Good Shepherd Health Care Center Of Santa Monica

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to receive input from the resident for their preferred foods for one of one sampled resident (Resident 1).This failure had the potential for the resident to lose weight because they were not receiving the foods they liked to eat.Findings: During the review of Resident 1's admission record, the admission record AR indicated the facility admitted the resident on 7/27/2024 and then readmitted on [DATE] with diagnosis that included but not limited to chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), severe protein-calorie malnutrition (a severe condition resulting from insufficient intake of protein and calorie, can lead to muscle waste, fat loss, and functional decline) and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). During the review of Resident 1's Minimum Data Set (MDS - a resident assessment tool) dated 1/9/2026, the MDS…

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

Based on observation and interview, the facility failed to: Ensure the dishwasher sanitizer machine had the correct chlorine concentration to clean the dishware. Date food items and discard expired food stored in the refrigerator and dry storage area. These failures had the potential to result in food borne illness in the residents. Findings:1.During and observation on 2/23/2026 at 8:06 AM in the kitchen, [NAME] 1 tested the chlorine concentration of the dishwasher sanitizer machine three times. The test strip indicated the chlorine concentration was 25 parts per million (ppm) all three times. During an interview on 2/23/2026 at 8:06 AM with [NAME] 1, [NAME] 1 stated the correct chlorine concentration level should be at least 50 ppm, and they need to adjust the sanitizer concentration if it is below 50 ppm. [NAME] 1 stated if dishes are not sanitized well the residents could get sick. During an interview on 2/23/2026 at 10:10 AM with Dietary Supervisor (DS), DS stated the chlorine sanitizer test reading should be at 50 ppm to ensure dishes have been sanitized well. DS stated they…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 infection prevention and control program was followed by failing to: Ensure that the antibiotic surveillance log (a record-keeping tool used by nursing homes to track, analyze, and manage infections among residents) was completed for Resident 4 and Resident 6.Ensure that the facility's Water Management Program ([WMP] - a written, step-by-step plan for buildings to ensure their water system was safe, clean, and efficient) was implemented and maintained as written.These deficient practices placed the residents, staff and visitors at risk for exposure to and transmission of infectious organisms, incomplete monitoring and follow up of infections, missed trends or outbreaks due to lack of surveillance data analysis, and unsafe water conditions.Findings: 1a. During a review of Resident 4's admission Record, the admission record indicated that Resident 4 was initially admitted to the facility on [DATE] and last re-admission was on 12/14/2025 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 obtain a current informed consent from the resident or resident's representative at the time influenza (an infection of the nose, throat and lungs, which are a part of the respiratory system) vaccine (a preparation that is used to stimulate the body's immune response against diseases) was administered for one of four sampled residents (Resident 6). This deficient practice violated Resident 6 or Resident 6's responsible party's rights to make an informed decision. Findings: During a review of Resident 6's admission Record, the admission record indicated that Resident 6 was initially admitted to the facility on [DATE], with diagnoses including type II diabetes mellitus (DM-a chronic condition that affects the way the body processes blood sugar), heart disease, venous insufficiency, and anemia (a condition where the body does not have enough healthy red blood cells). During a review of Resident 6's Minimum Data Set (MDS - a resident assessment 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.

Based on interview and record review the facility failed to ensure to provide documented evidence for two of four sample employees (Medical Director and Registered Dietitian (RD) Corona virus ([COVID-19] - contagious infectious disease) vaccination status and the provision of education on benefits and potential side effects.This failure had the potential to result in staff (refers to those individuals who work in the facility on a regular basis, this also includes individuals under contract) and residents contracting COVID-19 which can cause serious illness, hospitalization, and death.Findings: During a concurrent interview and record review on 2/25/2026 at 11:13 a.m., with Infection Prevention Nurse (IPN), the Employee's Vaccination Record 2025 was reviewed for the Medical Director and RD. The employee vaccination record indicated no documentation of COVID-19 vaccination status and provision of education on benefits and potential side effects of COVID-19 vaccine, and documentation that the COVID-19 vaccine was offered. The IPN stated that all staff members should be offered…

