosed with a serious mental illness, intellectual disability, developmental disability, or related condition(s). A review of Resident 4's admission record indicated she was originally admitted to the facility on [DATE] and most recently readmitted to the facility on [DATE] from a general acute care hospital (GACH), with medical diagnoses which included anxiety disorder (mental health condition marked by intense, persistent, and excessive worry or fear about everyday situations, leading to significant distress and impairment in daily life); obsessive compulsive disorder (a mental health condition where a person gets caught in a cycle 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 interview and record review, the facility failed to initiate a chance in condition process, and appropriately monitor and document a resident's response to treatment for one of eight sampled residents (Resident 71) after he suffered a hypertensive crisis (a medical emergency characterized by rapid, severe increase in blood pressure above 180/120 millimeters of mercury [mmHg, unit of measurement for blood pressure]).As a result, Resident 71 experienced another acute hypertension episode one week later, which could have been prevented with close supervision. This posed risks of severe harm, such as a heart attack, stroke, or organ damage to Resident 71.A review of Resident 71's admission record, dated 2/12/26, indicated he was originally admitted to the facility on [DATE], with diagnoses including hypertensive heart disease (heart damage caused by chronic, long-term high blood pressure), heart failure (a chronic condition where the heart cannot pump enough oxygen-rich blood to meet the body's needs),…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure safe medication storage and administration for one of eight sampled residents (Resident 53) when nursing staff left a medication at Resident 53's bedside, without an assessment, and physician order for self-administration of medications.This failure had the potential to result in serious medication errors, overdoses and theft. In addition, leaving medication unattended risked consumption by other residents, accidental ingestion, or misuse. A review of Resident 53's admission record (facility demographic), dated 2/12/26, indicated Resident 53 was admitted to the facility on [DATE], with medical diagnoses which included psoriatic arthritis mutilans (a rare, severe, and destructive condition causing painful, stiff, and swollen joints, often accompanied by scaly skin patches), generalized anxiety disorder (a chronic, excessive, and uncontrollable worry about everyday events), and venous insufficiency (a condition in which leg vein…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure a medication was labeled and stored safely when it was found in an unlocked area accessible by four residents (Resident 21, Resident 31, Resident 55 and Resident 71). This violated professional standards of nursing practice and state and federal regulations.This failure had the potential to result in medication errors potentially requiring medical intervention, theft, diversion and/or accidental ingestion by residents.During an observation on 2/09/26 at 10:30 a.m., in the common bathroom shared by the residents in room [ROOM NUMBER] and the residents in room [ROOM NUMBER], a bottle of medicine was found inside an unlocked, plastic chest of drawers containing various personal care items. The manufacturer's label in the medication bottle indicated, Senakot [Senna Docusate, a stimulant laxative and a stool softener to treat occasional constipation], 17.2 milligrams(mg, a unit of measurement), extra strength, 36 tablets. This…

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 infection prevention measures were provided for one of eight sampled residents (Resident 59) when: 1: Resident 59's portable oxygen concentrator (an oxygen delivery device) filter cabinet was dusty,2: Resident 59's nasal cannula (a tube that delivers oxygen directly into the nostrils) was not labeled, and;3: Resident 59's suctioning machine (a medical device used to remove fluids from the airway) was stored close to the floor and the yankauer (a suctioning tool that goes inside the mouth) was not covered during storage.These failures increased Resident 59's risk of infection. A review of Resident 59's admission record indicated he was admitted to the facility in November, 2023, with medical diagnosis which included chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), dysphagia (difficulty swallowing), and dementia (a progressive state of decline in mental abilities). A review of Resident 59's Minimum Data Set (MDS-a federally mandated resident assessment…

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

Based on observation, interview and record review, the facility failed to publicly post California Department of Public Health (CDPH) contact information for residents residing in facility. This failure resulted in residents not being afforded the right to make a complaint to CDPH regarding concerns with their care or the facility. Findings: During an interview on 5/13/25 at 2:04 p.m. with Resident Council members, eight out of eight residents stated they did not know how or where to file complaints to CDPH and could not recall if information was publicly available in the facility. During a concurrent observation and interview on 5/13/25 at 2:56 p.m. with the Activities Director (AD), CDPH contact information was not posted on the first or second floor of the facility. AD confirmed CDPH contact information was not posted in the facility. During a concurrent observation and interview on 5/13/25 at 2:58 p.m. with the Administrator (Admin) on first floor hallway. Admin confirmed CDPH contact information was not posted on first floor hallway. During an interview on 5/13/25 at 3:05 p.m.…

