Beachwood Post-Acute & Rehab

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure three of nine sampled residents (Residents 9, 37, and 157) were free from significant medication errors (an error in medication preparation or administration that can cause the resident discomfort or jeopardizes his or her health and safety) according to professional standards of practice by failing to: 1. Ensure Resident 37's Insulin Lispro (man-made version of human insulin used to manage blood sugar levels in people with diabetes [DM: a chronic condition where the body does not produce or use insulin properly, leading to high blood sugar levels]) Injection Solution 100 Unit/mL (milliliters) Inject 18 units subcutaneously (beneath the skin) before meals for DM 2 Rotate site. Hold for blood sugar (BS) less than (<) 100 and notify medical doctor (MD) if BS<80 or greater than (>) 400 was administered before dinner on 6/23/2025. 2. Ensure Licensed Vocational Nurse (LVN) 11 identified the discrepancy (differences) between the medication on hand 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 facility failed to ensure the kitchen staff stored food in a sanitary manner to prevent growth of microorganisms that could cause food borne illness (food poisoning: any illness resulting from the food spoilage of contaminated food, pathogenic bacteria, viruses, or parasites that contaminate food), as well as toxins when: 1. a. Food was not appropraitely stored b. Food was not labeled c. Prepared leftover tuna was not stored in the refrigerator d. Dietary staff did not follow cool down method e. Multiple food items were not labeled with expiration dates f. The ice machine and the kitchen stove were dirty with old, dried food, and debris. g. Clean water pitchers for the residents were stored on a cart with dirty dishes stored on the bottom of the cart. h. Employee water bottle sitting next to the clean cups on the counter top. 2. The walk in freezer floor in the kitchen had brown/blackish stains 3. The dish washing sink had a leaking pipe and green…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment by failing to implement standard precautions (a set of infection control practices used to prevent the transmission of diseases) in the provision of care for two of two sampled residents (Residents 10 and 131). This deficient practice placed residents at a higher risk of acquiring and transmitting infections to other residents, staff and visitors in the facility. Findings: During a review of Resident 131's admission Record, the admission Record indicated Resident 131 was originally admitted to the facility on [DATE] and re-admitted on [DATE], with diagnoses that included asthma (a chronic [long-term] condition that affects the airways in the lungs), epilepsy (a condition that affects your brain and causes seizures [abnormal electrical activity in your brain that temporarily affects your consciousness, muscle control 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.

Based on observation, interview, and record review, the facility failed to maintain the shared shower room on the 5th floor east in a safe and operating condition This deficient practice had the potential to result in resident injury and/or fall due to pieces of broken safety handles on the left side of the shower wall and a loose safety handle on the right side of the shower wall. Findings: During an observation on 6/24/2025 at 10:05 AM, of the East side shower room on the 5th floor in the facility, the safety hand railing on the left side in the shower was broken and the handrail to the right side of the same shower was loose. During a concurrent interview and observation on 06/24/25 10:19 AM, certified nursing assistant (CNA 1) stated the left side handrail was problematic because residents complained about it being in the way when they took showers. Residents primarily use the handrail to the right and in front, not the one to the left. CNA 1 also stated the handrail to the left had been broken for about two months. CNA 1 stated she was not sure how long the handrail on 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 call light was answered in a timely manner for three of three residents (Residents 23, 62, and 92) when the residents needed assistance with care including personal hygiene. This failure resulted in the residents becoming very upset, angry, and embarrassed. This deficient practice also had the potential for falls, injuries, and accidents. Findings: During a record review, Resident 62's admission record indicated Resident 62 was re-admitted to the facility on [DATE] and re-admitted on [DATE] with a diagnoses of Heart Failure, and lack of coordination. During a record review, Resident 62's Minimum Data Set (MDS- a resident assessment tool) dated 5/13/2025, indicated Resident 62's cognitive skills [the core skills your brain uses to think, read, learn, remember, reason, and pay attention] for daily decision making was intact. The MDS further indicated Resident 62 needed minimal assistance with Activity of Dailly Living (ADL-…

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's staff failed to ensure for One of one sampled resident (Resident 10): 1. Had a physician's order to self-administer a medical nutritional supplement/tube feeding formula via bolus feeding (a method of enteral tube feeding where a large dose of formula is administered into the stomach or small intestine over a short period of time, typically 15-20 minutes, several times a day) 2. Was assessed, educated and determined to have cognitive and physically demonstrated capability to safely self-administer a bolus feeding. These deficient practice had the potential to result in negative outcomes from food inhalation which could lead to adverse reactions, unnecessary hospitalization and possible poor outcomes for Resident 10. Cross reference F693 Findings: During a review of Resident 10's admission record indicated Resident 10 was originally admitted to the facility on [DATE] and re-admitted on [DATE], with diagnoses that include malignant neoplasm 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 ensure to provide a Notice of Medicare Non-Coverage (NOMNC, is a document used in Medicare [a Federal health insurance program] to inform beneficiaries when their Medicare-covered services are ending, and to explain their appeal rights) to one of three sampled resident ' s (Resident 254), representative (responsible party). This failure had the potential to result in Resident 254's representative not being able to exercise their right to file an appeal. Findings: During a review of Resident 254's admission Record, the admission Record indicated the facility admitted Resident 254 on 6/9/2025, with diagnoses including unspecified heart failure heart does not pump as well as it should), unspecified dementia(a progressive state of decline in mental abilities), unspecified edema (swelling caused by an abnormal accumulation of fluids in the body ' s tissues), hypertension(high blood pressure), dysphagia(difficulty swallowing), generalized muscle weakness, unsteadiness on feet, malaise(overall weakness or…

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

Based on observation, interview, and record review, the facility failed to ensure that one out of one sampled resident (Resident 404) was free from physical restraint by failing to ensure that the physicians order for hand mittens indicated a reason for the use of the mittens in accordance with the facility's policy and policy (P&P) titled Physician Orders with a revised date of 1/2025. This deficient practice had the potential to result in unnecessary restraints and placed the residents at risk of physical harm from impeding the circulation of resident 404's arms. Findings: During a review of Resident 404's admission Record, the admission record indicated the facility admitted Resident 404 on 4/8/2025 with diagnoses including encephalopathy (a disease or damage that affects the brain, leading to a change in how it functions), hypertension (HTN-high blood pressure), and diabetes (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 404's Minimum Data Set (MDS - a resident assessment tool) dated 4/9/2025, 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.

Based on observation, interview, and record review, the facility failed to follow through with the Preadmission Screening and Resident Review (PASARR- a federally required screening to help identify individuals with possible serious mental illnesses requiring a specialized follow up evaluation) recommendation to obtain a PASRR level II (assessment that determines if resident's mental condition could be met in the nursing facility or if the individual requires specialized services) evaluation for one of two sampled residents (Resident 150). This deficient practice had the potential to result in inappropriate placement and unidentified specialized services for Resident 150. Findings: During a review of Resident 150's admission Record, the admission record indicated the facility admitted Resident 150 on 12/5/2023 and readmitted the resident to the facility on 1/25/2025 with diagnoses including schizophrenia (a mental illness that is characterized by disturbances in thought), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest),…

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 refer and provide podiatry service to one of two sampled residents (Resident 62). Resident 62 has not seen a podiatrist since the resident's admission on [DATE] (1 year and 4 months ago). This deficient practice placed Resident 62 at risk for pain or discomfort. Findings: During a review of Resident 62's admission Record indicated the facility was originally admitted Resident 62 on 2/26/2024 and readmitted on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), heart failure (a heart disorder which causes the heart to not pump the blood efficiently) and Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 62's risk for skin breakdown care plan, initiated 2/26/2024, indicated the resident was at risk for skin breakdown due to prolonged periods of time sitting on electric…

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 three sampled resident's (Resident 162) urinary catheter (a hollow tube inserted into the bladder to drain or collect urine) was securely anchored (secured to the resident) per the resident's per the resident's physician order. This deficient practice had the potential for the resident to endure pain from potential pulling tractions and dislodgement of the catheter that may result in urethral (a muscular structure that helps keep urine in the bladder until voiding can occur) trauma. Findings: During a review of Resident 162's admission record indicated the facility admitted Resident 162 on 5/20/2024 with diagnoses that included neuromuscular bladder dysfunction (condition in which the nerves and muscles controlling the bladder do not work together properly), heart failure (a heart disorder which causes the heart to not pump the blood efficiently) and dementia (a progressive state of decline in mental abilities) During a review of Resident 162's Minimum Data Set (MDS - a resident assessment tool),…

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 error rate of 5 percent (%-unit of measurement) or less with 25 opportunities, for two of two sampled residents (Residents 9 and 157) during the medication administration, when: 1. Licensed nurses did not identify discrepancy (difference) between the medication on hand and what the medical doctor (MD) ordered for Resident 9. 2. Three of three sampled Licensed Vocational Nurses (LVNs- 9, 11, and 13) were not able to correctly identify basic nursing dosage calculation conversions including the conversions from one ounce (oz - standard unit of weight) to milliliters (ml - a unit of volume) and from a tablespoon (tbsp - a common prescription used to dose liquid medications) to milliliters. 3. One of nine licensed nurses did not use proper dosing measurement tools to accurately measure the medication for Resident 157 as ordered by the MD. This deficient practice resulted in 8% medication error rate and had the potential 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 observation, interview, and record review, the facility failed to ensure unopened insulin (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication) vials requiring refrigeration were stored in a refrigerator according to the manufacturer's requirements in one of five inspected medication carts (3rd Floor East Medication Cart). This deficient practice of failing to store medication per the manufacturer's requirements had the potential to lead the medication to reduced potency, making the medication less effective or even causing adverse reactions. Findings: During a concurrent observation and interview on 06/27/2025 at 07:56 AM, of (3rd Floor East Medication Cart), with Licensed Vocational Nurse (LVN) 7, one vial of insulin Lispro (a medication used to control blood sugar) for Resident 39 and another one for Resident 17 were observed unopened and stored in the medication cart. LVN 7 confirmed the observation and stated the medications should be stored in the refrigerator. LVN 7 stated it is important to follow…