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

Based on observations, interviews, and record reviews, the facility failed to ensure kitchen were routinely trained and possessed the necessary competencies to ensure the nutritional needs of residents were met. By failing to ensure kitchen staff: a.Followed the recipe for puree (foods that are smooth with pudding like consistency) ham and potato casserole for puree diet. b.Followed spreadsheet portion sizes for puree eggs. Residents were given two (2) ounces ([oz] a unit of measurement) instead of three (3) oz. c.Were aware of and able to verbalize the potential outcome of a dirty refrigerator and freezer during food storage. This failure had a potential to result in inadequacy of food and nutrients leading to weight loss and food borne illness (a disease caused by consuming food or drinks that are contaminated by germs or chemicals) for 46 of 46 residents who received food from the kitchen and were on Puree and regular diets (diet with no restriction). Findings: 1. During a review of the facility's daily spreadsheet titled Winter Menus, dated 12/28/2024, the spreadsheet 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.

Based on observations, interviews, and record reviews, the facility failed to prepare food by methods that conserved flavor and appearance for breakfast when: a.Ham and potato breakfast casserole was scooped instead of cutting it with a portion size of 2 ½ x 2 inches ([in] unit of measurement) as indicated in the facility's spreadsheet and was served in a bowl instead of on the plate for regular texture consistency (texture with no restriction). The plates had no garnish. b.Puree diet (foods that are smooth and pudding like consistency) /International Dysphagia Diet Standardization Initiative ([IDDSI] a framework for categorizing food textures and drink thickness) Level 4 received puree scrambled eggs instead of puree ham and potato breakfast casserole and the puree scrambled eggs was too dry. c.Puree wheat toast and puree raisin brand were too sticky. This failure had a potential to result in 46 of 46 facility residents being at risk of unplanned weight loss, a consequence of poor food intake, getting food from the kitchen. Findings: During a review of the facility's 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.

Based on observations, interviews, and record reviews, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen when: 1. Reach-in freezer temperature was at 30 degrees Fahrenheit (°F, a scale of temperature). 2. Turkey was stored on bottom of the beef. 3.Food preparation surfaces and kitchen equipment were not cleaned and sanitized. a.Reach-in refrigerator had food and dirt debris around the gasket. b. Reach-in freezer bottom shelves had dirt and food debris. c. Ice machine filter had dust and dirt buildup. d. Hood holes were not covered and had dust particles. e. Knife storage box had dust and food spillage. f. Mixer had food debris, food splashes and was stored on the floor. g. Scoop tray had food debris. h. Juice machine racks were sticky and dusty to touch. i. Food weighing scale was sticky to touch and had dirt and dust particles. j. Resident's vending machine had dust. 4. Utensils and kitchen equipment had cracks and scratches. a. Chopping boards had scratches. b. Eight (8) resident's tray had cracks and chips. c. Can opener…