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 and prepare food in a safe and sanitary manner when: 1. Lettuce was not rinsed per packing instructions prior to being chopped and plated onto salad bowls. 2. Two carts used for food transport from the Main Kitchen to the Nourishment Room were dirty. 3. Food items were not discarded after their use-by-date. 4. One bin of contaminated rice was not discarded. 5. Food items were not stored in sealed containers to prevent contamination. 6. Opened food items were not properly labeled with open and use-by-date. These failures had the potential to cause food-borne illnesses in an already medically fragile population. The kitchen served a population of 73 residents. Findings: 1. During a concurrent observation and interview on 5/12/25 at 5:06 p.m. with the Dietary Aide (DA ) in the Main Kitchen, the DA took romaine lettuce from a plastic package, chopped it, and plated the lettuce into salad bowls for distribution to the residents. The DA stated he did not rinse the lettuce prior to chopping because the lettuce…

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 Assurance Performance Improvement (QAPI- data-driven approach to improving quality in healthcare facilities) committee failed to identify the need for oversight of the Restorative Nursing Assistance (RNA) program. This failure resulted in residents not receiving the appropriate treatments per physician orders. (Refer to F688). Findings: During a review of the facility's Restorative Program Monthly Audit, dated 5/1/25, the Restorative Program Monthly Audit was completed for the month of April 2025. The Restorative Program Monthly Audit indicated a total of 84 missed visits from 13 Residents reviewed. During a review of the facility's Order Listing Report, dated 5/15/25, the Order Listing Report indicated there are a total of 22 Residents currently receiving RNA services. During an interview on 5/16/25 at 11:16 a.m. with the Director of Nursing (DON) and Director of Rehabilitation (DOR), The DOR stated the DON oversees the RNA program because it falls under nursing and the DOR is only responsible for training staff 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 licensed nurses followed professional standards of practice when they documented they administered medications which were not dispensed by the pharmacy for one of 24 sampled residents (Resident 6). This failure resulted in inaccurate documentation and the potential for Resident 6 to experience adverse effects such as shortness of breath. During a review of Resident 6's face sheet (demographics), the face sheet indicated Resident 6 was admitted on [DATE] with diagnoses including COPD (Chronic Obstructive Pulmonary Disease [ongoing lung condition that makes it difficult to breathe]) and asthma (a condition which makes it difficult to breathe). During an observation on 5/14/25 at 10:18 a.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 was observed administering Resident 6's respiratory medications. LVN 1 did not administer a Budesonide inhaler (medication inhaled into the lungs to prevent inflammation of the airways). LVN 1 stated…