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

Based on interview and record review, for one of three sampled residents (Resident 1), the facility failed to: 1. Ensure Augmentin (Amoxicillin-Pot Clavulanate - antibiotic - medication to treat infection) tablet 875-125 mg-unit of measurement) was readily available in the Emergency Kit (Ekit - a kit consisting of drugs, including controlled substances, needed to effectively manage a critical care incident or need of a patient). 2. Ensure Resident 1 received Amoxicillin-Pot Clavulanate tablet 875-125 mg 1 tablet by mouth BID (twice a day) for possible urinary tract infection (UTI- an infection in the bladder/urinary tract) for 10 days according to the physician's order dated 4/2/2025 at 11.14 a.m. 3. Ensure a physician was notified that Resident 1 was not administered Amoxicillin-Pot Clavulanate 875-125 mg according to physician's order dated 4/2/2025 at 11.14 a.m. As a result, Resident 1 never received Amoxicillin-Pot Clavulanate tablet 875-125 mg on 4/2/2025 (a total of 11 hours 16 minutes). Cross Reference F684 Findings: During a record review, Resident 1's admission record…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to complete a notice of bed-hold policy and return form when the resident was transferred to General Acute Care Hospital 1 (GACH 1) for one of two sampled residents (Resident 1). This deficient practice had a potential to result in the resident's responsible party being unaware of the bed hold policy and can lead to a transfer of the resident to another skilled nursing facility not of the resident's or responsible party's preference. Findings: During a review of the Resident 1 ' s admission Record, it indicated Resident 1 was admitted to the facility on [DATE] with diagnosis including multiple sclerosis (MS- a chronic, progressive disease involving damage to the nerve cells in the brain and spinal cord), ESRD (End Stage Renal Disease-irreversible kidney failure) and heart failure (a condition in which the heart does not pump blood as well as it should). The admission Record indicated, Resident 1 was discharged on 2/28/2025. During a review of the 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure Resident 1 received quality of care and treatment in accordance with facility ' s policy and procedure titled, Acute Changes, to monitor Resident 1 after she had a change of condition (COC) on 2/23/2025. This deficiency had the potential to result in poor quality of care and delayed response to resident needs after a COC. Findings: During a review of the Resident 1 ' s admission Record, it indicated Resident 1 was admitted to the facility on [DATE] with diagnosis including multiple sclerosis (MS- a chronic, progressive disease involving damage to the nerve cells in the brain and spinal cord), ESRD (End Stage Renal Disease-irreversible kidney failure) and heart failure (a condition in which the heart does not pump blood as well as it should). During a review of the Minimum Data Set (MDS - resident assessment tool) dated 2/20/2025, indicated Resident 1 ' s cognitive (mental action or process of acquiring knowledge and understanding) skills 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 for one of three sampled residents, Resident 1. The facility failed to provide and review discharge care instructions with the resident representative (RR) at the time of discharge. This deficient practice caused the RR to be unsure of the follow up instructions for Resident 1 ' s stage II pressure ulcer (Partial-thickness loss of skin, presenting as a shallow open sore or wound) on the sacrum (lower back) after discharge. Findings: During a record review, Resident 1 ' s admission Record indicated the facility originally admitted Resident 1 on 12/3/2024 and most recently on 1/7/2025 with diagnoses including, central cord syndrome at the cervical spine (injury of the spinal cord causing weakness in arms and legs), fracture of the second vertebrae (broken neck), Alzheimer ' s disease (a disease characterized by a progressive decline in mental abilities), essential hypertension (high blood pressure), end stage renal disease (End Stage Renal Disease-irreversible kidney failure) with attention to dialysis (a treatment to cleanse the blood of wastes…

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 reviews, facility failed to ensure one of four sampled residents, (Resident 2) was notified and informed by failing to: 1. Provide monthly statements for costs and charges of the services that facility provided for Resident 2. 2. Provide information how to dispute and/or appeal Resident 2 ' s share of cost as indicated in the facility ' s policy and procedure (P&P) titled, Medi-Cal Share of Cost. These deficient practices violated resident ' s right to be informed of the services that the facility charged and resident ' s wish to appeal. Findings. During a record review of the admission Record indicated Resident 2, was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including metabolic encephalopathy (a chemical imbalance in the blood affecting the brain), paraplegia (an injury that occurs lower down the spinal cord may only affect a person's lower body and legs) and urinary tract infection (UTI- an infection in the bladder/urinary tract). During a record…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to: 1. Ensure one of three sampled residents, (Resident 1) was thoroughly assessed and monitored after Resident 1 was found lying on the floor beside the bed and had an alleged fall which resulted in increased pain and bump on the occipital area (refers to the back of the head, specifically the area covered by the occipital bone). 2. Ensure Resident 1 was monitored and staff immediately documented the interventions to prevent falls after Resident 1 was found lying on the floor such as necessary laboratory test and/or radiology test to ensure resident was stable without any delayed complications. These deficient practices had a potential for Resident 1 ' s fall not properly assessed and investigated and placing resident at risk for further falls or accidents. Findings: During a review of the admission Record indicated Resident 1, was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including hemiplegia (total paralysis of the arm,…

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 staff failed to ensure resident received appropriate treatment and services to prevent urinary tract infection (UTI- an infection in the bladder/urinary tract) for one of three sampled residents (Resident 2) by failing to change and monitor Resident 2 ' s incontinent brief promptly when soiled. This deficient practice had the potential to result or resulted in urinary tract infections for the resident. Findings: During a review of the admission Record indicated Resident 2, was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including metabolic encephalopathy (a chemical imbalance in the blood affecting the brain), paraplegia (an injury that occurs lower down the spinal cord may only affect a person's lower body and legs) and UTI. During a review of the Minimum Data Set (MDS – a resident assessment tool) dated 1/15/2025, indicated Resident 2 ' s cognitive (mental action or process of acquiring knowledge and understanding)…

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 one of five sampled residents, (Resident 1) received treatment and care accordance with professional standards of practice to meet the resident's physical, mental, and psychosocial needs by failing to ensure the physician ' s order was carried out when physician ordered to check Resident 1 ' s vital signs (VS - measurements of the body's basic functions, including breathing, heart rate, blood pressure, and temperature) every shift for the whole month of January, 2025. This deficient practice resulted to failure in the delivery of necessary care and services for Resident 1. Findings: During a review of Resident 1's admission Record indicated the facility originally admitted this [AGE] year-old female on 10/21/2021 and most recently on 12/20/2024 with diagnoses including vascular Parkinsonism (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), Hemiplegia (total paralysis of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to assure that residents receive care and services for the provision of hemodialysis (HD-filtering the blood of a person whose kidneys are not working normally) consisted with professional standard of practice by failing to ensure ongoing assessment of the resident's condition and monitoring for complications after hemodialysis treatment was received for two of four sampled residents (Resident 1, Resident 2). This deficient practice had the potential to negatively impact the delivery of care and services provided to Resident 1 and Resident 2. Findings: i. During record review, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including ESRD (End Stage Renal Disease-irreversible kidney failure), respiratory failure (condition in which your blood does not get enough oxygen or has too much carbon dioxide) and type II 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to inform the Resident Representative (RR) of Residents return from the general acute care hospital (GACH) for one of four sampled residents (Resident 1). This deficient practice caused the resident Representative to not be informed of the resident's care. Findings: A review of Resident 1's admission Record indicated the facility originally admitted this [AGE] year-old female on 10/21/2021 and most recently on 12/20/2024 with diagnoses including vascular Parkinsonism (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), Hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) affecting the right side, Osteoporosis (weak and brittle bones due to lack of calcium and Vitamin D), Osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage), Primary Hypertension (high blood pressure), Hyperlipidemia (high cholesterol in the blood),…

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

Based on interviews and record reviews the facility failed to provide skin and pressure ulcer (injuries to the skin and underlying tissue, primarily caused by prolonged pressure on the skin) prevention care per the care plan for one out of four sampled residents (Resident 2) by failing to reposition Resident 2 every 2 hours per the resident ' s care plan. This deficiency had the potential to result in Residents 2 ' s left gluteal (buttocks) pressure ulcer/injury stage 2 (Partial-thickness loss of skin, presenting as a shallow open sore or wound) to worsen. Findings: During a review of Resident 2 ' s admission Record (Face Sheet), dated 12/20/2024 the face sheet indicated the facility admitted Resident 2 on 7/9/2024 with diagnoses including a left tibial fracture (a broken shinbone), pressure ulcer of the left buttocks stage 2, other malaise (a feeling of general discomfort, weakness, or lack of health), lack of coordination (the ability to use multiple body parts at the same time to perform a task smoothly and accurately), peripheral vascular disease (a chronic condition that occurs…

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 staff failed to ensure one of one sampled residents (Resident 2) received appropriate treatment and services for spontaneous peritonitis (a serious infection of the fluid in the abdomen that occurs when the lining of the abdomen, becomes infected without an obvious cause) by failing to clarify the correct use of Ciprofloxacin 250 milligrams (mg- metric unit of measurement, used for medication dosage and/or amount), one tablet orally daily given after hemodialysis on hemodialysis days, for one out of four sampled residents, Resident 3. This deficiency resulted in a medication error and for Resident 3 to receive the Ciprofloxacin for the correct diagnosis. Findings: During a review of Resident 3 ' s admission Record (Face Sheet), dated 12/20/2024 the face sheet indicated the facility admitted Resident 3 on 7/12/2024 with diagnoses including enterococcus (bacteria) as the cause of diseases classified elsewhere, sepsis, and spontaneous bacterial peritonitis (a serious infection of fluid that builds up in the abdomen without…

