Berkley East Healthcare Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop a comprehensive care plan that met the care/services based on the resident's individual assessed needs for one of five sampled residents (Resident 1) by failing to develop an individualized Care Plan (CP) for Resident 1 ' s behavior of removing his own wound dressing. This deficient practice had the potential to have a negative impact on residents ' health and safety, as well as the quality of care and services received. Cross Reference F686. Findings: During a review of the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnosis including surgical aftercare following surgery on the circulatory system (body's network of blood vessels and heart that delivers oxygen and nutrients to cells and removes waste products), Type II diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), peripheral vascular disease (PVD - a circulatory condition in which narrowed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to: 1. Obtain a wound consultation in the management of wound and maintain skin integrity for one of five sampled residents (Resident 1). 2. Ensure Resident 1 ' s Treatment Administration Record (TAR) were documented accurately per facility ' s policy and procedure (P&P) titled, Charting and Documentation. 3. Ensure Resident 1 ' s wound dressings are monitored and kept clean and dry per physician ' s order. These deficient practices had the potential to delay the provision of necessary care and services and deterioration of residents ' current wounds. Findings: A. During a review of the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnosis including surgical aftercare following surgery on the circulatory system (body's network of blood vessels and heart that delivers oxygen and nutrients to cells and removes waste products), Type II diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 1) remained free of recurrent falls by failing to provide supervision of Resident 1 who is a high fall risk. This deficient practice resulted in Resident 1 had an unwitnessed fall on 2/5/2025, and 3/19/2025 while trying to ambulate to bathroom. Findings: A review of Resident 1 ' s admission record indicated, Resident 1 was originally admitted to the facility on [DATE] with a diagnosis that includes multiple fractures of ribs, dysphagia (difficulty swallowing), history of falls, personal history of transient ischemic attack (TIA-a temporary disruption of blood flow to the brain), unspecified dementia (loss of cognitive functioning, thinking, remembering, and reasoning). A review of Resident 3 ' s Morse Fall Risk Screen (assessment tool for prediction of a patient's potential for experiencing a fall while in a facility) dated 9/30/2023 Indicated Resident 1 had a history of falling, have more…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 and safeguard the residents personal and medical records according to the facility's policy and procedures (P&P), titled, confidentiality of information and personal privacy, reviewed 1/2024 for 11 of 13 sampled residents (Residents 11, 31, 44, 59, 65, 78, 142, 242, 343, 345, and 346). This deficient practice violated the resident's rights for privacy. Findings: A review of Resident 11's admission Record indicated the facility admitted Resident 11 on 11/17/2024 with diagnoses including atrial fibrillation (a heart condition where the upper chambers of the heart beat irregularly and rapid causing racing sensation), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and anxiety disorder (a mental health condition that causes a person to experiences excessive and intense feelings of fear, worry, dread, and uneasiness). A review of Resident 31's admission Record indicated the facility admitted Resident 31 on 12/18/2019 and readmitted Resident 31…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, interview, and record review, the facility failed to: 1. Ensure the facility received and reviewed daily activity and discrepancy reports of the Cubex system (a computerized system that stores, dispenses, and tracks medications in healthcare setting), which was inconsistent with the facility policy for at least 11 months. 2. Ensure non-controlled drug dispositions (the process of returning or destroying unused medications) were performed and recorded by two licensed nurses as per policy for at least 8 months. 3. Ensure outdated medication are discarded and not stored in a medication cart. These deficient practices had the potential for medication errors, loss and/or diversion (transfer of medication from a lawful to an unlawful channel of distribution or use) of medications, and the potential for residents to receive outdated, deteriorated, and ineffective medication. Findings: 1. During an observation on [DATE] at 11:50 AM in a medication room on the 2nd floor, and a concurrent interview…

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

Based on observation, interview, and record review, the facility failed to ensure the standardized recipes for lunch menu was followed on 12/16/24 when: 1.25 residents on mechanical soft diet (for resident who experience chewing or swallowing limitations) received Cajun country rice with sliced turkey instead of the Cajun country rice with ground turkey per menu and spreadsheet (food production guide includes food portion and serving guide). One resident on Dysphagia diet (for people with difficulty swallowing- food is moist, mechanical altered easily mashed, or pureed requires little chewing) received baked fish instead of ground fish, received regular Cajun Country rice instead of pureed rice per food production guides (food portion and serving guide). This deficient practice had the potential to result in meal dissatisfaction, decreased nutritional intake, weight loss and increased risk of choking for the residents who were on mechanical soft and dysphagia diet. Findings: According to the facility lunch menu for mechanical soft diet on 12/16/24, the following items will be…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 safe food handling practices when: 1.One of one ice scooper was not cleaned and sanitized daily in accordance with the facility policy and procedure (P&P) titled, Ice Procedures. The ice scooper was not stored in a sanitary condition, the ice scooper had red color stains on it and was sticky. This deficient practice had the potential to result in harmful bacteria growth and cross contamination (transfer of harmful bacteria from one place to another) that could lead to food borne illness in101 out of 102 residents who received ice from the facility. Findings: During a concurrent observation and interview with Dietary Supervisor (DS) on 12/16/24 at 9:00AM the ice scooper was stored in the ice scoop container next to the ice machine. The Ice scooper had red stains on it and the stains were sticky to touch. DS stated it must be juice that is stuck on the ice scooper. DS stated the ice scooper is used to transfer ice from the ice machine and into water/juice pitchers for residents. DS stated the ice scoop is…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 label Resident 141's enteral feeding (aka tube feeding - the delivery of nutrients through a feeding tube directly into the stomach) for one of 22 sampled residents. This deficient practice had the potential to cause complications associated with enteral feeding, including infection. Findings: A review of Resident 141's admission Record indicated the facility admitted the resident on 12/2/2024 with diagnoses including tongue cancer, dysphagia (difficulty swallowing) and endocarditis (inflammation of (inflammation of cardiac tissue, usually caused by a bacterial infection. A review of Resident 141's Minimum Data Set (MDS- a resident assessment tool) dated 12/6/2024 indicated the resident's cognition was severely impaired. The MDS also indicated Resident 131 was totally dependent upon staff oral hygiene, bathing, dressing, toileting and personal hygiene. The MDS further indicated the resident had a feeding tube. A review of Resident 141's Physician Orders dated 12/4/2024 indicated every shift administer…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 obtain a physician's order for the use of Continuous Positive Airway Pressure (machine helps treat sleep apnea [a sleep disorder that causes breathing to repeatedly stop and start during sleep]. CPAP machine delivers continuous air through your mouth and/or nose to keep your airways)/Bilevel Positive Airway Pressure (BIPAP a noninvasive breathing device that helps people who have trouble breathing) upon admission for one of six sampled residents, Resident 191. This deficient practice had the potential to place Resident 191 at risk for respiratory distress and death. Findings: A review of Resident 191's admission Record indicated the facility admitted Resident 191 on 15/15/2024 with a diagnosis that included obstructive sleep apnea and polyneuropathy (a condition that occurs when many peripheral nerves in the body malfunction at the same time). A review of Resident 191's Information record dated 12/15/2024, indicated Resident 191 has a diagnosis of sleep apnea (CPAP at night). A review of Resident 191'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 that a hemodialysis (HD -a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) emergency kit was at the bedside for one of ten sampled residents (Resident 26). This deficient practice had the potential to delay life saving interventions during accidental bleeding. Findings: A review of Resident 26's admission Record indicated the facility admitted Resident 26 on 5/3/2024 and readmitted Resident 26 on 11/29/2024 with diagnoses including end stage renal disease (ESRD - irreversible kidney failure), metabolic encephalopathy (a disease or disorder that affects the structure or function of the brain), and generalized muscle weakness (feeling weak or lacking strength in most of the muscles throughout the body). A review of Resident 26's Minimum Data Set (MDS - a resident assessment tool) dated 12/3/2024, indicated Resident 26 had cognitive impairment (when a person has trouble remembering, learning new things, concentrating, or 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 failed to: 1. Ensure staff was competent on how to use a Continuous Positive Airway Pressure (machine helps treat sleep apnea [a sleep disorder that causes breathing to repeatedly stop and start during sleep]. CPAP machine delivers continuous air through your mouth and/or nose to keep your airways)/Bilevel Positive Airway Pressure (BIPAP a noninvasive breathing device that helps people who have trouble breathing) . 2. Ensure staff completed their annual skills competencies. These failures can cause or have the potential to cause a resident to go into respiratory distress. Findings: A review of Resident 191's admission Record indicated the facility admitted Resident 191 on 15/15/2024 with a diagnosis that included obstructive sleep apnea and polyneuropathy (a condition that occurs when many peripheral nerves in the body malfunction at the same time). A review of Resident 191's Information record dated 12/15/2024, indicated Resident 191 has a diagnosis of sleep apnea (CPAP at night). A review of Resident 191's admission Physician Orders 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 properly receive proper verificiation of informed consent (a principle in medical ethics and medical law that a patient should have sufficient information before making their own free decisions about their medical care) form prior to administering psychotropic medication Lexapro (an antidepressant medication) and Seroquel (an antipsychotic medication) for one of five sampled residents (Resident 77). This deficient practice had the potential for Resident 77 to receive medications without being properly informed of the medications' risks and adverse side effects that could lead to serious illness, hospitalization, or death. Findings: A review of Resident 77's admission Record indicated the resident was originally admitted to the facility on [DATE], and re-admitted on [DATE] with diagnoses that included but were not limited to encephalopathy (a disease damaged the functions of the brain) , sepsis (a very severe infection) and heart failure (condition 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 observations, interview, and record review, the facility failed to ensure the label matched the correct quantity of a controlled medication (medications that the use and possession of are controlled by the federal government) received by the facility for a former resident. This deficient practice had the potential for loss or diversion (transfer of a controlled medication from a lawful to an unlawful channel of distribution or use) of controlled medications. Findings: During an observation on 12/18/24 at 1:53 PM at Nursing Station 1 on floor 2, and an inspection of the Medication Cart 1, there was a bundle of medications wrapped together by a rubber band in the locked compartment. Licensed Vocational Nurs2 (LVN) 2 stated that the aforementioned wrapped bundle were discontinued controlled medications to be brought to the director of nursing (DON) for disposition. During an observation on 12/18/24 at 2:11 PM, DON was in a meeting and instructed LVN 2 to hand off those discontinued controlled meds with the Registered Nurse (RN) 1. RN 1 stated the discontinued medications which…