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 four of 24 sampled residents (Resident 1, 2, 35 and 58) received restorative nursing care (RNA -specialized form of nursing that focuses on helping patients regain or maintain their functional abilities and minimize weakness) per physician order. This failure had the potential to result in contractures (permanent shortening and stiffening of muscles, tendons, ligaments leading to limited movement and deformity) and decline in muscle strength. Findings: 1. During a review of Resident 1's admission Record, dated 5/16/25, the admission Record indicated Resident 1 was admitted to the facility on [DATE], with diagnoses of abnormalities of gait and mobility, absence of right leg below the knee and right artificial hip joint. During a concurrent observation and interview on 5/12/25 at 5:14 p.m. with Resident 1 in room [ROOM NUMBER], Resident 1 was self-propelling her wheelchair in her room and had a prosthetic right leg. Resident 1 stated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to complete and obtain informed consent (a consent that provides the risks and benefits of taking a medication, possible side effects, alternate treatments, and risk of no use) for a psychotropic medication (medications that affect the mind, emotions and behavior) for one of 24 sampled residents (Resident 1). This failure had the potential for Resident 1 not to be fully informed and consent to receive psychotropic medications. Findings: During a review of Resident 1's admission Record, dated 5/16/25, the admission Record indicated Resident 1 was admitted to the facility on [DATE], with diagnoses of Bipolar Disorder (mental health condition characterized by extreme shifts in mood, energy and activity levels), and Major Depressive Disorder (mental health condition characterized by persistent sadness and loss of interest) and Anxiety Disorder (mental health condition characterized by excessive and persistent worry, fear or panic). During a concurrent…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the call light was within reach for two of 24 sampled residents (Resident 2 and Resident 35). This failure had the potential to result in Resident 2 and Resident 35 being unable to contact staff for assistance. Findings: 1.During a review of Resident 2's admission Record, dated 5/16/25, the admission Record indicated Resident 2 was admitted to the facility on [DATE], with diagnoses of hemiplegia (inability to move one side of the body), and paraplegia (inability to move the lower parts of the body) and contracture of multiple sites (permanent shortening and stiffening of muscles, tendons, ligaments leading to limited movement and deformity). During a concurrent observation and interview on 5/12/25 at 6:32 p.m. with Resident 2, in room [ROOM NUMBER], Resident 2 was lying in bed with both hands contracted and her neck contracted to the left side. Resident 2's call light was placed by her collar bone, above her right hand. Resident 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure a clean environment when: 1. room [ROOM NUMBER] Bed A had a visibly soiled privacy curtain (curtain used between residents' beds). 2. Resident 2 had dirty clothes piled up on her nightstand. 3. room [ROOM NUMBER]'s air conditioner was in disrepair. These failures had the potential for residents to live in an unsafe and unclean, non-homelike environment. Findings: 1. During a concurrent observation and interview on 5/12/25 at 6:48 p.m. with Certified Nursing Assistant (CNA) 2, in room [ROOM NUMBER], Bed A's privacy curtain was visibly soiled with a brown substance in multiple spots. CNA 2 stated she was unaware of what the brown substance was, but the privacy curtain needed to be replaced immediately. During an interview on 5/14/25 at 10:58 a.m. with the Director of Nursing (DON), the DON stated curtains are changed when soiled. During a review of the facility's policy and procedure (P&P) titled, Cleaning and Disinfecting Residents'…