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 three sampled residents (Resident 1) was free from significant medication errors (causes the resident discomfort or jeopardizes his or her health and safety) according to professional standards of practice by failing to ensure Licensed Vocational Nurse (LVN1) administered Heparin Sodium Injection (medication to thin the blood) 5000 unit/ml (Heparin Sodium) Inject 0.5ml (ml=milliliters) subcutaneously (fatty tissue layer just beneath the skin) two times a day for DVT (Deep Vein Thrombosis-blood clot) prophylaxis (prevention) as per physician ' s order. As a result, on 11/2/2024 LVN 1 gave Resident 1 a double dose of Heparin. This deficient practice placed Resident 1 at risk for bleeding. Findings: A review of Resident 1 ' s admission Record the facility originally admitted this [AGE] year-old male on 11/30/2023 and most recently on 9/26/2024 with diagnoses including non-traumatic intracerebral hemorrhage (bleeding in the brain), epilepsy…

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 obtain a physician ' s order for a urine culture and sensitivity (C&S=a lab test that checks for bacteria in the urine and which medications will work) prior to obtaining a urine sample with a straight catheter (a thin flexible hollow tube used to drain urine from the bladder) for one of three sampled residents (Resident 1), who was suspected of having a (UTI, an infection in any part of the urinary system including the kidneys [organs in the body that filter waste materials out of the blood and pass them out of the body as urine, regulates blood pressure and the levels of water, salts, and minerals], and ureters [Tube/s that carry urine from the kidneys to the bladder and urethra]). This deficient practiced resulted in a urine specimen expiring, resulting in Resident 1 having to endure a straight catheter procedure twice in one week (10/30/2024 and 11/02/2024). Findings: A review of Resident 1 ' s admission Record the facility originally admitted 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 interview and record review, the facility failed to report an allegation of physical abuse to the state survey agency within 2 hours for one of three sampled residents (Resident 1) in accordance with the facility's policy and procedures (P&P) titled, Abuse Investigation and Reporting, revised 1/24. This deficient practice had the potential to result in a delay of an onsite inspection by the California Department of Public Health (CDPH) to ensure Resident 1's allegation was investigated timely. This deficient practice also had the potential to place Resident 1 at further risk for abuse. Findings: A review of Resident 1's admission Record indicated the facility originally admitted Resident 1 on 11/20/20 and re-admitted the resident on 6/2/21 with diagnoses of spinal stenosis (a condition in which the spaces in the spine narrow, placing pressure on the spinal cord and nerves which can lead to pain, numbness, tingling or cramping), post laminectomy syndrome (condition in which a person experiences pain after a surgery that removes part of a vertebra to relieve pressure on 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 record review, the facility failed to ensure one out of 3 sampled Residents (Resident 1) received treatment and care in accordance with professional standards of practice to meet the resident's physical, mental, and psychosocial needs by: Failing to timely administer bowel medication timely per doctors on order. This failure caused Resident 1 to experience unnecessary pain and placed the Resident 1 at risk for bowel impaction, bowel perforation, unnecessary hospitalization and even death. Findings: On 7/22/2024 at 8:45am an unannounced visit was made to the facility to investigate a complaint regarding neglect and quality of care. A review of Resident 1 ' s admission Record, indicated, Resident 1 was originally admitted to the facility on [DATE] with diagnoses that included osteomyelitis (an infection in a bone), neuromuscular bladder dysfunction (lack of bladder control due to a brain, spinal cord or nerve injury), anxiety disorder (persistent and excessive worry that interferes…

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 investigate and report allegations physical abuse (willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish) for one out of three sampled residents (Resident 1) to the Department of Public Health, Ombudsman (an official appointed to investigate individuals' complaints against maladministration), and to the local law enforcement in accordance with the facility's policy and procedures (P&P) titled Abuse investigation and Reporting revised 1/2024, by failing to report a resident-to-employee altercation to the State Survey Agency (SSA) within 2 hours after the allegation occurred on 7/16/2024. This deficient practice resulted in delayed onsite investigation by the SSA had the potential to place Resident 1 at increased risk for abuse. Findings: A review of Resident 1's admission Record indicated the resident was admitted to the facility on [DATE] and was readmitted on [DATE]…

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: 1. Obtain a physician's order for Out on Pass (OOP) for one of three sampled residents (Resident 1). 2. Ensure staff monitored/supervised Resident 1 while the resident was on unauthorized OOP. 3. Ensure Resident 1 signed out and back in on the OOP log. Facility was aware Resident 1 went on unauthorized OOP three times a week. These deficient practices placed Resident 1 at increased risk for falls, injuries, accidents, hospitalizations, and/or death. Findings: A review of Resident 1's admission Record indicated the resident was admitted to the facility on [DATE] and was readmitted on [DATE] with medical diagnoses including cervical spinal stenosis (space inside the bone is too small in the long column of bones in the neck area), generalized muscle weakness (a decrease in muscle strength), lack of coordination (Impaired balance that can be due to damage to brain, nerves, or muscles), and hypertension (HTN - High blood pressure). A review of Resident 1's…

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

Based on observation, interview, and record review, the facility failed to ensure missing narcotics (the controlled medications used to treat moderate to severe pain) were documented and reported per the facility's policy. This deficient practice had the potential for medication loss and diversion, placing the resident at risk not receiving pain medication when needed. Findings: During a concurrent observation and interview with licensed vocational nurse 2 (LVN 2) for a narcotic counting on 6/27/24 at 2:37 PM, there were two (2) tablets of hydrocodone (type of pain medication) 5-325 milligrams were missing and not signed out by any of the nurses on the medication cart on the station. LVN 2 confirmed and stated she received the medication cart with two tablets of Hydrocodone 5-325 milligrams missing from the 11pm-7am shift nurse but had not reported to the director of nursing (DON) or registered nurse (RN) supervisor of two tablets of hydrocodone 5-325 milligrams being missing. When asked what could happen if missing narcotics were not reported, LVN 2 stated the residents could be 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 observation, interview, and record review the facility failed ensure medications were discarded as per facility policy and procedure titled, Discarding and Destroying Medications dated 2001. By failing to: 1. Check the expiration date, remove, and discard from use, one box of BD Vacutainer Safety-Lok Blood Collection Set (tubing and needle used to collect blood specimens). 2. Remove one box of expired Bisacodyl (laxative- medication that prevents/treats constipation) 10 milligrams. These deficient practices had the potential to cause a mechanical failure of the expired blood collection set during an attempt to collect blood from a resident and affect medication efficacy (the power to produce the desired effect) and reduce the therapeutic (intended to treat diseases or disorders) effects of medications administered. Finding: During observation of the 4th floor medication storage area at the nursing station on 06/27/24 at 3:42 p.m., a half-used box of Safety-Lok Vacutainers were observed on the counter in the medication room open and ready for use and available for staff 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.