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

Based on observation, interview, and record review, the facility failed to ensure the reach in freezer was maintained in a good operating condition. The freezer had ice buildup inside the ceiling and walls. There was ice buildup on the door and the parameters of the door. Ice buildup on the door gasket and ice outside of the freezer door sealing the door and causing difficulty to open the freezer door. The freezer was operational in a manner that had the potential to affect food quality. This deficient practice results in the inappropriate storage of food and had the potential to affect 101 out of 102 residents, who eat food from the facility kitchen. Findings: During an observation in the kitchen on 12/16/24 at 9:30AM the reach in Freezer Number 7 (F7) temperature was at -10degrees Fahrenheit. There was large amount of ice buildup outside of the freezer door on the edges. The ice was stuck around the door parameters, and it was difficult to open the freezer door. Inside the freezer there was ice buildup on the ceiling, the door and on the gasket (a flexible elastic stirp attached…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 potential of misappropriation of her property (jewelry), by not reimbursing Resident 1's ring included on the inventory list upon admission to the facility. This deficeint practice had the potential for Resident 1 to be anxious and upset about her missing ring. Findings: A review of Resident 1 ' s admission Record indicated the facility originally admitted this [AGE] year-old female on 6/21/2024 and more recently on 7/11/2024 with diagnoses including Metabolic Encephalopathy (brain disorder), Chronic Obstructive Pulmonary Disease (COPD-a chronic lung disease causing difficulty in breathing), Chronic respiratory failure, Anemia (a condition where the body does not have enough healthy red blood cells, Essential Hypertension (HTN-high blood pressure) and Dependence on Supplemental Oxygen. A review of Resident 1 ' s Minimum Data Set (MDS - a resident assessment tool) dated 7/12/2024…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, and per facility policy and procedures (P&P) titled Bed-Holds and Returns reviewed 1/2024, the facility failed to inform in writing one of four sampled residents (Resident 1) of the bed-hold and return policy when the resident was transferred to General Acute Care Hospital 1 (GACH 1) on 8/13/2024. 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: A review of Resident 1's admission Record indicated resident was admitted to the facility on [DATE] with diagnoses including hypertensive heart disease (a group of heart conditions caused by chronic high blood pressure), emphysema (lung condition that causes shortness of breath) and dysphagia (difficulty swallowing). A review of the Minimum Data Set (MDS - resident assessment tool) dated 7/13/2024, 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 readmit one of four sampled residents (Resident 1) to the facility following hospitalization at General Acute Care Hospital 1 (GACH 1) on 8/13/2024 according to the facility's policy and procedure (P&P) titled, Transfer or Discharge, Facility-initiated. As a result, Resident 1 remained in GACH 1 and had the potential to cause psychosocial harm. Findings: A review of Resident 1's admission Record indicated resident was admitted to the facility on [DATE] with diagnoses including hypertensive heart disease (a group of heart conditions caused by chronic high blood pressure), emphysema (lung condition that causes shortness of breath) and dysphagia (difficulty swallowing). A review of the Minimum Data Set (MDS - resident assessment tool) dated 7/13/2024, indicated Resident 1 ' s cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions was severely impaired. The MDS indicated Resident 1 required moderate…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 revise a care plan for weight loss for two of four sampled residents (Resident 1 and 2), who had actual significant weight loss. This deficient practice had the potential to place Resident 1 and 2 at risk for recurrent weight loss. Findings: 1. A review of Resident 1's admission Record indicated resident was admitted to the facility on [DATE] with diagnoses including hypertensive heart disease (a group of heart conditions caused by chronic high blood pressure), emphysema (lung condition that causes shortness of breath) and dysphagia (difficulty swallowing). A review of the Minimum Data Set (MDS - resident assessment tool) dated 7/13/2024, indicated Resident 1 ' s cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions was severely impaired. The MDS indicated Resident 1 required moderate assistance from staffs for Activities of Daily Living (ADLs- routine tasks/activities such as bathing, dressing and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to meet professional standards of quality of care and services for one of three sampled residents (Resident 1) by failing to: 1. Ensure proper documentation was done when Resident 1 had a change of condition (COC/CIC). On 8/15/2024 at around 7:25 p.m., Licensed Vocational Nurse 2 (LVN2) notified Resident 1's physician (MD) via text message that Resident 1's family was concerned that Resident 1 was becoming confused and with hallucinations (a perception of having seen, heard, touched, tasted, or smelled something that wasn't actually there). 2. Ensure a urinalysis (UA-urine test) was done per physician's order (MD order). These deficient practices had the potential to negatively impact the delivery of care services provided to Resident 1. Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including left lower limb (arms/legs) cellulitis (bacterial skin…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 a BIPAP (bilevel positive airway pressure- a noninvasive machine that pushes air into the lungs via a mask to assist with breathing) was available from 6/21/2024 to 6/25/2024 for one of two sampled oxygen dependent (required 24-hour oxygen administration), residents (Resident 1). This deficient practice had the potential to place Resident 1 at risk for shortness of breath. Findings: A review of Resident 1's admission Record indicated the facility originally admitted this [AGE] year-old female on 6/21/2024 and most recently on 7/11/2024 with diagnoses that included metabolic encephalopathy (a problem with the brain caused by a chemical imbalance that can lead to personality changes), respiratory failure (inadequate gas exchange in the lungs) with hypoxia (low levels of oxygen in your body tissues), centrilobular emphysema (a long term, obstructive lung disease that occurs when there is damage to the center of the lungs), chronic obstructive…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 document Quality Control (QC-routine tests that verify the reliability of the machine) results on multiple days for the Glucometer (machine used to check blood sugars) as per policy. Additionally, based on observation, interview, and record review the facility failed to dispose of medications as per policy. These deficient practices had the potential to place residents at risk for inaccurate results when checking blood sugars for diabetic residents and had the potential to place staff at risk of diversion (when a medication is redirected from its intended destination for personal use, sale, or distribution to others) which could in turn place residents at risk. Findings: a. On 7/16/2024, the California Department of Public Health (CDPH) received a complaint alleging the facility ' s glucometers were not checked consistently. During a concurrent interview and record review on 7/29/2024 at 12:08 p.m. with the Director of Nursing (DON), the Daily Quality Control Record for Blood Glucose Testing dated 5/1/2024,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 policy on infection control to prevent the spread of coronavirus 2019 (COVID-19, a respiratory (organs involved in breathing) disease that is highly contagious thought to spread mainly from person to person through respiratory droplets produced when an infected person coughs, sneezes, or talks) and other diseases as evidenced by failing to: 1. Ensure Certified Nursing Assistant 1 (CNA 1), Licensed Vocational Nurse 1(LVN 1) and Central Supply staff (CS) performed hand hygiene by washing hands using soap and water or use alcohol-based hand rub (ABHR) after contact with residents and their environment. 2. Ensure visitors were screened before entry into the facility. These deficient practices had the potential to spread infection to the residents, staff, and visitors. Findings: During a concurrent observation and interview on 7/30/2024, at 9:35 A.M., with LVN 1, by resident rooms, LVN 1 was observed entering and leaving a resident's room without performing hand hygiene. LVN 1 stated, I need to wash…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 emergency generator started and transferred power to supply the facility within 10 seconds after interruption of normal power on 6/13/2024 at 8:28 PM As a result, the facility lacked power for over 30 minutes on 6/13/2024 for 88 of 88 residents in the facility. Findings: A review of Resident 1 ' s admission record (background information; a document containing demographic and diagnostic information) indicated Resident 1 was admitted to the facility on [DATE] with the following diagnoses: mechanical complication of internal fixation device of vertebrae (a surgical device used to stabilize and fixate the backbones), osteomyelitis (swelling that occurs in the bone) of vertebra, abnormalities of gait (a person ' s manner of walking) and mobility (ability to move freely and easily), and polymyalgia rheumatica (swelling disorder that causes muscle pain and stiffness, especially in the shoulders and hips). 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.