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

Based on interview and record review, the facility failed to assess and submit accurate data for one of 24 sampled residents (Resident 35) when the Minimum Data Set (MDS- an assessment tool used to guide resident care) did not reflect Resident 35's current status. This failure resulted in the transmission of inaccurate data to the Centers for Medicare and Medicaid Services (CMS). Findings: During a concurrent interview and record review on 5/15/25 at 11:34 a.m. with Minimum Data Set Coordinator (MDSC), Resident 35's MDS 3.0 Section I- Active Diagnoses, dated 3/4/25, and Order Summary Report, dated 5/15/25 were reviewed. Resident 35's MDS 3.0 Section I- Active Diagnoses indicated Resident 35 had an active diagnosis of viral hepatitis (an infection that damages the liver). Resident 35's Order Summary Report indicated there was no treatment for viral hepatitis. The MDSC stated Resident 35's MDS should not have been checked yes for hepatitis because she was not receiving any active treatment. During an interview on 5/15/25 at 11:38 a.m. with MDS Registered Nurse (MDS RN), MDS RN…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement interventions the physician prescribed to prevent skin breakdown for one of 24 sampled residents (Resident 37) when Resident 37's pressure reducing mattress (mattress designed to prevent development of pressure ulcers (bedsores) or worsening of existing ulcers by redistributing air and pressure while the machine controlled the air flow) was not turned on for an unknown amount of time. This failure had the potential to result in Resident 37 developing a pressure ulcer, skin damage, skin infections, and discomfort. Findings: During a review of Resident 37's Face Sheet (demographics), the Face Sheet indicated Resident 37 was admitted to the facility on [DATE] with diagnoses including dementia (progressive decline in cognitive function, memory, and behavior) and abnormalities of gait and mobility. During a concurrent observation and interview on 5/13/25 at 8:43 a.m. with Resident 37 in Resident 37's room, the machine connected to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure one of 24 sample residents (Resident 35) was weighed daily per physician order. This failure had the potential to result in Resident 35 not being properly monitored for weight loss and nutritional interventions not being implemented in a timely manner. Findings: During a review of Resident 35's admission Record, the admission Record indicated Resident 35 was admitted to the facility on [DATE] with diagnoses of dysphagia (difficulty swallowing) and severe protein-calorie malnutrition (serious medical condition characterized by a deficiency of both protein and calories, leading to severe weight loss and muscle wasting). During a review of Resident 35's Order Summary Report, dated 5/14/25, the Order Summary Report indicated, .Daily weights: Notify MD [Medical Doctor] of 3+ pounds weight gain in a day or 5+ pounds weight gain in 7 days . start date 1/25/25 . During a concurrent interview and record review on 5/14/25 at 10:31 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to label an enteral feeding (a method to provide food through a tube placed in the nose, the stomach, or the small intestine) bottle, an enteral feeding pump bag, and a syringe used for enteral feeding for one of 24 sampled residents (Resident 35). This failure had the potential for expired enteral feeding supplement and equipment to be used for Resident 35. Findings: During a review of Resident 35's admission Record the admission Record indicated Resident 35 was admitted to the facility on [DATE] with a diagnosis of dysphagia (difficulty swallowing) and severe protein-calorie malnutrition (serious medical condition characterized by a deficiency of both protein and calories, leading to severe weight loss and muscle wasting). During an observation on 5/12/25 at 6:04 p.m., in Resident 35's room, a Jevity 1.5 (an enteral feeding formula) was observed infusing at 50 ml/hr (milliliter per hour- a unit of measurement). Upon further inspection, the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the medication error rate was not five percent or greater when five identified medication errors out of 26 opportunities were observed: 1. Budesonide (medication inhaled into the lungs to prevent inflammation of the airways) was omitted for Resident 6. 2. Midodrine (medication used to treat orthostatic hypotension [a condition characterized by a sudden drop in blood pressure upon standing, leading to dizziness, light-headedness, and fainting]) was omitted for Resident 6. 3. Ipratropium 0.03% (nasal spray used to treat conditions affecting the lungs and nasal passages) was not administered according to manufacturer instructions and was administered at the incorrect time for Resident 6. 4. Trelegy (medication inhaler used for long-term control of breathing problems which causes shortness of breath) was administered at the incorrect time to Resident 6. 5. Midodrine was administered through a gastronomy tube (G-Tube) (small, flexible…

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 safe medication storage practices for two of 24 sampled residents (Resident 2 and 4) and 1 unsampled resident (Resident 30) when: 1. Resident 30's triamcinolone acetonide cream (medication used to treat various skin conditions) was found on Resident 30's bedside table. 2.Resident 2 had one large container of powdered Magnesium (supplement to support healthy nerve and muscle function), one bottle of [brand name] Sleep Aid, and one bottle of [brand name] PM (at night) Leg Cramp medication on top of a dresser at bedside. 3.Resident 4 had a bottle of multivitamins on the bedside table. These findings had the potential to result in the unauthorized administration of medications and serious adverse events such as overdosing or negative drug interactions. Findings: 1. During a review of Resident 30's Face Sheet (demographics), the Face Sheet indicated Resident 30 admitted on [DATE] with diagnosis of dementia (progressive decline in…

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

Based on interview and record review, the facility failed to protect one resident (Resident 1) of two sampled residents from misappropriation of resident property when Resident 1's credit card was used by a Front Desk Staff (FDS). This failure resulted in Resident 1 feeling taken advantage of, distrustful, and embarrassed. Findings: A review of Resident 1's admission record indicated admission to the facility in February 2025 diagnosis which included abnormalities of gait and mobility, need for assistance with personal care, bipolar disorder (a mental health condition characterized by mood swings that range from the lows of depression to elevated periods of emotional highs), depressive disorder (a mental health condition characterized by symptoms like sadness, loss of interest and low energy) with psychotic symptoms (a mental health condition characterized by symptoms of false beliefs and seeing or hearing things that do not exist), and anxiety disorder (a mental health condition characterized by excessive worry and fear that can interfere with daily life). A review of a Minimum…