REVIEWED Based on oservation, interview, and record review, the facility failed to ensure safe and sanitary food storage, food labeling practices in accordance with professional standards and facility policy to ensure food service safety and ensure routine maintenance of kitchen pipes was performed. These failures had the potential to result in harmful bacteria growth and cross contamination (a transfer of harmful bacteria from one place to another or one object to another) that could lead to foodborne illness (illness caused by food contaminated with bacteria, viruses and other toxins) and corrosion to the pipes, safety hazards in 211 of 211 medically compromised residents who received food and have food prepared from the kitchen, staff getting injured due to large puddles of water on the floor, and large industrial fan blowing in kitchen while food is being prepared. Findings: During an initial tour and observation of the facility kitchen with the Dietary Supervisor (DS) on 6/25/2024 at 7:50 AM. Two blocks of yellow sliced cheese were observed labeled with an expiration date 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 protect residents of one of three residents (Resident 143) to a dignified existence and self- determination by failing to properly dispose a soiled wash towel, cleaning and placing resident's toothbrush clean and secure environment after activities of daily living (ADL) care. This deficient practice had the potential to affect Resident 143's sense of self-worth and self-esteem. Findings: During a facility tour observation of Resident 143's bathroom on 6/25/2024 at 9:05 AM, a wash basin with a soiled washcloth and toothbrush was observed on top of the toilet lid of Resident 143's bathroom. During an interview with Licensed Vocational Nurse 9 (LVN 9) on 6/25/2024 at 9:10 AM, LVN 9 stated the wash basin with soiled wash cloth and toothbrush should not be placed on top of a toilet lid. LVN 9 stated placing the wash basin with soiled wash cloth and toothbrush on the to the toilet lid places increased the risk for contamination with disease causing baceria that could cause infection and demeans (lower) Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, and interview, the facility failed to ensure a safe, comfortable, sanitary, and clean homelike environment for three of seven residents (Residents 13, 71, and 328) by failing to: 1. Ensure Resident 328's room temperature was maintained between set at 74 or 75 Farenhiet (F- Unit of measurement). This failure resulted in Resident 328's room temperature was 68 degrees F, and the resident complained of feeling very cold and had the potential for the resident to develop hypothermia (a significant and dangerous drop in the body temperature). 2. Multiple dark spots on the floor in Resident 71 room were removed. 3. Soiled wash towel and toothbrush not left on top of a toilet lid in the bathroom for Residents 143 and 278. These dificient practices resulted in an unsanitary and unhomelike environemnt for Residents 71, 143 and 278. Findings: A. A review of Resident 328's admission Record indicated Resident 328 was admitted to the facility on [DATE], with medical diagnoses that included anxiety…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to provide oral (mouth) care for one of ten residents (Resident 4). This deficient practice resulted in Resident 4 developing a very dry tongue and lips with the potential for infection. Findings: A review of Resident 4's Face Sheet indicated Resident 4 was admitted to the facility on [DATE], with diagnoses that included chronic (ongoing) respiratory failure (when the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body), cerebral palsy (group of disorders that affect a person's ability to move and maintain balance and posture), dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), and candidiasis (infection caused by an overgrowth of a type of yeast). A review of Resident 4s History and Physical dated 10/20/23, indicated, Resident 4 did not have the capacity to understand and make decisions. 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 turn and reposition five of five residents (Residents 30, 99, 103, and 105) every 2 hours as per physician's order and inaccordance with the facility's policy and procedures titled Prevention of Pressure Ulcers, Prevention of Pressure Ulcers/Injuries, and Repositioning. This failure placed Residents 30, 99, 103, and at increased risk to develop new pressure ulcers and or worsening of existing pressure ulcers. Findings: A. A review of Resident 30's admission record (background information; a document containing demographic and diagnostic information) indicated Resident 30 was admitted to the facility on [DATE] with the following diagnoses of cerebral infarction (stroke), dysphagia (difficulty swallowing), hemiplegia (paralysis that affects one side of the body) and hemiparesis (weakness or the inability to move on one side of the body), left hand contracture (curl or pull in towards the palm), and pressure ulcer (damaged to an area of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, for one of ten residents (Resident 202) the facility failed to: 1. Monitor Resident 202's urine for signs and symptoms (S/S- something an individual experiences.) of urinary tract infection (UTI- an infection involving any part of the urinary system). Resident 202 had an indwelling catheter (a flexible tube to drain urine). 2. Notify a medical doctor (MD) that Resident 202's urine had sediments in the indwelling catheter. These deficient practices had the potential for Resident 202 to develop UTI. Findings: A review of Resident 202's Face Sheet indicated Resident 202 was admitted to the facility on [DATE], with diagnoses that included traumatic brain injury (a brain injury that is caused by an outside force), altered mental status (a disruption in how the brain works that causes a change in behavior) and multiple fractures (broken bones) of pelvis (area below the abdomen that includes the hip bones). A review of Resident 202's History and Physical dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the hourly water flush volume was administrated as ordered through a percutaneous endoscopic gastrostomy (PEG - surgically placed that allows a person to receive nutrition through the stomach) tube while on enteral feeding (delivery of nutrients through a feeding tube directly into the stomach) for one of two sampled residents (Resident 30). This deficient practice had the potential for Resident 30 to experience dehydration and tube blockage when the hourly water flush through the PEG tube ran less than the calculated amount as prescribed. Findings: A review of Resident 30's admission Record (background information; a document containing demographic and diagnostic information) indicated Resident 30 was admitted to the facility on [DATE] with the following diagnoses: unspecified sequelae of cerebral infarction (a loss of blood flow to part of the brain, which damages brain tissues), dysphagia (difficulty swallowing) following…

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 staff failed to ensure one of ten sampled residents (Resident 64) received tracheostomy (trach- a surgically created hole in your windpipe that provides an alternative airway for breathing) care by leaving his trach unsecured and not applying a dressing around the trach. This deficient practice placed Resident 64 at risk increased for the trach to become dislodged (move out of place) and the potential for respiratory distress and death. Findings: A review of Resident 64's Face Sheet indicated the resident was admitted to the facility on [DATE], with diagnoses including chronic (long term) respiratory failure (when the lungs cannot get enough oxygen into the blood), trach, dependence on ventilator (machine that assists in breathing) and schizophrenia (a serious mental health disorder characterized by disruptions in thought processes, perceptions, emotional responsiveness, and social interactions). A review of Resident 64's History and Physical dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of 13 sample residents (Resident 9) was free from significant medication errors. By failing to: 1. Obtain and document a physician's order to keep pain relieving medications (1). Salonpas Lidocaine 4% patch (patch used to reduce itching and relieve pain from certain skin conditions), and (2) Diclofenac Sodium topical gel 1% (medication used to relieve pain and reduce inflammation) at bedside. 2. Allow Resident 9's responisble party (RP) to administer Diclofenac Sodium topical gel 1% and a box with 7 Salonpas Lidocaine 4% patches to Resident 9 without supervision or assessment of competency to administer medications. This deficient practice had the potential to cause complications of redness, swelling, blisters, or changes in the skin color at the site of application and serious allergic reactions including itching/swelling of the face/tongue/throat) severe dizziness and trouble breathing. Cross-reference F658 and F759 Findings: 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 call lights (device with a button or touch pad a resident uses to set off an alarm that flashes/rings to alert the facility staff the resident needs assistance) were within reach for one of seven sampled residents (Resident 165). This deficient practice had the potential to result in a delay in meeting Resident 165's needs for hydration, toileting, and activities of daily living. Findings: A review of Resident 165's admission Record indicated Resident 165 was admitted to the facility on [DATE], with medical diagnoses that included: Paraplegia (a chronic condition that causes the loss of muscle function and feeling in the lower half of the body, including both legs), major depressive disorder (a common and serious medical illness that negatively affects how you feel, the way you think and how you act), and muscle weakness (a lack of physical or muscle strength, throughout the body). A review of Resident 165's Minimum Data Set (MDS -…

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

Based on interview, and record review the facility failed to ensure a licensed administrator was appointed by the governing body to run the facility. This failure had the potential to affect resident care and management of the facility. Findings: During an interview with the front desk staff (FDS) on 5/8/24 at 10:00 am, the FDS identified the current Administrator (ADM 1) as being the facility's ex-Administrator (XADM). The FDS further stated XADM is at the facility Mondays, Wednesdays and sometimes Fridays. During an interview on 5/8/24 at 10:25 am, Licensed Vocational Nurse 1(LVN 1) identified XADM as the current Administrator and further stated that ADM 1 works under the XADM. During an interview on 5/8/24 at 10:27 am, Registered Nurse Supervisor 1 (RNS 1) identified the XADM as the current Administrator and stated he (XADM) is here at the facility full time. The RNS further stated the ADM 1 is working under the XADM. During an interview on 5/8/24 at 10:34 am, Certified Nursing Assistant 1 (CNA 1), identified the XADM as the current Administrator. CNA 1 further stated ADM 1 works…

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 1 was free from injury while being repositioned in bed for one of two sampled residents (Resident 1) by failing to: 1. Ensure Certified Nurse Assistant 1 (CNA 1) had a second staff member present to assist with repositioning Resident 1 as per Physical Therapy (is a healthcare profession, as well as the care provided by physical therapists who promote, maintain, or restore health through patient education, physical intervention, disease prevention, and health promotion) Discharge Summary report. 2. Obtain a Physician's Order to use a low air loss mattress (LALM - is a mattress designed to prevent and treat pressure wounds) for Resident 1. 3. Develop and implement a plan of care with appropriate interventions for the LALM for Resident 1. 4. Ensure CNA 1 locked the bed brakes before repositioning Resident 1 in bed. Resident 1 was dependent on staff and had a right and a left leg below knee amputation (a surgical procedure…