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 for two of five sampled residents (Residents 2) by failing to ensure that Resident 2 ' s albuterol sulfate (used to prevent and treat wheezing and shortness of breath caused by breathing problems) medication was not left unattended. This deficient practice had the potential to result in residents in unintended complications related to the management of medication. Findings: 1. A review of Resident 2 ' s admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including emphysema (lung condition that causes shortness of breath), chronic obstructive pulmonary disease (COPD - a group of lung diseases that block airflow and make it difficult to breathe) and asthma (respiratory condition marked by spasms in the bronchi of the lungs, causing difficulty in breathing). A review of Resident 2 ' s Minimum Data Set (MDS - a standardized assessment and screening tool), dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to accurately perform a neuro check (assessing mental status and level of consciousness, pupil response, motor strength, sensation, and walking) after a fall for one of five sampled residents, (Resident 3). This deficient practice had the potential to result in a delay to transport Resident 3 to the general acute care hospital (GACH) where he was diagnosed with a mild displaced mildly comminuted subcapital fracture of the right femoral neck (right hip fracture). Findings: A review of the Resident 3 ' s admission Record indicated the facility originally admitted Resident 3 on 10/05/2023 with a subsequent admission on [DATE] with diagnoses that included atrial fibrillation (an irregular and often very rapid heart rhythm), congestive heart failure (CHF- A weakened heart condition that causes fluid buildup in the feet, arms, lungs, and other organs ), nonrheumatic mitral valve insufficiency (when blood leaks from an improperly closed mitral valve back 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 provide enough certified nursing aids (CNA) ' s to provide assistance with toileting for one of five sampled Residents, (Resident 3). This deficient practiced caused Resident 3 to fall while unattended in the bathroom; subsequently develop leg pain that required transport to the general acute care hospital (GACH) where he was diagnosed with a mild displaced mildly comminuted sub capital fracture of the right femoral neck (right hip fracture). Findings: A review of the Resident 3 ' s admission Record indicated the facility originally admitted this [AGE] year old male on 10/05/2023 with a subsequent admission on [DATE] with diagnoses that included atrial fibrillation (an irregular and often very rapid heart rhythm), congestive heart failure (CHF- A weakened heart condition that causes fluid buildup in the feet, arms, lungs, and other organs ), nonrheumatic mitral valve insufficiency (when blood leaks from an improperly closed mitral valve back 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 observation, interview, and record review the facility failed to administer antihypertensive (medications to lower blood pressure) medications timely for one of four sampled residents, Resident 4. This deficient practice placed Resident 4 at risk of having elevated blood pressure which can lead to severe Headache, hemorrhagic stroke (bleeding in the brain) or death. Findings: A review of Resident 4 ' s admission Record indicated the facility admitted this [AGE] year-old female on 5/15/2024 with diagnoses including after care after shoulder joint prosthesis (artificial joint placement), Chronic Obstructive Pulmonary Disease (COPD- lung disease causing mucus and shortness of breath), Diabetes Mellitus (DM- long term disease causing high blood sugar), Asthma, Hypertension (HTN- high blood pressure). A review of Resident 4 ' s Minimum Data Set (MDS-a standardized assessment and care planning tool), dated, 5/19/2024 indicated Resident 4 ' s cognition (mental ability to make decisions for daily living) was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review the facility failed to apply a non-rebreather oxygen mask (NRBM- It is a face mask oxygen delivery device that fits over your mouth and nose. An elastic band stretches around your head to keep mask on. The mask connects to a small bag filled with oxygen (reservoir bag), and the bag is attached to an oxygen tank. Oxygen should be set on 10-15 lpm (liters per minute) to administer a higher concentration of oxygen in an emergent situation) correctly in an emergent situation for one of three sampled residents, Resident 1. This deficient practice could have caused Resident 1 to remain short of breath due to not enough oxygen delivery. Findings: A review of Resident 1's admission Record indicated the facility admitted this [AGE] year-old- male on 4/27/2024 with diagnoses including Parkinson's Disease (a disorder of the nervous system that affects movement, often causing tremors), Asthma (long term disease in which the airways in the lungs become narrow and swollen 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure that licensed nurses had the skills and knowledge apply a non-rebreather oxygen mask (NRBM- It is a face mask oxygen delivery device that fits over your mouth and nose. An elastic band stretches around your head to keep mask on. The mask connects to a small bag filled with oxygen (reservoir bag), and the bag is attached to an oxygen tank. Oxygen should be set on 10-15 lpm (liters per minute) to administer a higher concentration of oxygen in an emergent situation) correctly in an emergent situation for one of three sampled residents, Resident 1. This deficient practice could have caused Resident 1 to remain short of breath due to not enough oxygen delivery and potentially places other residents having severe shortness of breath at risk. Findings: A review of Resident 1's admission Record indicated the facility admitted this [AGE] year-old- male on 4/27/2024 with diagnoses including Parkinson's Disease (a disorder of the nervous…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 a care plan for discharge planning for one of three sampled residents (Resident 1). This deficient practice had the potential to place Resident 1 at risk of needs not been met and delay in necessary intervention during discharge. Findings: A review of Resident 1's admission Record indicated the facility admitted Resident 1, a [AGE] year-old male on [DATE] with diagnoses including Parkinson's disease (a progressive disorder that affects the nervous system and parts of the body controlled by the nerves), chronic kidney disease (gradual, prolonged loss of Kidney's ability to filter fluids and waste from the body), Dementia (a condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking), Anxiety (a feeling of worry, nervousness or unease), adult failure to thrive (syndrome of weight loss, decreased appetite and poor nutrition, and inactivity and dysphagia. A review…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure 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 Resident 1 was routinely checked and monitored to maintain safety and well-being per facility ' s policy and procedure (P&P) titled, Routine Resident Checks. This deficient practice resulted to failure in the delivery of necessary care and services for Resident 1. Findings: A review of Resident 1's admission Record indicated the resident was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis including urinary tract infection (UTI- an infection in any part of the urinary system, including the kidney, bladder or urethra), chronic obstructive pulmonary disease (COPD - a group of lung diseases that block airflow and make it difficult to breathe), malignant neoplasm of unspecified part of bronchus [a large…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 Licensed Vocational Nurse 3 (LVN 3) have the specific competencies and skill sets necessary to care for one of one sampled resident (Resident 1) by failing to properly monitor and assessed Resident 1 per facility ' s policy and procedure titled, Routine Checks. This deficient practice resulted in a negative effect to Resident 1 ' s plan of care and delivery of necessary care and services. Cross Reference F684. Findings: A review of Resident 1's admission Record indicated the resident was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis including urinary tract infection (UTI- an infection in any part of the urinary system, including the kidney, bladder or urethra), chronic obstructive pulmonary disease (COPD - a group of lung diseases that block airflow and make it difficult to breathe), malignant neoplasm of unspecified part of bronchus [a large airway that leads from the trachea (windpipe) to a lung]…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 nine sampled residents (Resident 1) by failing to develop a comprehensive care plan for Resident 1's diagnosis of Parkinson's disease (a disorder in the brain that affects movement, often including tremors). 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. Findings: A review of Resident 1's admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including Parkinson's disease, chronic kidney disease (CKD-a longstanding disease of the kidneys leading to renal failure), dementia (loss of cognitive functioning-thinking, remembering, and reasoning), contracture of muscle, upper arms (occurs when muscles, tendons, joints, or other tissues tighten or shorten causing a deformity) and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a resident received adequate and continuous supervision and monitoring to prevent falls and injury for one of two sampled residents (Resident 1) who was a high risk of fall by failing to: 1. Ensure Resident 1 was closely supervised when he was left alone in his room while sitting on a wheelchair. According to Certified Nursing Assistant 2 (CNA 2), she did not monitor Resident 1 while Certified Nursing Assistant 1 (CNA 1) went for her lunch break. 2. Failing to use two people to transfer Resident 1 from bed to wheelchair, using a Hoyer lift (sling lift, an mechanical assistive device that allows residents to be transferred between a bed and a chair, by the use of electrical or hydraulic power) as indicated in the facility ' s policy and procedure. As a result, Resident 1 was on the floor for approximately 24 minutes alone and was found by Family Member 1 (FM 1) on 1/13/2024. Resident 1 sustained an abrasion on frontal scalp area that needed daily…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 pneumonia (PNA-infection that inflames air sacs in one or both lungs and can be life-threatening to anyone but particularly to infants, children, and people over [AGE] years old) vaccine was offered to one of five sampled residents (Resident 1). This deficient practice placed Resident 1 at a higher risk of possibly acquiring and transmitting pneumonia infection to other residents in the facility. Findings: A review of Resident 1 ' s admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including Parkinson ' s disease (a disorder in the brain that affects movement, often including tremors), chronic kidney disease (CKD-a longstanding disease of the kidneys leading to renal failure), dementia (loss of cognitive functioning-thinking, remembering, and reasoning), contracture of muscle, upper arms (occurs when muscles, tendons, joints, or other tissues tighten or shorten causing a deformity) and dysphagia…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 resident's clinical records were updated regarding Physician Orders for Life-Sustaining Treatment (POLST - is a form designed to improve patient care by creating a portable medical order form that records patients' treatment wishes so that emergency personnel know what treatments the patient wants in the event of a medical emergency) for two out of two sampled residents (Resident 1 and Resident 2) by failing to maintain a completed form of the resident's POLST in the resident's medical record. This deficient practice had the potential to cause conflict with resident's wishes regarding health care. Findings: 1. A review of Resident 1 ' s admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including atherosclerotic heart disease (build-up of fats, cholesterol, and other substance in and on the arterial walls), Type II diabetes mellitus (DM-a chronic condition that affects the way the body processes blood…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to develop a baseline care plan for one of six sampled residents (Resident 1), addressing Resident 1 ' s identified risk of aspiration and physician ' s diet orders. This deficient practice had the potential for delayed provision of necessary care and services. Findings: A review of Resident 1 ' s admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including atherosclerotic heart disease (build-up of fats, cholesterol, and other substance in and on the arterial walls), Type II diabetes mellitus (DM-a chronic condition that affects the way the body processes blood sugar [glucose]), peripheral vascular disease (PVD - a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs) and dysphagia (difficulty swallowing food or liquid). A review of the Minimum Data Set (MDS - a comprehensive assessment and care screening tool) dated 12/6/2023, indicated Resident 1 ' s cognitive (mental action 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 observation, interview, and record review, the facility failed to develop and/or implement an individualized person-centered plan of care with measurable objectives, timeframe, and interventions to meet the residents' needs for one of three sampled residents (Resident 1) by failing to develop an individualized/person-centered care plan with goals and interventions upon readmission for being at risk for aspiration. This deficient practice had the potential for Resident 1 to aspirate (when something enters your airway or lungs by accident) during meals for Resident 1. Cross reference F678 Findings: A review of Resident 1 ' s admission record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including cerebral infarction (CVA-also known as a stroke refers to damage to tissues in the brain due to a loss of oxygen to the area), metabolic encephalopathy (occurs when problems with your metabolism cause brain dysfunction), and Alzheimer ' s disease (a progressive disease beginning with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide services in compliance with the applicable Federal, State, and local laws, regulations, and codes and with accepted professional standards and principles for two of two sampled residents (Residents 1 and 4) by failing to: 1. Ensure timely reporting and notification of death to appropriate agencies for Residents 1 and 4. Resident 1 expired on [DATE] and Resident 4 expired on [DATE]. 