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

Based on observation, interviews, and record reviews, the facility failed to dispose garbage and refuse properly by not completely covering 1 (one) of 2 black dumpsters (large trash container designed to be emptied into a truck) and keeping the area free from trash like plastic cups, plastic, and other trash around the trash area. This failure had a potential to result to attract birds, flies, insects, pest and possibly spread infection to 46 of 46 facility residents. Findings: During an observation on 12/27/2024 at 6:19 a.m. of the dumpster area outside of the facility, one (1) of the dumpsters was overflowing with trash and was not completely closed. During an interview on 12/28/2024 at 8:40 a.m. with Dietary Supervisor (DS), DS stated the dumpster had to always be closed and not overflowing with trash. DS stated a dumpster was not closed or covered and could attract pest and flies. DS stated it was not a good practice to leave a dumpster open and overflowing with trash as it could potentially cause food borne illness (a disease caused by consuming food or drinks that are…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 record review, the facility failed to ensure their Payroll Based Journal (PBJ - information of the provider's daily staffing hours for the appropriate care of the residents) data had been submitted to the Center for Medicare and Medicaid Services (CMS) for one of four required quarters (1st fiscal quarter due 02/14/2024) in 2023. This deficient practice had the potential to place all 45 facility residents as risk for delays in care, treatment, and services necessary to maintain physical and emotional wellbeing. Findings: A review of the facility's Certification and Survey Provider Enhanced Reporting system (CASPER: Shows the facility percentage and how the facility compares with other facilities in their state and in the nation) revealed no PBJ data had been submitted from the facility to CMS from 10/1/2023 - 12/1/2023. A review of CMS' website Staffing Data PBJ Submission website (https://www.cms.gov/medicare/quality/nursing-home-improvement/staffing-data-submission) indicated the deadlines for each reporting period were: - The 1st fiscal quarter was from…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, the facility failed to ensure mail was delivered to 4 of 11 residents (Resident 11, Resident 30, Resident 33, and Resident 41) at the resident council meeting (an organized group of residents who meet regularly to discuss and address concerns about their rights, quality of care, and quality of life), who verbally confirmed not receiving mail on Saturdays. This had the potential to affect all 45 residents in the facility who received personal mail, denying the residents the right to receive mail. Findings: On 12/28/2024 at 10:40 AM a group of residents met to discuss the resident council meeting with surveyors. When asked whether residents received their mail on Saturdays, several residents stated they did not receive mail on Saturdays. Resident 33 stated Social Services delivered mail from Monday through Friday only. During the same meeting, Resident 41 stated the residents did not receive mail on Saturdays. During an interview on 12/28/2024 at 3:53 PM, the Social Services Director (SSD) stated the social services delivered the mail to residents Monday through…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to effectively manage a resident's pain for two out of two sampled residents (Resident 12 and Resident 42): 1. For Resident 12, the facility failed to follow directions to remove a lidocaine patch (a prescription-only topical local anesthetic) after 12 hours of application per physician's order. 2. For Resident 42, the facility failed to administer Buprenorphine HCI (medication used to help relieve severe ongoing pain) Sublingual Tablet 2 MG Give 2 tablet sublingually (SL - under the tongue) every 4 hours for pain management per physician order. These deficient practices placed the residents at risk of inadequate pain relief and the possibility to experience health complications from their medication therapy. Findings: A. A review of Resident 12's admission record indicated the facility originally admitted the resident on 5/7/2022 and readmitted the resident on 9/24/2024 with diagnoses including chronic obstructive pulmonary disease (COPD-a…

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

Based on observation, interview, and record review the facility failed to follow the puree menu (foods that are smooth and pudding like consistency) and ensure nutritional needs were met when: 1. Staff served plain pureed scrambled eggs to residents on puree diet instead of pureed ham and potato casserole as indicated in the nutritional spreadsheet. 2. Scoop #16 (2 ounces ([oz] a unit of measurement) was used for puree scrambled eggs instead of #12 (3oz) scoop as indicated in the spreadsheet. This failure had the potential to result in decreased food and nutrient intake resulting in malnutrition and weight loss. Findings: 1. During a review of the facility's daily spreadsheet titled Winter Menus, dated 12/28/2024, the spreadsheet indicated puree diets would include the following foods on the tray: Juice 4 oz Puree raisin bran ½ cup (c, household measurement) Puree ham and potato breakfast casserole 1 Puree wheat toast 1 slice or 2 oz Margarine 1 tsp Parsley sprig garnish: no Milk 8 oz During an observation on 12/28/2024 at 7:10 a.m. of the trayline (an area where foods were…