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 policy regarding reporting of an injury of unknown source and to submit a conclusion report of investigation within five days or in accordance with state or federal law for one of three sampled resident (Resident 1). This deficeint practice resulted in a delay of an onsite inspection by the Department to ensure the safety of the residents and had the potential to place residents at further risk for injuries. Cross Reference F610. Findings: A review of Resident 1 ' s admission Record indicated the resident was admitted on [DATE] with diagnoses including atrial fibrillation (afib- an irregular and very rapid heart rhythm that and can lead blood clots in the heart), restless legs syndrome (RLS - is a condition in which one has feelings of pulling, [NAME], drawing, tingling, bubbling, or crawling beneath the skin, usually in the calf area), dysphagia (difficulty swallowing food or liquid) and abnormalities of gait and mobility. 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 interview and record review, the facility failed to implement their policy regarding reporting of an injury of unknown source and to submit a conclusion report of investigation within five days or in accordance with state or federal law for one of three sampled resident (Resident 1). This deficeint practice resulted in a delay of an onsite inspection by the Department to ensure the safety of the residents and had the potential to place residents at further risk for injuries. Cross Reference F609. Findings: A review of Resident 1 ' s admission Record indicated the resident was admitted on [DATE] with diagnoses including atrial fibrillation (afib- an irregular and very rapid heart rhythm that and can lead blood clots in the heart), restless legs syndrome (RLS - is a condition in which one has feelings of pulling, [NAME], drawing, tingling, bubbling, or crawling beneath the skin, usually in the calf area), dysphagia (difficulty swallowing food or liquid) and abnormalities of gait and mobility. 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 interview and record review, the facility failed to develop and implement a comprehensive care plan that met the care/services based on the resident's individual assessed needs for one of three sampled residents (Resident 2) by failing to develop a comprehensive care plan for physician ' s order of Cefazolin (antibiotic medication used to treat infection) medications. This deficient practice had the potential to result negative impact on residents ' health and safety, as well as the quality of care and services received. Cross Reference F760. Findings: A review of Resident 2's admission Record indicated the resident was admitted to the facility on [DATE] with diagnosis including sepsis (a life-threatening condition that arises when the body ' s response to infection causes injury to its own tissues and organs), chronic hepatitis C (an infection caused by a virus that attacks the liver and leads to inflammation) and community acquired pneumonia (lung infection that inflames air sacs with fluid or pus). 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 a resident who is incontinent of bowel and bladder receives appropriate treatment and services to prevent occurrence of urinary tract infection (UTI - an infection that can occur in any area of the urinary tract, including the ureters, bladder, kidneys, or urethra) for one of five sampled residents (Resident 4) by failing to ensure Resident 4 ' s skin remain clean, dry and free of irritation. This deficient practice had the potential to negatively affect the resident's physical comfort and psychosocial well-being and had the potential for formation of pressure sores (injury to skin and underlying tissue resulting from prolonged pressure on the skin) to the resident. Findings: A review of admission Record indicated Resident 4 was admitted to the facility on [DATE] with diagnoses including left knee prosthetic fracture (fractures around joint replacement prostheses), muscle weakness and difficulty in waking. A review of the 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, facility failed to ensure one of three sampled residents (Resident 2) was free from significant medication error by failing to ensure the Cefazolin (antibiotic medication used to treat infection) medications were given on time as ordered by the physician. This deficient practice has the potential to result in Resident 2 in unintended complications related to the management of infection. Cross Reference: F656. Findings: A. A review of Resident 2's admission Record indicated the resident was admitted to the facility on [DATE] with diagnosis including sepsis (a life-threatening condition that arises when the body ' s response to infection causes injury to its own tissues and organs), chronic hepatitis C (an infection caused by a virus that attacks the liver and leads to inflammation) and community acquired pneumonia (lung infection that inflames air sacs with fluid or pus). A review of Resident 2's Physician ' s History and Physical dated 3/23/2024 indicated,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure prompt attempt was made to resolve grievances for one of two sampled resident (Resident 1). This deficient practice violated Resident 1's responsible party (R1 RP ' s) right to have grievance addressed. Findings: A review of Resident 1's admission Record indicated Resident 1 was admitted to the facility on [DATE], with diagnoses including chronic respiratory failure (condition in which your blood does not get enough oxygen or has too much carbon dioxide), tracheostomy (an opening surgically created through the neck into the trachea [windpipe] to allow direct access to the breathing tube) and gastrostomy tube (GT- a flexible tube surgically inserted through the abdomen into the stomach for feeding, fluid, and medication administration). A review of the Minimum Data Set (MDS - a comprehensive assessment and care screening tool), dated 2/1/2024, indicated Resident 1 ' s cognitive (mental action or process of acquiring knowledge and understanding)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide the necessary treatment and service to one of three sampled residents (Resident 1) consistent with the resident ' s needs and professional standard of care by failing to ensure Resident 1 ' s low air loss mattress (LAL-a mattress designed to prevent and treat pressure wounds) was in appropriate setting per facility's policy. This deficient practice can place Resident 1 at risk of poor wound healing of the current pressure ulcer (injury to skin and underlying tissue resulting from prolonged pressure on the skin) and possibly development of a new pressure injury. Findings: A review of Resident 1 ' s admission Record indicated Resident 1 was admitted to the facility on [DATE], with diagnoses including chronic respiratory failure (condition in which your blood does not get enough oxygen or has too much carbon dioxide), tracheostomy (an opening surgically created through the neck into the trachea [windpipe] to allow direct access to 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 implement their protocol for Antibiotic (medication that fight bacterial infection) Stewardship by ensuring a process on tracking/monitoring, reporting, and documenting antibiotic use for two of four sampled residents (Residents 1 and 6). This deficient practice had the potential for Resident 1 and 6 to develop antibiotic resistance (not effective to treat infection) from unnecessary or inappropriate antibiotic use. Findings: 1. A review of Resident 1 ' s admission Record indicated Resident 1 was admitted to the facility on [DATE], with diagnoses including chronic respiratory failure (condition in which your blood does not get enough oxygen or has too much carbon dioxide), tracheostomy (an opening surgically created through the neck into the trachea [windpipe] to allow direct access to the breathing tube) and gastrostomy tube (GT- a flexible tube surgically inserted through the abdomen into the stomach for feeding, fluid, and 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 Certified Nursing Assistant 2 (CNA2) was not standing while feeding one of four sampled residents (Resident 5). This deficient practice violated the right to be treated with dignity and respect for Resident 5. Findings: A review of Resident 5 ' s admission Record indicated that Resident 5 was admitted to the facility on [DATE], with diagnoses including cerebral infraction (lack of blood flow resulting in severe damage to some of the brain tissue), emphysema (lung condition that causes shortness of breath), and lack of coordination. A review of Resident 5's Minimum Data Set (MDS - a comprehensive standardized assessment and care-screening tool), dated 1/17/2024, indicated Resident 5 had severely impaired cognition (mental action or process of acquiring knowledge and understanding) for daily decision-making and requiring extensive assistance from staff for activities of daily living (ADL-bed mobility, surface transfer, eating, walk in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide professional standards of care and practice to one of eight sampled residents (Resident 2) by failing to ensure proper documentation of refusals of showers, appropriate education and care planning was provided to Resident 2. This deficient practice had the potential to negatively impact the delivery of care service provided to Resident 2. Findings: A review of Resident 2 ' s admission Record indicated Resident 2 was admitted to the facility on [DATE], with diagnoses including cervical spinal cord (a long tube-like band of tissue connecting the brain and the lower back) injury, quadriplegia (paralysis of all four limbs [arms/legs]) and depression (a mood disorder that causes persistent feeling of sadness and loss of interest). admission Record also indicated that Resident 2 stayed in the facility for total of 13 days. A review of the Resident 2 ' s Minimum Data Set (MDS - a comprehensive assessment and care screening tool), dated 10/10/2022,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to maintain complete and accurate medical record in accordance with accepted professional standards and practices for one of eight sampled residents (Resident 5) by failing to ensure proper documentation of activities of daily living (ADLs) for Resident 5. This deficient practice had the potential for a delay in communication between facility staff which can negatively impact the delivery of service given to Resident 5. Findings: A review of Resident 5 ' s admission Record indicated Resident 5 was admitted to the facility on [DATE], with diagnoses including cerebral infraction (lack of blood flow resulting in severe damage to some of the brain tissue), emphysema (lung condition that causes shortness of breath), and lack of coordination. A review of Resident 5's Minimum Data Set (MDS - a comprehensive standardized assessment and care-screening tool), dated 1/17/2024, indicated Resident 5 had severely impaired cognition (mental action or process 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: 1. Ensure an interdisciplinary team (IDT-a coordinated group of experts from several healthcare fields that actively coordinate treatment goals for the patient) meeting was done in coordination with two of four sampled residents (Resident 1 and Resident 2 ' s) family or representative per facility policy. 2. Ensure revision of comprehensive care plan for one of four sampled residents (Resident 1) when Resident 1 had multiple episodes of fall. These deficient practices had the potential for Resident 1 and Resident 2 ' s not receiving appropriate care treatment and/or services by the facility. Findings: 1a. A review of Resident 1 ' s admission Record indicated Resident 1 was admitted to the facility on [DATE], with diagnoses including chronic respiratory failure (condition in which your blood does not get enough oxygen or has too much carbon dioxide), congestive heart failure (CHF-a chronic condition in which the heart does not pump blood as well as it…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to monitor and supervise one of four sampled residents (Resident 1) by failing to ensure Resident 1 did not have any further episodes of falling. Resident 1 had episodes of falling on 10/21/2023, 12/27/2023 and 12/31/2023. This deficient practice had a potential for further episodes of Resident 1 ' s falling and possibly life-threatening conditions such as major injuries and even death. Findings: A review of Resident 1 ' s admission Record indicated Resident 1 was admitted to the facility on [DATE], with diagnoses including chronic respiratory failure (condition in which your blood does not get enough oxygen or has too much carbon dioxide), congestive heart failure (CHF-a chronic condition in which the heart does not pump blood as well as it should), tracheostomy (an opening surgically created through the neck into the trachea [windpipe] to allow direct access to the breathing tube) and hypertension (HTN - elevated blood pressure). A review of Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure to develop a baseline care plan addressing one of four sampled residents (Resident 2) by failing to ensure care plan for refusals of care was completed for Resident 2. This deficient practice had the potential to negatively affect the provision of care and services provided to Resident 2. Findings: A review of Resident 2 ' s admission Record indicated Resident 2 was originally admitted to the facility on [DATE] and was re-admitted on [DATE] with diagnoses including acute respiratory failure (condition in which your blood does not get enough oxygen or has too much carbon dioxide), tracheostomy (an opening surgically created through the neck into the trachea [windpipe] to allow direct access to the breathing tube), and aphasia (loss of ability to understand or express speech, caused by brain damage). A review of Resident 2's Minimum Data Set (MDS - a comprehensive standardized assessment and care-screening tool), dated 12/5/2023, indicated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement, a comprehensive person-centered care plan for one of four sampled residents (Resident 2) when Resident 2 ' s left arm was not properly elevated per plan of care. This deficient practice had the potential to negatively affect the provision of care and services provided to Resident 2. Findings: A review of Resident 2 ' s admission Record indicated Resident 2 was originally admitted to the facility on [DATE] and was re-admitted on [DATE] with diagnoses including acute respiratory failure (condition in which your blood does not get enough oxygen or has too much carbon dioxide), tracheostomy (an opening surgically created through the neck into the trachea [windpipe] to allow direct access to the breathing tube), and aphasia (loss of ability to understand or express speech, caused by brain damage). A review of Resident 2's Minimum Data Set (MDS - a comprehensive standardized assessment and care-screening tool), dated 12/5/2023, indicated Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) was informed of/or offered an advance directive (a written instruction, such as a living will or durable power of attorney for health care, recognized under State law, relating to the provision of health care when the individual is incapacitated [describes a state where a patient is unable to participate in a meaningful way in medical decisions]). This deficient practice violated resident ' s and/or the representative's right to be fully informed of the option to formulate advanced directives and had the potential to cause conflict with health care wishes for Resident 1. Findings: A review of Resident 1 ' s admission Record indicated Resident 1 was admitted to the facility on [DATE], with diagnoses including encephalopathy (a disease in which the functioning of the brain is affected by some agent or condition-such as viral infection or toxins in the blood), atrial fibrillation (AF-an irregular rapid…