2. Ensure reporting of any positive COVID-19 (Coronavirus- a deadly respiratory disease transmitted from person to person) resident ' s death to the Los Angeles County Department of Public Health (LAC-DPH). Resident 4 tested positive on [DATE]. 3. Ensure reporting of Resident 1's unwitnessed fall with complain of pain, left temporal (area behind the ear) area bump, left forearm hematoma (large bruise; when an injury causes blood to collect and pool under the skin) and small cut in Resident 1 ' s eyebrow. These deficient practices resulted in delayed investigation 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 staff failed to promptly inform the physician (MD) for one of four sampled residents (Resident 3's) STAT (immediately, urgent or rush) laboratory results. This deficient practice had the potential to result in possible delayed provision of necessary care and services to Resident 3. Resident 3 expired in the facility on [DATE]. Cross Referenced F726. Findings: A review of Resident 3's admission Record indicated Resident 3 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), sepsis (a life-threatening condition that arises when the body ' s response to infection causes injury to its own tissues and organs) and neoplasm (a new and abnormal growth of tissues) of thyroid gland (a gland that controls hormones in the body). A review of Resident 3's Minimum Data Set (MDS - a comprehensive standardized…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to 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 since admission for one of two sampled resident (Resident 3). This deficient practice had the potential for Resident 3 not receiving appropriate care/ treatment and/ or services to be provided by the facility such as offering palliative care (interdisciplinary medical caregiving approach aimed at optimizing quality of life to patients who have serious or life-threatening disease or illness) and when Resident 3 had a fall. Findings: A review of Resident 3's admission Record indicated Resident 3 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), sepsis (a life-threatening condition that arises when the body ' s response…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 physician (MD) progress notes for one of four sampled residents (Resident 3) was up to date when Resident 3's MD assessed and visited Resident 3 on [DATE]. This deficient practice had the potential to delay necessary services, poor continuity of care and follow up for Resident 3. Findings: A review of Resident 3's admission Record indicated Resident 3 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), sepsis (a life-threatening condition that arises when the body ' s response to infection causes injury to its own tissues and organs) and neoplasm (a new and abnormal growth of tissues) of thyroid gland (a gland that controls hormones in the body). admission Record also indicated that Resident 3 expired on [DATE]. A review of Resident 3's Minimum Data Set (MDS - a comprehensive…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 nursing staff had specific skills necessary to care for one of three sampled resident (Resident 3 ' s) needs by failing to: 1. Ensure prompt notification of Resident 3 ' s lab result to the physician (MD). 2. Ensure proper documentation pertaining Resident 3 ' s death was recorded in the nurse progress notes. 3. Ensure a change of condition documentation was completed when Resident 3 ' s physician ordered STAT (immediately, urgent or rush) lab works and dextrose 5 percent (%) in water (D5W) at 50 cubic centimeter per hour (cc/hr) for one liter intravenously (IV-administering fluid medication through a needle or tube inserted into a vein) for Resident 3 ' s episode of poor oral intake. 4. Ensure Resident 3 ' s physician order of D5W at 50 cc/hr for one liter via IV was transcribed in the IV medication administration record (MAR). These deficient practices violated facility ' s policy and procedure (P&P) in accordance with current nursing…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility's interdisciplinary team (IDT-a coordinated group of experts from several different fields who work together) failed to ensure medications were not left at the bedside without a physician's order and Medication Self-Administration Assessment was completed for four of 27 sampled residents (Resident 85, 89, 107 and 330). These deficient practices had the potential to result in unsafe medication application and delayed necessary health intervention. Findings: 1. A review of Resident 85's admission Record indicated Resident 85 was originally admitted to the facility on [DATE] and was readmitted on [DATE], with diagnoses including hemiplegia and hemiparesis (loss of the ability to move in one side of the body) following cerebral infarction (lack of blood flow resulting in severe damage to some of the brain tissue) affecting left non-dominant side, paroxysmal atrial fibrillation (afib- an irregular and very rapid heart rhythm that and can lead blood clots…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 comprehensive care plan to meet the care/services needs based on the resident's individual assessed needs for five of 25 sampled residents (Residents 85, 89, 107, 127 and 330) by failing to: 1. Implement a comprehensive care plan for bed side rails for Residents 85, 107 and 127 2. Implement a comprehensive care plan for contact isolation precaution and on antiviral therapy (a class of medication used for treating viral infection [are illnesses you get from tiny organisms that use your cells to make more copies of themselves]) for Resident 280 3. Implement a comprehensive care plan for oxygen therapy for Resident 330 . These deficient practices had the potential to result in negative impact on the health, safety and quality of care and services provided for Residents 85, 107 and 127. Findings: 1a. A review of Resident 85's admission Record indicated Resident 85 was originally admitted to the facility on [DATE] and readmitted on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide effective pain management to maintain the highest practical level of well-being for two of 27 sampled residents (Residents 230 and 383) by failing to: 1. Assess, recognize, develop, and implement an individualized pain management care plan for Resident 230. 2. Ensure accurate documentation for Oxycodone hydrochloride (narcotic [a drug or other substance that affects mood or behavior and is consumed for nonmedical purposes, especially one sold illegally] pain medication) 10 milligram (mg - unit of measurement) give one tablet by mouth every four hours as needed for severe pain. in Resident 230's electronic Medication Administration record (eMAR). 3. Ensure Resident 230 was offered nonpharmacological (therapies that do not involve medications) interventions for pain management. 4. Ensure staff educated Resident 383 on Oxycodone (a group of drugs known as opioids used to relieve pain severe when other pain medicines did not work well enough 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 post daily the actual hours worked by licensed and unlicensed nursing staffing directly responsible for resident care per shift in a visible and prominent place for residents and visitors. This deficient practice resulted in the actual staffing information not being readily accessible and available to residents and visitors and had the potential to cause inadequate staffing. Findings: On 11/24/23 at 2:00 p.m., a projected, not an actual DHPPD (Direct Care Services Hours Per Patient Day) was observed at the nurse's station counter of the 2nd, 3rd and 4th floor of the facility. On 11/25/23 at 2:00 p.m., a projected, not an actual DHPPD (Direct Care Services Hours Per Patient Day) was observed at the nurse's station counter of the 2nd, 3rd and 4th floor of the facility. On 11/26/23 at 11:00 a.m., a projected, not an actual DHPPD (Direct Care Services Hours Per Patient Day) was observed at the nurse's station counter of the 2nd, 3rd and 4th floor of the facility. During an interview with Director of Nursing (DON)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record reviews, the facility failed to: 1. Ensure discontinued medications were removed from the medication cart and returned to back to the resident for one of three sampled discharged residents (Resident 121). Resident 121 was discharged to home on [DATE] without Resident 121's own clonazepam (medication that can treat seizures, panic disorder, and anxiety) 0.5 milligram (mg - unit of measurement) . 2. Ensure Controlled Drug Record (CDR- accountability record of medications that are considered to have a strong potential for abuse) matched/corresponded with the Medication Administration Records (MAR) for two of five sampled residents (Residents 65 and 230) by failing to: a. Account and document on CDR and on the MAR for 4 (four) doses of oxycodone HCL (controlled strong pain medication) 5 milligrams (mg- unit dose measurement) for the month of 11/2023 for Resident 230. b. Document on CDR and MAR and account for 10 doses of oxycodone HCL 5 mg (for mild pain) for the month 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, for two out of four sampled medication carts (medication cart 3 and medication cart 4) the facility failed: 1. To label an open date on Resident 5's ipratropium-albuterol inhalation solution (medications to help relieve shortness of breath) and Pulmicort (medication that helps with breathing by decreasing swelling in the lungs) inhalation located in medication cart 3 solution that that could expire according to manufacture guidelines. 2. To label an open date on Resident 86's albuterol inhaler (medication that help relieve shortness of breath) located in medication cart 3 that could expire according to manufacture guidelines. 3. To label an open Resident 233's Budesonide-formoterol fumarate dihydrate (medications that help with breathing by decreasing swelling in the lungs) inhalation solution located in medication cart 3 that could expire according to manufacture guidelines. 4. To label an open date on Resident 381's Ipratropium-Atrovent inhalation solution…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 food handling practices by: 1. Failing to label an open bag of wheat bread with the date it was opened and use by date inside one of one walk in Refrigerator 1. 2. Failing to seal the open box of turkey skinless links, veggie patties, green beans in the one of one Freezer (Freezer 1) and label with the open and use by date. 3. Failing to ensure an open almond milk and grape juice in Refrigerator 3 was dated with open and use by date inside one of two Refrigerator (Refrigerator 1). 4a. Failing to ensure food and drinks brought in from outside the facility kitchen had a date food was prepared and open and use by date. 4b. Failing to ensure one of three Residents' Refrigerator (Residents' fridge 3) temperature was checked every day. These deficient practices had the potential to result in foodborne illness for 90 out of 90 residents who receive and consume food from the facility kitchen and for resident who received outside food. Findings: 1. During a concurrent observation and interview on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to maintain an infection control measure and prevention program by failing to: 1. Ensure two of six sampled facility staff (Housekeeper 1 [HK1] and Housekeeper 2 [HK2]) wore proper fit tested N95 (filtering facepiece respirator) mask when entering a COVID-19 (Coronavirus- a deadly respiratory disease transmitted from person to person) isolation room. 2. Ensure one of three sampled Residents' refrigerator (Residents' fridge #3) temperature log was checked and documented. 3. Ensure proper signages for droplet/contact (precautions used for diseases that can be transmitted during contact with the patient or patient's environment) transmission-based precaution (TBP) were placed on the room entrance of two of five sampled rooms. 4. Ensure water pitcher was not placed on top of Resident 127's bedside commode (a movable toilet). 5. Ensure signages for contact TBP were removed when isolation order was discontinued for Resident 280. 6. Ensure 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: 1. Pneumonia (PNA-infection that inflames air sacs in one or both lungs and can be life-threatening to anyone but particularly to infants, children, and people over [AGE] years old) vaccine was offered to four of 19 sampled residents (Resident 4, 28, 44, and 62). 2. Influenza (Flu-common viral infection that can be deadly, especially in high-risk groups) vaccine was offered to five of 19 sampled residents (Resident 4, 38, 44, 62, 280). These deficient practices placed Residents 4, 28, 38, 44, 62, and 280 at a higher risk of possibly acquiring and transmitting influenza and pneumonia infection to other residents and staff in the facility. Findings: 1a. A review of Resident 4's admission Record indicated Resident 4 was originally admitted to the facility on [DATE], and was re-admitted on [DATE], with diagnoses including sacral (area at the bottom of the spine [backbone] and the coccyx [tailbone]) region pressure ulcer (injury to skin and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that COVID-19 (a viral infection, highly contagious, that easily transmits from person to person, causing respiratory problems and may cause death) vaccination was offered/ re-offered and/or administered to eight of 19 sampled residents (Resident 4, 28, 38, 41, 44, 48, 60, 280). This deficient practice might have the potential for not preventing Resident 4, 41, and 48, who were tested positive for COVID 19, from COVID-19 infection, and placed other residents and staff at risk for COVID-19 infection. Findings: 1. A review of Resident 4's admission Record indicated Resident 4 was originally admitted to the facility on [DATE], and was re-admitted on [DATE], with diagnoses including sacral (area at the bottom of the spine [backbone] and the coccyx [tailbone]) region pressure ulcer (injury to skin and underlying tissue resulting from prolonged pressure on the skin), malnutrition (lack of sufficient nutrients in the body) and gastrostomy tube (GT- a…