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 policy and procedure when: 1. Steam table pans were not air-dried before stacking; 2. The drain under the dishwasher did not have an air gap (the unobstructed vertical space between the water outlet and the flood level of a fixture and prevents backflow of outlet water); and, 3. A pan of beef was not cooked to the appropriate temperature before placing on the steam table to serve. These failures could potentially result in food-borne illness in a vulnerable population. Findings: 1. During an observation and concurrent interview on 8/14/23 at 9:26 a.m., the initial kitchen tour was conducted with Registered Dietitian (RD). A drying rack shelf contained stacks of three different sizes of steam table pans. When the pans were pulled apart, water was present inside the stacked pans. The RD verified the pans were stacked wet and stated they should be dry before they were stacked. The RD began to separate the pans and placed them individually on the rack. During an interview on 8/18/23 at 3:30 p.m., the RD…

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 place the results of State surveys (inspections) where they were accessible to residents, who were unable to view them without having to ask for assistance. This failure resulted in residents being unable to read the State survey reports when they did not know where the reports were kept, or could not reach or lift the binder containing the reports. Findings: During a confidential resident council interview on 8/15/23 at 10:04 a.m., five out of five residents did not know where the results of the Department's inspections could be found for them to review. Anonymous Resident 1 stated he would be interested to read the inspection results. During an observation on 8/15/23 at 10:46 a.m., a binder containing the Department's survey results was found outside the dining room in a black, wall-mounted file holder approximately four feet from the floor. The binder contained several years of survey results and was heavy. The label on the front of the binder indicated the binder contained the Department's survey results…

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 and records review, the facility failed to ensure notices of the bed-hold policy were provided to two of three hospitalized residents (Resident 45 and Resident 42). This failure could have resulted in residents being unaware they could return to the facility after hospitalization, and if they needed to submit payment to reserve a bed. Findings: During an interview with Resident 45 on 8/15/23 at 9:24 a.m., Resident 45 stated he was transferred to the hospital twice since his admission to the facility. Resident 45 stated the facility did not discuss the facility's bed-hold policy either with him or his representative upon his transfer to the hospital. During a record review for Resident 45, the document titled, Notice of Transfer/ Discharge, dated 5/24/23 and 7/23/23, indicated Resident 45 was sent to the hospital. During a record review for Resident 42, the document titled, Notice of Transfer/ Discharge, dated 6/15/23, indicated Resident 42 was sent to the hospital. During a record review for Resident 42, the Progress Note, dated 8/4/23 at 1:12 a.m., indicated, 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 interviews and records review, the facility failed to ensure the Minimum Data Set (MDS - health status screening and assessment tool) was accurately completed for three of 15 sampled residents (Residents 3, Resident 29 and Resident 16). This failure resulted in unidentified areas of risk for the residents in order to develop the most appropriate plan of care. Findings: Resident 3 During a record review for Resident 3, the Minimum Data Set (MDS -health status screening and assessment tool used for all residents), dated 6/15/23, indicated Resident 3 had a BIMS score of 02 out of 15 points (Brief Interview for Mental Status - a 15-point cognitive screening measure that evaluates memory and orientation. A score of 13 to 15 is cognitively intact, 08 to 12 is moderately impaired, and 00 to 07 is severe impairment). During an interview with Unlicensed Staff B on 8/15/23 at 10:03 a.m., Unlicensed Staff B stated Resident 3 did not speak English. Unlicensed Staff B stated Resident 3 was able to communicate her needs in one-word-Spanish and answered yes or no questions through 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, interviews, and records review, the facility failed to develop and implement person-centered care plans for 3 of 15 sampled residents (Resident 3; 16; and 159). This failure had the potential for facility staff to provide inadequate care to vulnerable residents when their individual needs and interests were not addressed appropriately. Findings: Resident 3 During an interview with Unlicensed Staff B on 8/15/23 at 10:03 a.m., Unlicensed Staff B stated Resident 3 did not speak English. Unlicensed Staff B stated Resident 3 was able to communicate her needs in a one-word Spanish sentence and answers yes or no questions through a Spanish translator. During a record review for Resident 3 and concurrent interview with the MDS (Minimum Data Set - an assessment tool completed by clinical staff to identify potential resident problems, strengths, and preferences) Coordinator (MDSC - a nursing professional who helps manage a nursing team in a medical facility) on 8/18/23 at 11:54 a.m., the MDS assessment, dated 9/14/22, indicated Resident 3 did not need an interpreter to…