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 meet professional standards of care and practice for one of three sampled residents (Resident 1) by failing to ensure vital signs were checked and documented at least once every shift and as needed for any change in condition (COC- a change in resident ' s condition nursing documentation). This deficient practice had the potential to negatively impact the delivery of care service provided to Resident 1. Findings: A review of Resident 1 ' s admission Record indicated Resident 1 was admitted to the facility on [DATE], with diagnoses including encephalopathy (a disease in which the functioning of the brain is affected by some agent or condition-such as viral infection or toxins in the blood), atrial fibrillation (AF-an irregular rapid heart rate that commonly causes poor blood flow) and anemia (disorder in which red blood cells [cells that carry oxygen to all parts of body] are destroyed faster than they can be made). A review of the Minimum Data Set (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 interview and record review, the facility failed to meet professional standard of care and practice for one of three sampled residents (Resident 1) by failing to ensure facility did not provide emergency basic life support such as CPR (cardiopulmonary resuscitation-refers to any medical intervention used to restore circulatory and/or respiratory function that has ceased) to Resident 1 who had a physician order of Do Not Resuscitate (DNR-refers to a medical order issued by a physician or other authorized non-physician practitioner that directs healthcare providers not to administer CPR in the event of cardiac or respiratory arrest). This deficient practice had the potential to negatively impact the delivery of care service provided to Resident 1. Findings: A review of Resident 1 ' s admission Record indicated Resident 1 was admitted to the facility on [DATE], with diagnoses including encephalopathy (a disease in which the functioning of the brain is affected by some agent or condition-such as viral…

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 Controlled Drug Record (CDR- accountability record of medications that are considered to have a strong potential for abuse) coincided with the Medication Administration Records (MAR) for one of five sampled residents (Resident 1). This deficient practice had the potential to result in medication error and/or drug diversion (illegal distribution or abuse of prescription drug). Findings: A review of admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses including sepsis (a life-threatening condition that arises when the body ' s response to infection causes injury to its own tissues and organs), end stage renal disease (ESRD-a medical condition in which a person ' s kidney [organ in the body that lifters waste and excess fluid from the blood] function stop functioning on a permanent basis), idiopathic gout (a painful form of arthritis) and major depressive disorder (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 interview and record review, the facility failed to implement their policy regarding reporting of residents' allegation of abuse and to submit a conclusion report of investigation within five days or in accordance with state or federal law for one of five sampled residents, Resident 2. This resulted in a delay of an onsite inspection by the Department of Public Health to ensure the residents' allegation of abuse was investigated which can also lead to a delay in prevention of further abuse for Resident 2. Findings: A review of admission Record indicated Resident 2 was originally admitted to the facility on [DATE]and readmitted on [DATE], with diagnoses including spinal stenosis (narrowing of the spaces within the spine, which can put pressure on the nerves that travel through the spine), type II diabetes mellitus (DM-a chronic condition that affects the way the body processes blood sugar [glucose]), and major depressive disorder (a mental disorder that have a persistent feeling of loss of pleasure or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement its abuse prevention policy by failing to report an allegation of abuse within 2 hours or in accordance with state or federal law for one of five sampled residents (Resident 2). This resulted in a delay of an onsite inspection by the Department of Public Health to ensure the residents' allegation of abuse was investigated which can also lead to a delay in prevention of further abuse for Resident 2. Cross Reference F609. Findings: A review of admission Record indicated Resident 2 was originally admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses including spinal stenosis (narrowing of the spaces within the spine, which can put pressure on the nerves that travel through the spine), type II diabetes mellitus (DM-a chronic condition that affects the way the body processes blood sugar [glucose]), and major depressive disorder (a mental disorder that have a persistent feeling of loss of pleasure or interest in life). 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 meet professional standards of quality of care for one out of five sampled residents, Resident 1 by failing to ensure medications were given on time as ordered by the physician. These deficient practices jeopardized Resident 1,'s health and safety by failing to administer necessary medications in accordance with the physician order. Findings: A review of admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses including sepsis (a life-threatening condition that arises when the body's response to infection causes injury to its own tissues and organs), end stage renal disease (ESRD-a medical condition in which a person's kidney [organ in the body that lifters waste and excess fluid from the blood] function stop functioning on a permanent basis), idiopathic gout (a painful form of arthritis) and major depressive disorder (a mental disorder that have a persistent feeling…

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 effectively manage a resident's pain by not following physician's medication order for one of five sampled residents (Resident 1). This deficient practice resulted in Resident 1 experienced unnecessary pain. Findings: A review of admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses including sepsis (a life-threatening condition that arises when the body's response to infection causes injury to its own tissues and organs), end stage renal disease (ESRD-a medical condition in which a person's kidney [organ in the body that lifters waste and excess fluid from the blood] function stop functioning on a permanent basis), idiopathic gout (a painful form of arthritis) and major depressive disorder (a mental disorder that have a persistent feeling of loss of pleasure or interest in life). A review of the Minimum Data Set (MDS - a comprehensive assessment and care screening…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to maintain an infection control measure and prevention by failing to: A. Ensure the staff wear full personal protective equipment (PPE-mask, gown, eye protection, gloves) before entering one of one sampled resident, Resident 3 ' s room who tested positive for COVID-19 [a deadly respiratory disease transmitted from person to person] infection) per facility policy. B. Ensure that a current physician order for transmission-based precaution for Resident 3 was in placed. These deficient practices had the potential to result in the spread of disease and infection to residents and staff. Findings: A review of Resident 3's admission Record indicated resident was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including chronic kidney disease (CKD-a longstanding disease of the kidneys leading to renal failure), type II diabetes mellitus (DM-a chronic condition that affects the way the body processes blood sugar…

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 it's policy titled Laryngectomy [a surgery to remove part or all your larynx [voice box] done to treat laryngeal cancer or severe larynx damage] Site Care, by failing to ensure that one of three sampled resident's stoma was not noted with thick greenish mucous when Resident 1's Familiy Member (FM 1) visited him. This deficiency practice resulted in Resident 1 contracting pneumonia (Infection that inflames air sacs in one or both lungs, which may fill with fluid) Findings: A review of resident 1's admission Record (FS) was admitted to the facility on [DATE] with diagnoses which included malignant neoplasm (cancerous tumor) of oropharynx (the middle section of your throat), essential hypertension (high blood pressure that is not due to another medical condition), and acute respiratory failure (occurs when the lungs can't release enough oxygen into your blood) with hypoxia (low levels of oxygen in your body tissues, causing…

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

Based on observation, interview, and record review the facility failed to provide pertinent intervention to prevent fall for one of three sampled residents (Resident 1) who was identified as a high fall risk by failing to ensure there was no clutter in Resident 1's room. As a result, Resident 1 had a fall on 11/6/2023 and suffered a 1-inch laceration (a deep cut or tear in skin or flesh) above the left eye and was sent to General Acute Care Hospital (GACH) where she received sutures (also known as stitches, are sterile surgical threads used to repair cuts) to the injury. Findings: A review of Resident 1's admission Record (Face sheet), indicated the facility originally admitted Resident 1 on 11/7/20222 with diagnoses including, unsteadiness on feet (Unsteady gait is a symptom of instability while walking. Problems with walking can be due to disease or injury to the legs, feet, spine, or brain), encephalopathy (a group of conditions that cause brain dysfunction. Brain dysfunction can appear as confusion, memory loss, personality changes and/or coma in the most severe form) difficulty…

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 the physician order and its policy on Enteral Tube Feeding via Continuous Pump (Enteral Tube is also known as gastric tube or g-tube - a flexible plastic tube placed into the stomach to deliver nutrition to those that cannot obtain nutrition though the mouth or cannot swallow safely) for two of four sampled residents (Resident 3 and Resident 6) by failing to ensure: 1. Resident 3's feeding pump (machine used to deliver g-tube feeding formula) was set to the rate ordered by Resident 3's physician. 2. Resident 3 ' s g-tube feeding formula packaging was filled out with the time the feeding was prepared and the rate the feeding was infusing. 3. Resident 6 had the correct g-tube feeding formula and water volume infusing as ordered by Resident 6's physician. These deficient practices resulted in Resident 3 ' s g-tube feeding pump being set to the incorrect rate and Resident 6 receiving the incorrect feeding formula. Findings: 1-2. 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 observation, interview and record review, the facility failed to ensure that one of three sampled residents (Resident 8), who was admitted to the facility with pressure ulcer / injury (also called bedsores or pressure sores, are injuries to the skin and underlying tissue, primarily caused by prolonged pressure on the skin; usually affect people confined to bed or who sit in a chair or wheelchair for long periods of time) was provided a Low Air Loss Mattress (LALM, an air mattress designed to relieve pressure) as ordered by the physician. This deficient practice placed Resident 8 at risk for poor wound healing and deterioration of his current wounds. Findings: A review of Resident 8 ' s admission Record (Face Sheet) indicated Resident 8 was admitted to the facility on [DATE] with diagnoses that included squamous cell carcinoma of the skin (skin cancer) and anemia (a condition where the body does not get enough oxygen-rich blood). A review of the Physician Order, dated 10/26/2023, indicated 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure standard infection control practices (Standard Precautions) were followed for one of three sampled residents (Resident 8) by failing to ensure Licensed Vocational Nurse 5 performed hand hygiene and changed gloves during wound care treatment. This deficient practice placed Resident 8 at risk for infection. Findings: A review of Resident 8 ' s admission Record (Face Sheet) indicated Resident 8 was admitted to the facility on [DATE] with diagnoses that included squamous cell carcinoma of the skin (skin cancer) and anemia (a condition where the body does not get enough oxygen-rich blood). A review of the Physician Order, dated 10/25/2023, indicated an order to cleanse GT site (G-tube or Gastric Tube - a flexible plastic tube placed into the stomach to deliver nutrition to those that cannot obtain nutrition though the mouth or cannot swallow safely) with normal saline and cover with T- drain dressing (a dressing with a pre-cut T-slit…