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

Based on observation, interview and policy review, the facility failed to maintain patient care equipment in safe working condition when: - One sit-down bicycle was missing foot straps. - One sit-down bicycle's monitor screen was not working. - One stand-up bicycle was missing foot straps. These deficient practices had a potential to cause incidental accidents to the residents while using the equipment. Findings: During an observation in the Rehabilitation Gym with the Director of Rehabilitation (DOR) on 11/26/2023 at 9:15 a.m., the following equipment conditions were observed: i. One sit-down bicycle had a monitor screen turned off with a manual timer taped around it. ii. One of the other two sit-down bicycle was missing both foot straps. iii. One stand-up bicycle was missing both foot straps. During an interview with the DOR on 11/26/2023 at 9:23 a.m., the DOR stated two bicycles were missing foot straps, and one bicycle's monitor screen was not working which was the reason that they taped a manual timer to the bicycle. The DOR stated she had requested the maintenance department…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide care in a manner that promote or enhanced resident's dignity and respect for two of five sampled residents (Resident 12 and 232) by failing to: 1. Ensure adhering to facility's care plan, policy, and procedure (P&P) regarding non-English-speaking residents for one of three sampled residents (Resident 12). This deficient practice violated Resident 12's right to have effective mode of communication and to communicate her needs to facility staff as desired. 2. Ensure one of three sampled residents (Resident 232) was informed of confirmed COVID-19 (a viral infection, highly contagious, that easily transmits from person to person, causing respiratory problems and may cause death) cases in the facility. This deficient practice had the potential to cause psychosocial harm to Resident 232 by violating resident's right to be treated with respect and dignity. Findings: A review of Resident 12's admission Record indicated Resident 12 was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure residents were provided with room change notification for one of three sampled residents (Resident 430). This deficient practice violated resident 430's right to room change notification. Findings: A review of Resident 430's admission Record indicated Resident 430 was admitted to the facility on [DATE], with diagnoses that included joint replacement surgery (when a surgeon removes a damaged joint and replaces it with an artificial one), diabetes mellitus (DM -when the blood sugar is too high) and atherosclerosis (thickening or hardening of the arteries). A review of Resident 430's Minimum Data Set (MDS-a standardized assessment and care screening tool), dated 11/21/2023, indicated Resident 430 had intact cognitive skills (thought processes) for daily decision making and required partial/moderate to substantial/maximal assistance on staff for activities of daily living (ADLs-sit to standing, lying to sitting on side of bed, bed to chair…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure residents were informed or offered an advanced directive (written statement of a person's wishes regarding medical treatment made to ensure those wishes are carried out should the person be unable to communicate them to a doctor) in a timely manner for four out of four sampled residents (Resident 85, Resident 89, Resident 127, and Resident 430). This deficient practice had the potential to cause conflict with resident's wishes regarding health care (Resident 85, Resident 89, Resident 127, and Resident 430). Findings: A. A review of Resident 430's admission Record indicated Resident 430 was originally admitted to the facility on [DATE], with diagnoses that included joint replacement surgery (when a surgeon removes a damaged joint and replaces it with an artificial one), diabetes mellitus (DM -when the blood sugar is too high) and atherosclerosis (thickening or hardening of the arteries). A review of Resident 430's Minimum Data Set (MDS-a…