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

Based on interviews, and records review, the facility failed to ensure showers for one of three sampled residents (Resident 29) was given during his scheduled shower days. This failure to maintain Resident 29's personal grooming and hygiene needs had the potential to raise the risk of unidentified skin issues, bacterial or fungal infections. Findings: During a record review for Resident 29, the Minimum Data Set (MDS - an assessment tool completed by clinical staff to identify potential resident problems, strengths, and preferences), dated 4/25/23, indicated Resident 29 had a BIMS score of 07 out of 15 points (Brief Interview for Mental Status - a 15-point cognitive screening measure that evaluates memory and orientation. A score of 13 to 15 is cognitively intact, 08 to 12 is moderately impaired, and 00 to 07 is severe impairment). The MDS indicated it was somewhat important for Resident 29 to choose between a tub bath, shower, bed bath or sponge bath. The MDS indicated Resident 27 required total assistance from facility staff with bathing needs. Review of the document titled, Shower…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and records review, the facility failed to provide meaningful activities for two of 15 sampled residents (Residents 3 and 29). This failure resulted in residents not receiving activities according to their preferences and needs, which could potentially impact their physical, mental, and psychosocial well-being. Findings: Resident 3 During a record review for Resident 3, the Face sheet (A one-page summary of important information about a resident) indicated Resident 3 was admitted on [DATE], with diagnoses including but not limited to Major Depressive Disorder (a mental disorder characterized by a persistently depressed mood and long-term loss of pleasure or interest in life) and Anxiety Disorder (intense, excessive, and persistent worry and fear about everyday situations). During a record review for Resident 3, the Minimum Data Set (MDS -health status screening and assessment tool used for all residents), dated 9/14/22, indicated it was somewhat important for Resident 3 to have…

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

Based on observations, interviews and records review, the facility failed to ensure the medication error rate was below 5%, when two of four licensed staff (Licensed Staff M and F) did not follow the doctor's order and manufacturer's specifications regarding administration of medication. The failures resulted in a 17% medication error rate which had the potential to compromise the residents' health and well-being for not getting the required medication according to the doctor's order. Findings: 1. During an observation on 8/16/23 at 8:24 a.m., in front of Resident 212's room, Licensed Staff M was preparing the medications for Resident 212. Licensed Staff M poured one tablet of Aspirin 81 mg (milligram-a unit of mass) EC (enteric coated - Coated with a material that permits transit through the stomach to the small intestine before the medication is released) into the medicine cup. Licensed Staff M administered the medication to Resident 212. During a review of the Medication Administration Record (MAR) for Resident 212 and concurrent interview with Licensed Staff M on 8/16/23 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 observations, interviews, and records review, the facility failed to implement measures to reduce the risk of disease and infection transmission when: 1. Two Unlicensed Staff (Unlicensed Staff B and H) did not perform proper hand hygiene before passing food trays to the residents. This failure had the potential for spreading disease-causing microorganisms and/or transmission of diseases to the residents. 2. Four residents (Resident 29, 209, 213 and 19) were not offered hand hygiene before meals. This failure had the potential risk for residents getting sick from common germs including Escherichia coli (E. coli - type of bacteria) which can cause stomach aches and vomiting. 3. Licensed Staff E did not perform hand hygiene, according to the facility policy, during medication pass. This failure had the potential for spreading disease-causing microorganisms and/or transmission of diseases to the residents. 4. Licensed Staff E did not follow the facility policy on subcutaneous injection (the injection is given in the fatty tissue, just under the skin), when Licensed Staff E put…

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 records review, the facility failed to meet professional standards for pain medication administration for one of 15 sampled residents (Resident 29). This failure had the potential to compromise the resident's health and well-being for not getting the required dose of medication according to the doctor's order. Findings: During a record review for Resident 29, the Face sheet indicated Resident 29 was admitted on [DATE], with diagnoses including but not limited to Cutaneous T-cell lymphoma (CTCL- is a rare type of cancer that begins in white blood cells [responsible for protecting your body from infection]); Malignant Neoplasm of Prostate (when cells in the prostate gland [found only in males; the hollow organ where urine is stored] start to grow out of control); and Dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities). During a record review for Resident 29, the document titled Weekly Pressure Ulcer Report, dated 8/14/23 at 9:12…