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 plan of care with measurable goals and individualized interventions for one of four sampled residents, Resident 1 who was refusing his medications. This deficient practice had the potential to result in a delay in delivery of care and services. Findings: A review of Resident 1 ' s admission Record indicated that Resident 1 was originally admitted to the facility on [DATE] with diagnoses including cerebral infarction (lack of blood flow resulting in severe damage to some of the brain tissue), hemiplegia and hemiparesis (loss of the ability to move in one side of the body) and dysphagia (dysphagia (difficulty swallowing food or liquid). A review of Resident 1's Minimum Data Set (MDS - a comprehensive standardized assessment and care-screening tool), dated 7/28/2023, indicated Resident 1 has intact cognition (mental action or process of acquiring knowledge and understanding) for daily decision-making…

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

Based on interview, and record review, the facility failed to ensure that pain management was provided consistent with professional standards of practice to one of eight sampled residents (Resident 3). The facility failed to provide pain medication as ordered by the physician (MD) when Resident 3 complained of 7/10 pain on the pain scale (Pain Scale -0=no pain, 1-3=mild pain, 4-6=moderate pain, 7-9=severe pain, 10=worst pain). This deficient practice had the potential to negatively affect Resident 3 ' s physical comfort and psychosocial well-being and had the potential to increase the pain level and result in an unmanageable pain level. Findings: During a review of Resident 3 ' s admission Record, indicated the facility admitted Resident 3 on 8/31/2023, with diagnoses including sepsis (a life-threatening condition that arises when the body ' s response to infection causes injury to its own tissues and organs), urinary tract infection (UTI-infection in the urinary system [kidneys, bladder, or urethra]) and congenital (disease or physical abnormalities present from birth)malfunctions…

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 regular insulin (medication used to control blood sugar) and blood sugar checks (a quick bedside procedure to determine blood sugar levels) were ordered upon return from General Acute Care Hospital (GACH) for one of three sample residents (Resident 3). This failure resulted in Resident 3 not receiving previously ordered regular insulin and having blood sugar checks which had the potential of complications related to uncontrolled blood sugars. Findings: During a review of Resident 3's admission Record, dated 8/18/23, the admission record indicated, the resident was readmitted to the facility on [DATE] with diagnoses including diabetes mellitus type two (a condition in which the body has difficulty processing blood sugar leading to high blood sugar levels in the blood), hypertensive (high blood pressure) heart disease with heart failure (chronic disease affecting the way the heart pumps blood to the rest of the body). During a review of Resident 3…

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 protect one of six sampled residents (Resident 3) from misappropriation (the unauthorized, improper, or unlawful use of funds or other property for purposes other than that for which intended) of property and personal belongings by: 1. failing to immediately report and investigate after Resident 1 reported that there was unauthorized credit card purchase after her purse went missing while in the facility. 2. failing to implement policies and procedures for reporting the possible crime to law enforcement. These deficient practices had the potential to result in unidentified abuse in the facility and failure to protect residents from abuse. Findings: A review of Resident 3's admission Record indicated the resident was admitted to the facility on [DATE] with diagnosis including chronic respiratory failure (condition in which your blood does not get enough oxygen or has too much carbon dioxide), type II diabetes mellitus (DM-a chronic condition…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement its abuse prevention program policy by failing to submit a conclusion report of investigation within five days or in accordance with state or federal law for one of six sampled residents (Resident 3). This deficient practice had the potential to result in placing the residents at risk for undetected elder abuse and misappropriation of property. Cross reference: F610 Findings: A review of Resident 3's admission Record indicated the resident was admitted to the facility on [DATE] with diagnosis including chronic respiratory failure (condition in which your blood does not get enough oxygen or has too much carbon dioxide), type II diabetes mellitus (DM-a chronic condition that affects the way the body processes blood sugar [glucose]), and major depressive disorder (a mental disorder that have a persistent feeling of loss of pleasure or interest in life). A review of the Minimum Data Set (MDS - a comprehensive assessment and care screening tool),…

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 its' policy regarding investigating and reporting of misappropriation of personal property to the state agency (Department of Public Health), Ombudsman (an official appointed to investigate individuals' complaints against the facility) and Law enforcement officials for one of six sampled residents (Resident 3) after Resident 3 reported an allegation of misappropriation of property. This resulted in a delay of an onsite inspection by the Department of Public Health to ensure the residents' misappropriation of property allegation was investigated which can also lead to a delay in prevention of abuse for Resident 3. Cross Reference- F609 Findings: A review of Resident 3's admission Record indicated the resident was admitted to the facility on [DATE] with diagnosis including chronic respiratory failure (condition in which your blood does not get enough oxygen or has too much carbon dioxide), type II diabetes mellitus (DM-a chronic condition 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 5. A review of Resident 30's Face Sheet, indicated the facility admitted Resident 30 on 10/16/2020, with diagnoses that included chronic respiratory failure, candidiasis, chronic kidney disease (kidneys are damaged and can't filter blood the way they should), and anxiety disorder (symptoms of intense anxiety or panic that are directly caused by a physical health problem). A review of Resident 30's MDS, dated [DATE], indicated Resident 30 was dependent on staff for bed mobility, dressing, eating, toilet use, and personal hygiene. 7. A review of Resident 54's Face Sheet indicated the facility admitted Resident 54 on 8/4/2019, with diagnoses that included DM, essential hypertension (high blood pressure) and anemia. A review of Resident 54's MDS, dated [DATE], indicated Resident 54 had intact cognition. The MDS indicated Resident 54 needed extensive staff assist with bed mobility and dressing and was totally dependent of transfer, toilet use, and personal hygiene. 11. A review of Resident 93's Face Sheet, indicated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure four of four sampled residents (Resident 1, 93, 509 and 511) received care and services when providing parenteral fluids consistent with professional standards of practice by failing to 1. Ensure intravenous (IV - canula being placed inside a vein) site was being monitored for any signs and symptoms of infection for Resident 93, 509 and 511. 2. Ensure IV dressing was changed, with labels and date per facility policy for Resident 1 and 509. 3. Ensure IV site for Resident 1 was removed when IV therapy was discontinued and documented upon removal per facility policy. These deficient practices had the potential to result in Resident 1, 93, 509 and 511's IV sites to develop complication such as infection. Findings: 1a. A review of Resident 93's admission Record indicated the facility admitted the resident on 6/24/2020 with diagnoses including, but not limited to, unspecified sequelae of cerebral infarction (stroke - disruption in blood…

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

2. During an observation on 04/26/2022 at 2:51 p.m., a medication cart in the fourth floor common hallway was observed unlocked. There were staff and residents near the medication cart. During an interview on 04/26/2022 at 2:51 p.m., LVN 11 stated the medication cart was unlocked, and it should be locked. LVN 11 also stated anyone can access the medication cart when the cart is not locked. A review of the facility's P&P titled, Storage of Medications, revised November 2020, indicted, The facility stores all drugs and biologicals in a safe, secure, and orderly manner. 1. Drugs and biologicals used in the facility are stored in locked compartments . 3. During a concurrent observation and interview with LVN 9 on 4/27/2022 at 3:13 p.m., an opened foil pouch of Xopenex, dated 4/7/2022 was observed in the drawer of the medication cart. LVN 9 stated the medication should be discarded within 30 days upon opening and should be used during that timeframe. During a concurrent observation and interview with Administrator (Admin) on 4/27/2022 at 3:22 p.m., the Admin verified via manufacturer's…

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

Based on observation, interviews and record review, the facility failed to employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition services when: 1) Dietary Aide 2 (DA 2) did not know the required sanitizing contact time (how long a disinfectant needs to stay wet on a surface in order to be effective) while manually washing dishes; and 2) Dietary Aide 3 (DA 3) who oversaw food delivery and labeling did not know when to discard supplement shakes. This failure had the potential to result in unsafe and unsanitary food preparation and production, and a potential for food-borne illness affecting the residents who consumed the food prepared by the facility kitchen. Findings: 1) During a concurrent observation and interview on 4/26/2022, at 10:25 a.m., with DA 2 and Dietary Supervisor (DS), DA 2 demonstrated the manual dishwashing process and stated that he should immerse washed and rinsed kitchenware in the sanitizing solution for 10-20 seconds as the sanitizing process. A review of the facility's document titled,…

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 portion size as written on the menu for residents on pureed diet when 23 residents on pureed diet received inaccurate portion for their food. This deficient practice had the potential for the residents to receive wrong protein and caloric intake, which could result in undernutrition or overnutrition and compromise their health and well-being. Findings: A review of the facility's document titled, Cooks Spreadsheet Spring Cycle Menus, dated 3/29/22, 4/26/22, and 5/24/22, indicated that a regular portion of pureed roast turkey should be served with the #8 scoop serving a 1/2 cup. During a concurrent observation and interview on 4/26/2022, at 11:40 a.m., with Dietary Supervisor (DS) and Dietary Aide 2 (DA 2), DA 2 was using the #16 scoop serving a 1/4 cup for pureed roast turkey. DA 2 stated he chose the #16 scoop per the Cooks Spreadsheet. After reviewing the Cooks Spreadsheet again, DA 2 stated that he made a mistake. The DS stated that DA 2 should choose accurate scoops according to the Cooks Spreadsheet.