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

Based on interview and record review, the facility failed to follow its policies and procedure by failing to notify the physician immediately upon identification of COVID-19 (a viral infection, highly contagious, that easily transmits from person to person, causing respiratory problems and may cause death) positive result for one of three sampled residents (Resident 48). This deficient practice resulted in a delay of necessary treatment for COVID-19 and could result in a decline in medical condition for Resident 48. Findings: A review of Resident 48's admission Record indicated the facility admitted Resident 48 on 2/14/2018 with diagnoses including fracture of the left leg, atrial fibrillation (irregular and abnormal heart rate) and muscle weakness. A review of Resident 48's Minimum Data Set (MDS- a standardized assessment and screening tool), dated 9/13/2023, indicated the resident's cognition (ability to think, understand and reason) was severely impaired. A review of Resident 48's Situation, Background, Assessment and Recommendation (SBAR- is a structured communication framework…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure two of three randomly selected residents (Residents 26 and 121) were provided with the Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (skilled nursing facility Advanced Beneficiary Notice [SNF-ABN]) complete appeal process. This deficient practice had the potential to result in Residents 26 and 121 and their responsible parties not being able to exercise their right to decide if they wished to continue receiving the skilled services that may not be paid for by Medicare and to assume financial responsibility. Findings: A. A review of Resident 26's admission Record indicated Resident 26 was admitted to the facility on [DATE], with diagnoses including acute osteomyelitis, right ankle and foot (inflammation or swelling that occurs in the bone), type II diabetes mellitus (DM-a chronic condition that affects the way the body processes blood sugar [glucose]), and cellulitis of right lower limb (bacterial skin infection). A review…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to complete a change in condition (COC - a deterioration in health, mental, or psychosocial status) assessment for one of three sampled residents (Resident 390). On 11/24/2023, Resident 390 intravenous (IV - a within a vein) line (a soft, flexible tube placed inside a vein, usually in the hand or arm) on the left forearm, infiltrated (when fluid or medication accidentally leaks into the surrounding tissues outside a vein). As a result, Resident 49 experienced swelling, redness and pain of the left forearm. Findings: A review of Resident 390's admission Record indicated Resident 390 was admitted to the facility on [DATE], with diagnoses that included, urinary tract disease (infection of the bladder), hypertensive heart disease (heart problems that occur because of high blood pressure that is present over a long time), and Extended Spectrum Beta Lactamases Resistance (ESBL-Beta lactamases are enzymes produced by some bacteria that may cause resistance to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to meet professional standards of quality by failing to ensure trazodone (medication used to treat depression and may help to improve mood, appetite, and energy level as well as decrease anxiety and insomnia [difficulty falling or staying asleep]) was not left unattended at the bedside for one of five sampled residents (Residents 107) This deficient practice had the potential to result in residents in unintended complications related to the management of medications. Findings: A review of Resident 107's admission Record indicated Resident 107 was originally admitted to the facility on [DATE] and was readmitted on [DATE], with diagnoses including type II diabetes mellitus (DM-a chronic [ongoing] condition that affects the way the body processes blood sugar [glucose]), and atherosclerotic heart disease (build-up of fats, cholesterol, and other substance in and on the arterial walls), and depression (a mood disorder that causes persistent…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure two of 27 sampled residents (Residents 387 and 330) received treatment, care, and services in accordance with professional standards of practice by failing to: 1. Assess, identify risk factors, and provide Resident 387 with a call device the resident could use independently and without risk for injury or harm. 1.1 On 11/25/2023 at 6:22 p.m., Resident 387 was observed to have a silver bell with a black handle tightly tied to resident's left middle finger with a white gauze causing an indentation (area of skin that looks pushed in close to the bone of the finger) and redness, pain, and swelling to the resident's finger. 1.2. On 11/25/2023 at 7:57 p.m., the same bell was observed tied to Resident 387's left index finger. 1.3. On 11/26/2023 at 8:40 a.m., the same bell was observed tied to Resident 387's left index finger again. 2. Ensure Physical Therapist (PT- -a person qualified to treat disease, injury, or deformity by physical…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to: 1. Ensure the Peripherally Inserted Central Catheter PICC- a long, flexible catheter (thin tube) that's put into a vein in your upper arm and goes all the way up to a vein near the heart or just inside the heart) line dressing was changed every seven days for Resident 387. 2. Ensure peripheral intravenous (IV-a small, flexible tube placed into a small vein used to administer medications and fluids) for Resident 223 by failing to: 2.1. Replace IV site no more frequently than every 72 to 96 hours. 2.2. Date and initial when IV dressing is changed. 2.3. Document and assess and monitor the IV site after IV for infection. These deficient practices placed Residents 233 and 387 at increased risk to develop infections at IV site with a potential to sepsis (a serious and life threatening condition in which the body responds improperly to an infection) and death. Findings: 1. A review of Resident 387's admission record indicated Resident 387 was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide respiratory care that was consistent with professional standards of practice to meet the goal ensure for two of five sampled residents (Residents 113 and 330) by: 1. Failing to ensure Resident 113's oxygen nasal cannula tubing and oxygen humidifier had a date when the humidifier and tubing were changed. 2. Failing to ensure to obtain a physician order for Resident 330's oxygen therapy. This deficient practice had the potential to result in complications including infections related to oxygen therapy for Residents 113 and 330. Findings: A. A review of Resident 113's admission Record indicated the facility admitted Resident 113 on 10/29/2023 with diagnoses including atrial fibrillation (irregular heartbeat), anemia (low red blood cells in the body) and stroke (medical emergency that damage the brain from the interruption of its blood supply). A review of Resident 113's Minimum Data Set (MDS- a standardized assessment and 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 ensure proper use of bed rails (a barrier attached to the side of the bed) for three out of five sampled residents (Residents 85, 107 and 127) as indicated in the facility's policy and procedure titled Proper Use of Side Rails. These deficient practices had the potential to result in inappropriate use of bed siderails and placed the residents at risk for serious injury or harm. Findings: 1. A review of Resident 85's admission Record indicated resident was originally admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses including hemiplegia and hemiparesis (loss of the ability to move in one side of the body) following cerebral infarction (lack of blood flow resulting in severe damage to some of the brain tissue) affecting left non-dominant side, and paroxysmal atrial fibrillation (a fib- an irregular and very rapid heart rhythm that and can lead blood clots in the heart), and acute respiratory failure (condition 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 ensure the Medication Regimen Review (MRR-a thorough evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences associated with medication) for two of five sampled residents (Residents 49 and 113) was free from unnecessary drug. This deficient practice resulted in unnecessary use of antibiotics and at risk for side effects of antibiotics for Resident 113 and had the potential to place Resident 49's receiving unnecessary medication and possibly hospitalization. Findings: A review of Resident 49's admission Record indicated Resident 49 was originally admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included hemiplegia and hemiparesis (loss of the ability to move in one side of the body) following cerebral infarction (lack of blood flow resulting in severe damage to some of the brain tissue) affecting left non-dominant side, diabetes mellitus (DM…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 and procedures (P & P) titled, Psychotropic Medication Use,, by failing to indicate the behavioral symptoms and follow up with the recommendation for a gradual dose reduction for Seroquel (This medication is used to treat certain mental/mood conditions, such as bipolar disorder [a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration] or depression) for one of six sampled residents (Resident 17). These deficiencies had the potential to result in the use of unnecessary medication and expose Resident 17 to adverse side effects related to higher or prolong use of antipsychotic drugs (medication taken to exert an effect on the chemical makeup of the brain and nervous system). Findings: A review of Resident 17's admission Record, indicated Resident 17 was admitted to the facility on [DATE], and readmitted on [DATE] and 8/07/2022 with diagnoses including dementia (loss of memory),…

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

Based on interview and record review, the facility failed to ensure one out of five sampled residents (Resident 60), were free from significant medication errors by: 1.Failing to ensure Resident 60's benazepril hydrochloride (medications to treat high blood pressure (BP) [the force of the blood pushing on the blood vessel walls is too high]) was administered in accordance with the physician's order with parameters (low and high limits set by the physician telling the nurse when a medication can and cannot be given) to hold (do not give) the medication if Resident 60's systolic blood pressure (SBP-measures the pressure in your arteries [pathway that carries blood away from the heart] when your heart beats) was less than 110 millimeters of mercury (mmHg). 2.Failing to ensure Resident 60's Amlodipine Besylate (medication to treat high blood pressure) 10 mg, give one tablet by mouth one time a day for hypertension was administered in accordance with the physician's order with parameters indicating to hold the medication if the resident's SBP was less than 100 mmHg. These deficient…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 promptly notify the physician of one of two sampled residents (Resident 113) about abnormal hemoglobin (blood cells that is responsible for delivery of oxygen to the tissues), hematocrit (measures the percentage of the red blood cells in the blood) and potassium (electrolyte) levels. On 11/20/2023 Resident 113 had a documented hemoglobin level of 8.3 grams per deciliter (gm/dL, ranges from 13.2 to 16.6 gm/dL), a documented Hematocrit level of 27.5 percent (%-ranges from 38.3% to 48.6%), and a documented potassium level of 3.3 millimoles per liter (mmol/L, ranges from 3.6 to 5.2mmol/L). This deficient practice placed the resident at risk for insufficient blood and oxygen supply to the entire body, brain, and heart, muscle weakness, heart attack, heart failure, and worsening of current medical conditions which could lead to death. Findings: A review of Resident 113's admission Record indicated the facility admitted the resident on 10/29/2023 with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to assist with arranging transportation services to a follow up Orthopedic (a doctor that is specialized in the musculoskeletal [muscles and bones] system) appointment for one of three sampled residents (Resident 12). This deficient practice resulted in Resident 12 missing a scheduled physician's appointment with the potential to negatively affect Reident 12's health and wellbeing. Findings: A review of Resident 12's admission Record indicated Resident 12 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including chronic pancreatitis (caused by damage to the pancreas [gland behind the stomach] by long standing inflammation [generally painful swelling]), diabetes mellitus (DM -when the blood sugar is too high), and hypertensive heart disease (hypertensive [high or raised] blood pressure. A review of Resident 12's Minimum Data Set (MDS-a standardized assessment and care screening tool), dated 11/12/2023 indicated the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to maintain accurate medical record in accordance with accepted professional standards and practices for three of 19 sampled residents (Residents 4, 41, and 90) by failing to ensure complete and accurate pneumonia (PNA-infection that inflames air sacs in one or both lungs which may fill with fluid), influenza (Flu-common viral infection that can be deadly, especially in high-risk groups) and COVID-19 (Coronavirus- a deadly respiratory disease transmitted from person to person) vaccination consents were properly completed. This deficient practice had the potential to negatively impact the delivery of services given to Residents 4, 41, and 90. Findings: 1. A review of Resident 4's admission Record indicated Resident 4 was originally admitted to the facility on [DATE], and was re-admitted on [DATE], with diagnoses including sacral (area at the bottom of the spine [backbone] and the coccyx [tailbone]) region pressure ulcer (injury to skin and underlying…