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

Based on observations, interviews, and record reviews, the facility failed to prepare foods in a form designed to meet individual needs when residents on puree diet (foods that are smooth with pudding like consistency/International Dysphagia Diet Initiative ([IDDSI] a framework for categorizing food textures and drink thickness) Level four (4) received puree eggs that were dry and the puree bread and puree bran cereals were too sticky and did not fall from the spoon during a spoon tilt test (a method used to determine the stickiness of food and ability of the food to hold together) This failure had a potential to result in coughing, choking (to keep from breathing the normal way) and death for 8 of 46 residents on puree/IDDSI level 4 diet. Findings: a.During a review of the facility's daily spreadsheet titled Winter Menus, dated 12/28/2024, the spreadsheet indicated residents on puree diet/IDDSI] Level 4 would include the following foods in the tray: Juice 4 fluid ounces (oz, a unit of measurement) Puree raisin bran ½ cup (c, household measurement) Puree ham and potato breakfast…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to meet the requirement of 80 square feet per resident in a double occupancy patient room and 100 square feet (sq. ft) per resident in a single occupancy room. There were 23 out of 24 resident rooms in the facility that did not meet the requirement of 80 square feet per resident. This deficient practice had the potential to result in inadequate space to provide safe nursing care and privacy for the residents. Findings: A review of the facility's room waiver letter and the client accommodations analysis form completed by the facility on 3/29/2024, indicated the following 23 rooms provided less than 80 feet per resident: Rooms # Beds Room Size(ft.) Sq. Ft/Bed 3 2 138.7 69.35 4 2 138.7 69.35 5 2 138.7 69.35 6 2 138.7 69.35 7 3 150.7 50.25 8 2 138.7 69.35 9 2 138.7 69.35 10 2 138.7 69.35 11 2 138.7 69.35 12 2 138.7 69.35 14 2 138.7 69.35 15 2 138.7 69.35 16 2 138.7 69.35 17 2 138.7 69.35 18 2 138.7 69.35 19 2 138.7 69.35 20 2 138.7 69.35 21 2…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to protect the residents' privacy and dignity by failing to ensure the indwelling urinary catheter (foley catheter - a soft hollow tube, which is passed into the bladder to drain urine, for persons who cannot empty their bladder in the usual way) drainage bag was always covered for one of three sampled residents (Resident 97). This deficient practice had the potential to affect Resident 97's sense of self-worth and self-esteem. Findings: A review of the admission Record indicated Resident 97 was admitted to the facility on [DATE] with diagnoses including acute kidney failure (a condition in which the kidneys suddenly can't filter waste from the blood) and benign prostatic hyperplasia (BPH - is a condition that occurs when the prostate gland enlarges, potentially slowing or blocking the urine stream). A review of the Minimum Data Set (MDS - resident assessment tool) dated 10/9/2024, indicated Resident 97'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 observations, interviews, and record reviews, the facility failed to ensure that one out of three sampled residents (Resident 34) were free from physical restraint by failing to ensure the use of bilateral bed siderails consent was completed per individualized assessment. This deficient practice violated resident's right to be treated with respect and dignity with the use of restraints Cross Reference: F604 Findings: A review of Resident 34's admission record indicated the resident was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including chronic kidney disease (CKD-a longstanding disease of the kidneys leading to renal failure), pressure ulcer of sacral region (the triangular bone at the base of the spine that connects the spine to the pelvis) and pressure ulcer of left hip (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence). A review of Resident 34's Minimum Data Set (MDS - resident assessment 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 observation and interview, the facility failed to allow one of eight sampled residents (Resident 39) to retain his personal possession(s). This failure resulted in or had the potential to result in Resident 39 being angry. Findings: A review of Resident 39's admission Record indicated Resident 39 was admitted to the facility on [DATE] with diagnoses including essential hypertension (high blood pressure), and polyneuropathy (when multiple nerves become damaged). During an observation on 12/27/24 at 05:46 p.m., Resident 39 was noted in his room sitting up in bed watching TV. Resident 39 stated he has been in the facility for 8 months. Resident 39 stated since he has been residing in the facility he was missing 2 packages. Resident 39 stated he cannot remember when he did not receive the first package. Resident 39 further stated the last time his package was missing was 2 days ago. Resident 39 stated his friend sent him a package of brownies to the facility. Resident 39 was able to show the photo of where…