Based on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety when: 1) Multiple condiments and a juice box were not labeled properly; 2) Multiple resident foods were not kept per the facility's policy; 3) The concentrations of sanitizing chemical in two sanitizer buckets were measured below 100 parts per million (ppm - Usually describes the concentration of something in water or soil); 4) Interior surfaces of the popcorn machine placed in the dry food storage were rusty; and 5) Multiple environmental defects were observed in Kitchen. These deficient practices had the potential to result in food-borne illness (any illness resulting from the spoilage of contaminated food, bacteria-germs, viruses, or parasites that contaminate food, as well as toxins (poisons)) and pest entrance or harborage for 155 of 218 residents who consumed the food prepared by the facility kitchen. Findings: 1) During a concurrent observation and interview on 4/25/22, at 9:45 a.m., with Dietary…

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 overripe onions were disposed of in a timely manner to prevent fruit flies. This deficient practice had the potential to result in food-borne illness (any illness resulting from the spoilage of contaminated food, bacteria-germs, viruses, or parasites that contaminate food, as well as toxins [poisons]) and pest entrance or harborage in the facility kitchen. Cross Referenced with F812 Findings: During a concurrent observation and interview on 4/25/22, at 9:40 a.m., with Dietary Supervisor (DS) in the facility kitchen, fruit flies were observed on two separate open bins of overripe onions under a food prep area. The DS stated, those should not be there because they could compromise food safety. During a review of the facility's policy and procedure (P&P) titled, Pest Control, version 1.1 (undated), the P&P indicated, the facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents. During a review of the facility's policy and procedure titled, Food…

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 its' Psychotropic Medication Management policy and procedures to ensure the residents and/or responsible party (RP) were informed in advance, of the risks and benefits of psychoactive medication (a drug that changes brain function and results in alterations in perception, mood, consciousness, or behavior) for two of two sampled resident (Residents 192 and 509). This deficient practice violated the residents' right to make informed decision regarding the use of psychoactive medications for Residesst 192 and 509. Findings: 1. A review of Resident 192's admission Record indicated the facility originally admitted Resident 192 on 2/25/2020 and readmitted on [DATE], with diagnosis that included sepsis (a life-threatening condition that arises when the body's response to infection causes injury to its own tissues and organs), cerebral infarction (lack of blood flow resulting in severe damage to some of the brain tissue) and respiratory…

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 its' Activities of Daily Living (ADLs), Supporting policy and procedures (P&P) to ensure the breakfast tray remained inside the food cart and not left at the bedside table for one of one sampled resident (Resident 112). Resident 112 required extensive staff assist with eating food. This deficient practice resulted in Resident 112 waiting for 31 minutes to eat breakfast and had potential for the breakfast to get cold and decrease the resident's appetite and or food intake. Findings: A review of Resident 112's Face Sheet, indicated the facility admitted Resident 112 on 8/31/2021, with diagnoses that included Parkinson's disease (damage to nerve cells in the brain that cause problems with movement and balance) seizures (abnormal brain activity), secondary hypertension (high blood pressure), mild cognitive impairment (impaired thought process that includes problems with memory, language, thinking, and judgement), and dysphagia oropharyngeal phase (difficulty in swallowing in the mouth or throat). 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 residents identifiable information on discarded tube feeding (TF-the means of providing nutrition via a feeding tube inserted into the gastrointestinal tract) was appropriately destroyed according to facility's Resident Rights policy and procedures (P&P) for one of one sampled resident (Resident 192). This deficient practice violated the resident's right for privacy and had the potential to release/disclose Resident 192's personal information to unauthorized person(s). Findings: 1. During a concurrent observation and interview on 4/25/2022, at 10:55 a.m., in Resident 192's room with Licensed Vocational Nurse 2 (LVN 2), a TF formula bottle was observed inside a trash bin. Resident 192's name, room number, date, time, and run time were observed written on the TF bottle. LVN 2 stated a resident's identifiable information must be protected and removed prior to disposing TF bottle(s) in a trash bin. LVN 2 stated this violated 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 develop and implement a resident centered comprehensive care plans (documents a resident's needs and interventions to meet those needs) for three of three residents (Residents 72, 93, and 109) by failing to develop and implement: 1) Non-compliance care plan for refusing (RNA- rehabilitation care to help people regain or improve their physical, mental, and emotional health) Restorative Nursing Assistant services for 23 days for Resident 93. 2) Non-compliance care plan for refusing to wear identification wrist band for Resident 72 and Resident 109. These deficient practices had the potential to result in inability to: 1. Meet the physical mobility, psychosocial needs, and increase the risk to develop contractures (permanent tightening of the muscles, tendons, skin, and nearby tissues that causes the joints to shorten and become very stiff) for Resident 93. 2. Identify Residents 72, and 109. Findings: 1) A review of Resident 93's Face Sheet,…

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, facility failed to meet professional standards of quality by not obtaining a physician's order regarding inserting a peripheral intravenous (IV-a small, flexible tube placed into a small vein for intravenous therapy such as medication fluids) on the lower extremities (legs) for one of three sampled residents, Resident 62. This deficient practice has the potential to result in Resident 62's IV site to develop complication such as infection. Findings: A review of Resident 62's Face Sheet indicated the facility admitted Resident 62 on 2/1/2021 with diagnoses that included acute respiratory failure (condition in which your blood does not get enough oxygen or has too much carbon dioxide), Type II diabetes (a chronic condition that affects the way the body processes blood sugar [glucose]) and anemia (a condition which the blood does not have enough health red blood cells). A review of the Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 2/4/2022, indicated Resident 62 had severe cognitive (mental action…

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 Resident 93 received oral care. This deficient practice could place the resident at risk for discomfort and possible infection due to lack of oral hygiene care. Findings: A review of Resident 93's admission Record indicated the facility admitted Resident 93 on 6/24/2020 with diagnoses including, but not limited to, unspecified sequelae of cerebral infarction (stroke - disruption in blood supply to the brain), acute respiratory failure with hypoxia (difficulty getting enough oxygen to the lungs and problem releasing carbon dioxide (CO2 - colorless, odorless gas produced by breathing), and cerebral aneurysm, non-ruptured (ballooning of a blood vessel in the brain that has not burst). A review of Resident 93's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 1/10/2022, indicated moderately impaired cognitive skills for daily decision making. The same MDS indicated Resident 93 was totally dependent of mobility, dressing, eating, toilet use and needed extensive 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.

Based on observation, interview and record review, the facility failed to ensure an environment free of accidents and hazards for one of five sampled residents (Resident 37). This deficient practice had the potential to result in an accident or injury to Resident 37. Findings: A review of Resident 37's Face Sheet, indicated the facility admitted Resident 37 on 5/11/2017 with diagnoses including, hemiplegia (loss of muscles function on one side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction (stroke - disruption in blood supply to the brain) affecting right dominant side, dysphagia (difficulty swallowing) following cerebral infarction, and essential hypertension (high blood pressure not a result of a medical condition). A review of Resident 37's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 2/1/2022, indicated cognitive skills for daily decision making were severely impaired. The same MDS indicated, Resident 37 was totally dependent of bed mobility, dressing, eating, toilet use, and personal hygiene.…

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 three sampled residents (Resident 62), who are fed by enteral means received appropriate treatment and services by ensuring the gastrostomy tube (GT - a tube inserted through the abdomen that delivers nutrition directly to the stomach) was kept clean and dry. This deficient practice has the potential to result in Resident 62's' enteral nutrition therapy to develop an infection. Findings: A review of Resident 62's Face Sheet indicated Resident 62 was admitted to the facility on [DATE] with diagnoses that included acute respiratory failure (condition in which your blood does not get enough oxygen or has too much carbon dioxide), Type II diabetes (a chronic condition that affects the way the body processes blood sugar [glucose]) and anemia (a condition which the blood does not have enough health red blood cells). A review of the Minimum Data Set (MDS - a comprehensive assessment and care screening tool), dated 2/4/2022,…

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

Based on observation, interview and record review, the facility failed to ensure proper disposition of returning and/or destroying unused medications. This deficient practice had the potential to result in medication error when the discontinued medication was not returned or destroyed. Findings: On 4/27/2022 at 11:45 a.m., during a concurrent observation and interview with the Licensed Vocational Nurse 5 (LVN 5), a bottle of Lactulose (a synthetic sugar used to treat constipation) was found in the medication cart. LVN 5 stated that the bottle of Lactulose belonged to a resident who had been discharged and was no longer in the facility. A review of the resident's electronic medical record indicated the resident was discharged from the facility on 04/13/2022. On 04/28/2022 10:00 a.m., during an interview with the Director of Nursing (DON), when asked about what happens to a resident's medication once the resident is no longer receiving care in the facility, the DON stated the medications for all residents not receiving care in the facility should be immediately discontinued, 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 observation, interview, and record review, the facility failed to observe infection control measures by failing to: 1. Ensure Certified Nursing Assistant (CNA 4) was using proper Personal Protective Equipment (PPE-such as gloves, gowns, masks and eye protections) while providing care to Resident 35. 2. Cleaning and sanitizing a common resident shower room between resident showers. These deficient practices had the potential to result in the spread of diseases and infection to residents, staffs, and visitors. Findings: 1. A review of Resident 35's admission Record indicated the resident was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 35's diagnoses included chronic respiratory failure (condition in which your blood does not get enough oxygen or has too much carbon dioxide) and anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety or fear that are strong enough to interfere with one's daily activities). A review of the Minimum Data Set…

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