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

Based on interview and record review, the facility failed to implement its antibiotic stewardship (actions designed to use antibiotic medications effectively while reducing the possibility of being prescribed an unnecessary medication) program by failing to conduct infection surveillance and complete the infection control reporting form when signs and symptoms of infection were identified and antibiotics were initiated for one of five sampled residents (Residents 113). This deficient practice had the potential for Resident 113 to develop antibiotic resistance (not effective to treat infection) resulting from unnecessary or inappropriate antibiotic use. Findings: A review of Resident 113's admission Record indicated the facility admitted the resident on 10/29/2023 with diagnoses including atrial fibrillation (irregular heartbeat), anemia and stroke (medical emergency that damage the brain from the interruption of its blood supply). A review of Resident 113's Minimum Data Set (MDS- standardized assessment and screening tool dated 11/2/2023, indicated the resident's cognition (the…

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

Based on interview and record review, the facility failed to ensure the Infection Preventionist Nurse (IPN), who is responsible for the facility's Infection Prevention Control Program (IPCP), adequately maintained the facility's vaccination program and properly monitored the facility's antibiotic stewardship program (ASP). This deficient practice had the potential to increase the spread of infection and possible transmission of communicable diseases between residents, staff and the community. Cross Reference F880, F881, F883 and F887 Findings: During a concurrent interview and record review with the Infection Preventionist Nurse (IPN) on 11/26/2023 at 11:04 a.m., the IPN validated multiple missing follow ups on facility's vaccination program and ASP. The IPN stated his inability to finish all the work was because of the facility's size. The IPN also stated, as an IPN, it was his (IPN's) job to make sure both vaccinations and ASP were up to date and monitored. During an interview with the Director of nursing (DON) on 11/26/2023 at 3:12 p.m., the DON stated that it was the IPN's job…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 a homelike environment for one of five sampled residents (Resident 1) by failing to ensure the shower chair was cleaned before and after use. This deficient practice had the potential to negatively impact the quality of life and increased risk for physical discomfort 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 hemiplegia affecting right dominant side (loss of the ability to move in one side of the body), systemic lupus erythematosus ((SLE) - an autoimmune disease in which the immune system attacks its own tissues, causing widespread inflammation and tissue damage in the affected organs), persistent asthma (respiratory condition marked by spasms in the bronchi of the lungs, causing difficulty in breathing). A review of Resident 1's Minimum Data Set (MDS - a standardized assessment and screening tool), dated 10/29/2023,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 for two of five sampled residents (Residents 1 and Resident 4) by failing to: 1. Ensure that Resident 1 ' s Lidoderm patch (eases pain by numbing the nerves and making them less sensitive to pain) medications were not left unattended. 2. Ensure Resident 4 ' s potassium chloride tablet (a medication used in the management and treatment of hypokalemia [low potassium level]) was not left unattended. These deficient practices had the potential to result in residents in unintended complications related to the management of medications. Findings: 1. A review of Resident 1 ' s admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including hemiplegia affecting right dominant side (loss of the ability to move in one side of the body), systemic lupus erythematosus ((SLE) - an autoimmune disease in which the immune system attacks its own tissues, causing widespread…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 safe and functional shower room for 1 out of 5 shower rooms in the facility, by having a broken shower door knob. This deficient practice had the potential to negatively impact the psychosocial wellbeing of the residents or result in delayed provision of services. Findings: A review of Resident 1's admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including hemiplegia affecting right dominant side (loss of the ability to move in one side of the body), systemic lupus erythematosus ((SLE) - an autoimmune disease in which the immune system attacks its own tissues, causing widespread inflammation and tissue damage in the affected organs), persistent asthma (respiratory condition marked by spasms in the bronchi of the lungs, causing difficulty in breathing). A review of Resident 1's Minimum Data Set (MDS - a standardized assessment and screening tool), dated 10/29/2023, indicated 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.