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 and records review, the facility failed to ensure one of 15 sampled residents (Resident 3) was provided with a communication tool or resources to effectively communicate her needs. This failure had the potential for Resident 3 not to understand and carry out activities of daily living (ADL) which could lead to a decline in Resident 3's quality of life. (Reference F679) Findings: During a record review for Resident 3, the Minimum Data Set (MDS -health status screening and assessment tool used for all residents), dated 6/15/23, indicated Resident 3 had a BIMS score of 02 out of 15 points (Brief Interview for Mental Status - a 15-point cognitive screening measure that evaluates memory and orientation. A score of 13 to 15 is cognitively intact, 08 to 12 is moderately impaired, and 00 to 07 is severe impairment). During an interview with Unlicensed Staff B on 8/15/23 at 10:03 a.m., Unlicensed Staff B stated Resident 3 did not speak English. Unlicensed Staff B stated Resident 3 was able to communicate her needs in one-word Spanish sentence and answered yes or 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.

Based on observations, interviews, and record reviews, the facility failed to accurately assess and provide necessary services to prevent the development of a facility-acquired pressure ulcers (injuries to skin and underlying tissue resulting from prolonged pressure on the skin) and worsening of the pressure ulcer, for one of five sampled residents, Resident 20, when: The facility did not identify the presence of a pressure ulcer timely for Resident 20, which resulted in the development of an Unstageable (Full thickness tissue loss in which the ulcer is covered with by slough - Slough is necrotic (dead) tissue that needs to be removed from the wound for healing to take place) and/or eschar (Eschar, pronounced es-CAR, is dead tissue that sheds or falls off from the skin. It's commonly seen with pressure ulcer wounds) in the wound bed (the base or floor of the wound) pressure ulcer on her sacrum (The sacrum is a triangular bone composed of five vertebrae (small bones forming the backbone) that make up the second to last portion of the spine) two days after her weekly skin check. This…

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 records review, the facility failed to ensure staff provided appropriate respiratory care for one of three sampled oxygen dependent residents (Resident 3), when the facility did not attach a humidifier bottle (moistens the air to prevent a resident's nasal membranes from becoming dry, sore and scabby) to the oxygen (O2 - life-supporting component of the air) concentrator [a device used to provide oxygen to a resident in a steady even flow by means of a nasal cannula (a small, soft plastic tube that is divided into two prongs, which are placed in the nostrils)] when Resident 3 was on 5 liters (a metric unit of volume) of oxygen. This failure had the potential to result in Resident 3's discomfort associated with a dry nose from continuous oxygen use. Findings: During a record review for Resident 3, the document titled, Order Summary Report, indicated a doctor's order, written on 9/08/22, for Resident 3 to be on continuous oxygen via (by way of) nasal cannula to maintain an O2 sat (oxygen saturation/sat -refers to how much oxygen [air] is carried…

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, interviews, and record reviews, the facility failed to ensure one of three sampled residents, Resident 109, was free from significant medication errors, when her pain medication, Oxycodone HCL (Oxycodone Hydrochloride is used to relieve pain severe enough to require opioid treatment and when other pain medicines did not work well enough or cannot be tolerated) was not administered, as ordered by the physician. This failure had the potential to result in ineffective pain management, sedation, or possible dependence or addiction to the medication. Findings: A review of Resident 109's, Order Summary Report, dated 8/17/23, indicated she had a physician's order for Oxycodone HCL Oral Tablet 10 mg (milligram), give 0.5 tablet (1/2 tablet,= 5 mg) by mouth every 4 hours as needed for moderate pain (4-6) and Oxycodone HCL 10 mg Oral Tablet, give 1 tablet by mouth every 4 hours as needed for severe pain (7-10). During an interview on 8/15/23, at 10:42 p.m., with Resident 109, inside her room, Resident 109 was asked if she was having some pain today, and she stated, Yes.…

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.