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 four sampled residents (Resident 10) with an indwelling catheter (urinary catheter-a flexible plastic tube inserted into the bladder that remains there to provide continuous urinary drainage) received proper care and services consistent with professional standard of care by failing to: 1. Ensure Resident 10 ' s urinary catheter drainage bag was not touching the floor. 2. Ensure Resident 10 ' s urinay catheter drainage bag was covered with privacy bag. These deficient practices had the potential to cause urinary issues such as infection and had the potential to violate Resident 10 ' s rights to be treated with dignity. Findings: During a review of Resident 10 ' s admission Record, indicated the facility originally admitted Resident 10 on 6/26/2020, and was re-admitted on [DATE] with diagnoses including disorder of the muscle, lack of coordination and hemiplegia (paralysis on one side of the body)and hemiparesis (weakness…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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: a. Ensure the quality control testing for the Assure glucometer machine (device that measures how much sugar is in the blood sample) are performed correctly according to the manufacturer guidelines for 11 out of 11 glucometer machines. This deficient practice has the potential to result in residents with unintended complications related to the management of their blood glucose. b. Ensure the medication disposition record log for discarding and destroying medications are complete with date when it was discarded for one of three medication disposition log (Medication room [ROOM NUMBER]) according to their policy. This deficient practice has the potential to result in drug diversions. c. Ensure a Restorative Nursing Assistant (RNA) meeting was done on a monthly basis. This deficient practice had the potential not to meet residents care and needs that may lead to decline in range of motion (ROM). Findings: 1a. During a concurrent interview…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to notify resident upon changes to the charges for items and services that the facility offers in writing at least 30 days of implementation of the change according to their policy for one of five sampled residents, Resident 1. This deficient practice had the potential to result in Resident 1 and her responsible parties not being able to exercise their rights. Findings: A review of Resident 1's the admission Record indicated Resident 1 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), malignant neoplasm of colon (another term for a cancerous tumor, neoplasm refers to an abnormal growth of tissue in the colon), and disorder of muscle. A review of the Minimum Data Set (MDS - a comprehensive assessment and care screening tool), dated 7/19/2023, indicated Resident 1's cognitive (mental action or process of acquiring knowledge…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 protection of resident ' s medical record for three of three sampled residents (Resident 11, 12 and 14) when Resident 11, 12 and 14 ' s information was not removed from the medication containers. This deficient practice had the potential to result on violating Resident 11, 12 and 14 ' s right to privacy and confidentiality. Findings: 1. During a review of Resident 11 ' s admission Record, indicated the facility admitted Resident 11 on 9/20/2023 with diagnoses including dislocation of left shoulder, osteoarthritis (inflammation of the bone)and abnormalities of gait (ambulation) and mobility. admission Record also indicated Resident 11 was discharge on [DATE]. During a review of Resident 11 ' s Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated 9/24/2023, the MDS indicated Resident 11's cognitive skill for daily decision-making was intact and requiring supervision for activities of daily livings (ADLs-…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow its policy by failing to report a sexual abuse within 2 hours of occurrence to law enforcement, the State Agency and Ombudsman for one of five sampled residents (Resident 3). This deficient practice resulted in a delay of an onsite investigation by the law enforcement and the State Agency to ensure the rights and safety of the resident involved. Findings: A review of Resident 3's admission Record indicated Resident 3 was admitted to the facility on [DATE] with diagnoses that included fracture of unspecified part of neck of left femur (a break in the uppermost part of thighbone, next to the hip joint), cognitive communication (the individual may struggle with social language skills, paying attention when conversing or being spoken to, reasoning and judgment abilities, and short and long-term memory) and chronic kidney disease (CKD-a longstanding disease of the kidneys leading to renal failure). A review of Resident 3's Minimum Data Set (MDS - a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide the necessary treatment and service to three of seven sampled residents (Resident 7, 9 and 10) consistent with the resident ' s needs and professional standard of care by failing to ensure Resident 7, 9, and 10 ' s low air loss mattresses (LAL-a mattress designed to prevent and treat pressure wounds) were in appropriate setting per manufacturer ' s guideline. This deficient practice can place Resident 7, 9 and 10 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: 1. During a review of Resident 7 ' s admission Record, indicated the facility originally admitted Resident 7 on 11/24/2021, 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), diabetes mellitus (DM-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: a. Report missing ring to the Administrator timely, and b. Initiate and Investigate allegation of a missing ring thoroughly and timely as per facility policy for one of three sampled residents, (Resident 1). This deficient practice could have place other residents at risk of possible theft due to prolonged and incomplete investigation. Findings: A review of Resident 1's admission Record indicated the facility admitted this [AGE] year-old female on 10/2/2023 with diagnoses including cerebral infarction due to embolism (a blood clot in the vessels of the brain interrupting blood flow causing brain tissue death), difficulty walking, Dementia (a progressive, persistent loss of intellectual functioning causing impairment in memory and abstract thinking) without behavioral disturbance, gastrostomy (permanent opening created surgically into the abdominal wall for insertion of a feeding tube), Dysphagia (difficulty swallowing), altered mental status (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 report possible misappropriation of property for one of three sampled residents, (Resident 1), to the California Department of Public Health (CDPH) per policy. This deficient practice resulted in a delay in the investigation of the allegation of the misappropriation of property for Resident 1. Findings A review of Resident 1's admission Record indicated the facility admitted this [AGE] year-old female on 10/2/2023 with diagnoses including cerebral infarction due to embolism (a blood clot in the vessels of the brain interrupting blood flow causing brain tissue death), difficulty walking, Dementia (a progressive, persistent loss of intellectual functioning causing impairment in memory and abstract thinking) without behavioral disturbance, gastrostomy (permanent opening created surgically into the abdominal wall for insertion of a feeding tube), Dysphagia (difficulty swallowing), altered mental status (a disruption in how your brain works that causes…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that the call light (A device used by a patient to signal his or her need for assistance from professional staff) for one of four sampled residents (Resident 2) was answered in a timely manner. This deficient practice had the potential for Resident 2's needs not being met. Findings: During an initial tour on an unannounced visit to the facility on [DATE] at 10:25 am, a light outside room A was observed to be on. During a concurrent observation and interview, Resident 2 was observed lying down in bed looking uncomfortable. She stated that she had pushed the call light earlier and does not remember exactly what time, but it was a long time ago. She stated that she had pain 9/10 on the pain scale of 0-10 (used to measure pain 0-3 mild, 4-6 moderate, 7-8 severe) but stated that the nurse had just given her pain medication not so long ago but could not remember when. When asked how often it happens that her call light takes a while, she…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 the Director of Nursing (DON) have the specific competency and skill set necessary to ensure the facility's policy of elopement (leaving the facility unsupervised and without staff knowledge) was implemented by failing to investigate and report the unusual occurrence to the State Survey Agency within 24 hours after Resident 1 left the facility unsupervised and without staff knowledge for one of five sampled residents (Resident 1). 2. ensure that Licensed Vocational Nurse (LVN 5) and Licensed Vocational Nurse 6 (LVN 6) have the specific competencies and skill sets necessary to care for one of five sampled residents (Resident 2) by failing to properly document in the Medication Administration Record (MAR) when medications were refused and withheld. These deficient practices had the potential to result in a negative effect to Resident 1 and Resident 2's plan of care and delivery of necessary care and services. Findings: 1. 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 provide the State Survey Agency a written report of the findings of the investigation of an unusual occurrence of elopement (leaving the facility unsupervised and without staff knowledge) after 5 working days of Resident 1's leaving the facility unsupervised and without staff knowledge for one out of five sampled residents (Residents 1). This deficient practice had a potential for an ongoing reoccurrence of elopement. Findings: A review of Resident 1's admission Record dated 3/21/2023, indicated Resident 1 was admitted to the facility 9/6/2023, with diagnoses including hemiplegia and hemiparesis (loss of the ability to move in one side of the body) following cerebral infarction (lack of blood flow resulting in severe damage to some of the brain tissue) affecting right dominant side, dysarthria (weakness in the muscles used for speech, which often causes slowed or slurred speech) following cerebral infarction and type II diabetes mellitus (DM-a chronic…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 of elopement (leaving the facility unsupervised and without staff knowledge) by failing to investigate and report the unusual occurrence to the State Survey Agency within 24 hours after Resident 1 left the facility unsupervised and without staff knowledge for one of five sampled residents (Resident 1). This deficient resulted in a delay of an onsite inspection by the Department of Public Health and had potential for an ongoing reoccurrence of elopement. Cross reference F609. Findings: A review of Resident 1's admission Record dated 3/21/2023, indicated Resident 1 was admitted to the facility 9/6/2023, with diagnoses including hemiplegia and hemiparesis (loss of the ability to move in one side of the body) following cerebral infarction (lack of blood flow resulting in severe damage to some of the brain tissue) affecting right dominant side, dysarthria (weakness in the muscles used for speech, which often causes slowed or slurred…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 an individualized person-centered plan of care with measurable objectives, timeframe, and interventions to meet the residents' needs for two of five sampled residents (Residents 2 and 3) by failing to: 1. Implement the care plan for Resident 3's self-administration of Vyndamax (used to treat a certain type of heart failure) medication when Licensed Vocational Nurse 1 (LVN 1) confirmed that Resident 3 takes his own medication, and the medication was left at bedside. 2. Implement the care plan for Resident 2's refusal of taking Biktarvy (prescriptions medicine used to treat human immunodeficiency virus [HIV 1 - a virus that attacks the body's immune system] in adults and children) medications. This deficient practice had the potential to result in inconsistent implementation of the care plan and can lead to a delay or lack of delivery of necessary care and services. Findings: 1. A review of Resident 3's admission Record 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 revise a care plan for at risk of elopement (leaving the facility unsupervised and without staff knowledge) for one of five sampled residents (Resident 1), who left the facility unsupervised and did not notify the staff and without physician's order. This deficient practice placed Resident 1's at risk for recurrent elopement. Findings: A review of Resident 1's admission Record dated 3/21/2023, indicated Resident 1 was admitted to the facility 9/6/2023, with diagnoses including hemiplegia and hemiparesis (loss of the ability to move in one side of the body) following cerebral infarction (lack of blood flow resulting in severe damage to some of the brain tissue) affecting right dominant side, dysarthria (weakness in the muscles used for speech, which often causes slowed or slurred speech) following cerebral infarction and type II diabetes mellitus (DM-a chronic condition that affects the way the body processes blood sugar [glucose]). 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, facility failed to meet professional standards of quality for two of five sampled residents (Resident 2 and 3) by failing to: 1. Implement the facility ' s policy and procedure titled, Medication Administration (General) , to assess each resident ' s mental and physical abilities, to determine whether a resident is capable of self-administering medications. 2. Clarity with the physician for order of Resident 3 ' s Vyndamax (used to treat a certain type of heart failure) medication left at bedside. 3. Failing to ensure a timely assessment for self-administration of Vyndamax medication for Resident 3. These deficient practices increased the risk for accidents, unintended complications from receiving more or less than the required medications dose for Resident 3, potential to result in unintended consequences of the management of illness such as exacerbation of disease (increase in severity) and resulted in Resident 3 missing doses of his medication. Findings: 1.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Cross reference to F657 Based on observation, interview, and record review, the facility failed to ensure one of five sampled residents (Resident 1) was properly supervised to prevent elopement (leaving the facility unsupervised and without staff knowledge) by failing to: 1. Ensure to evaluate and analyze hazard(s) and risk(s) of elopement when Resident 1 was observed walking around his room and made attempt of leaving as he was observed walking in the hallway and attempting to take the elevator. 2. Implement the comprehensive care plan for risk of elopement related to Resident 1 verbalizing of wanting to go home and expressing to his (Resident 1) daughter of not wanting to stay in the facility. These deficient practices resulted in Resident 1 eloping on 9/23/2023, took the bus unsupervised and without notifying the staffs. Police department called the facility and was notified of Resident 1's actual location and Resident 1 was triaged back to the facility. Findings: A review of 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 provide, and document sufficient preparation for discharge for two of two sampled residents (Residents 3 and 4) by failing to ensure Resident 3 and 4 had a proper arrangement for a home health care services (HHCS-healthcare services at home to people with specialized needs) when Resident 3 and 4 was discharged to home with a physician (MD) order for a HHCS. This deficient practice had a potential for an unsafe discharge to home for Resident 3 and 4. Findings: a. During a review of Resident 3 ' s admission Record (AR), indicated that facility admitted Resident 3 on 6/12/2023, with diagnoses including left hip joint replacement (hip joint is preplaced by a prosthetic implant [artificial device that replaces a missing body part]) surgery, abnormalities of gait (walking) and mobility and diabetes mellitus (DM-a chronic condition that affects the way the body processes blood sugar [glucose]). AR also indicated that Resident 3 was discharge on [DATE]. During…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to 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 since admission for one of two sampled resident (Resident 4) per facility policy. This deficient practice had the potential for Resident 4 not receiving appropriate care/ treatment and/ or services by the facility. Findings: During a review of Resident 4 ' s admission Record (AR), indicated that facility admitted Resident 4 on 7/21/2023, with diagnoses including right hip joint replacement (hip joint is preplaced by a prosthetic implant [artificial device that replaces a missing body part]) surgery, abnormalities of gait and mobility and bilateral osteoarthritis (inflammation of the bone) of knee. AR also indicated that Resident 4 was discharge on [DATE]. During a review of Resident 4 ' s Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated 7/23/2023,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 provide appropriate competencies and skill sets to provide nursing and related services to provide care and respond to each residents ' individualized needs by failing to maintain competencies of nursing staff per facility policy for 10 of 13 sampled facility licensed nurses (Assistant Director of Nursing-ADON, Licensed Vocational Nurse 1-LVN 1, Licensed Vocational Nurse 2-LVN 2, Licensed Vocational Nurse 3-LVN, Licensed Vocational Nurse 4-LVN4, Licensed Vocational Nurse 5-LVN5, Licensed Vocational Nurse 6-LVN6, Licensed Vocational Nurse 10-LVN10, Licensed Vocational Nurse 12-LVN12, and Licensed Vocational Nurse 13-LVN13). This deficient practice violated the facility ' s policy and had the potential for residents not receiving the appropriate nursing care and related services. Cross Reference F760. Findings: During a concurrent interview and record review on 8/12/2023 at 9:31 a.m., with the Director of Nursing (DON) and ADON, facility licensed nurses ' (ADON, LVN1, LVN2, LVN 3, LVN4, LVN5, LVN6, LVN10, LVN12 and LVN13)…

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