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

Based on observation, interview, and record review, the facility failed to ensure that one out of three sampled residents (Resident 34) were free from physical restraint by failing to ensure the physician's order for bilateral bed siderails was in placed and ensure the proper use of use rails according to facility's policy and procedure titled Proper Use of Side Rails, dated 1/31/2024. This deficient practice had the potential to result in entrapment and injury with the use of restraints. Cross Reference F552 Findings: A review of Resident 34's admission Record indicated the facility originally admitted the resident on 1/4/2024 and readmitted the resident on 3/22/2024 with diagnoses including chronic kidney disease (CKD-a longstanding disease of the kidneys leading to renal failure), pressure ulcer of sacral region (the triangular bone at the base of the spine that connects the spine to the pelvis) and pressure ulcer of left hip (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence). A review of the Minimum Data Set (MDS - 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 interviews and record reviews, the facility failed to implement their policy regarding reporting of an injury of unknown source in accordance with state or federal law for one of one sampled resident (Resident 34). This resulted in a delay of an onsite inspection by the Department of Public Health to ensure the residents' injury and accidents were investigated and had the potential to place residents at further risk for injuries. Findings: A review of Resident 34's admission record indicated the resident was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including chronic kidney disease (CKD-a longstanding disease of the kidneys leading to renal failure), pressure ulcer of sacral region (the triangular bone at the base of the spine that connects the spine to the pelvis) and pressure ulcer of left hip (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence). A review of the Minimum Data Set (MDS - resident assessment…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to apply handroll to the right hand for one of four sampled residents (Resident 43). This failure had the potential to delay service and placed Resident 43 at a higher risk for further decline. Findings: A review of Resident 43's admission Record indicated Resident 43 was re-admitted to the facility on [DATE] with diagnoses including weakness (lack of strength or ability) and chronic kidney disease (a condition where the kidneys are damaged and can't filter blood properly). A review of Resident 43's Minimum Data Set (MDS- a federally mandated resident assessment tool) dated 11/20/24, indicated the resident intact cognition (mental ability to make decisions of daily living). The MDS also indicated the resident needed moderate/maximum assistance with bed mobility, transfer, dressing, eating, toilet use and personal hygiene. A review of Resident 43's Order Summary Report dated 12/1/24, indicated RNA to apply bilateral handrolls 4-6 hours per…

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

Based on observation, interviews, and record reviews, the facility staff failed to ensure resident received appropriate treatment and services to prevent urinary tract infections urinary tract infection (UTI- an infection in the bladder/urinary tract) for one of three sampled residents (Resident 97) by failing to ensure resident's indwelling urinary (foley) catheter (a hollow tube inserted into the bladder to drain or collect urine) was placed below the level of the bladder at all times. This deficient practice had the potential to result or resulted in urinary tract infections for Resident 97. Findings: A review of Resident 97's admission Record indicated the facility admitted the resident on 10/3/2024 with diagnoses including acute kidney failure (a condition in which the kidneys suddenly can't filter waste from the blood) and benign prostatic hyperplasia (BPH - is a condition that occurs when the prostate gland enlarges, potentially slowing or blocking the urine stream). A review of the Minimum Data Set (MDS - resident assessment tool) dated 10/9/2024, indicated Resident 97'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 observations, interviews, and record reviews, the facility failed to provide necessary respiratory care services for one of two sampled residents (Resident 10) by failing to ensure a physician's order was in place for oxygen (O2) therapy and failing to ensure the resident's humidifier (a device used to make supplemental oxygen moist) was changed per facility's policy. This deficient practice had the potential to cause complications associated with oxygen therapy. Findings: A review of Resident 10's admission record indicated the facility originally admitted the resident on 8/30/2017 and readmitted on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD - a group of lung diseases that block airflow and make it difficult to breathe), atrial fibrillation (afib- an irregular and very rapid heart rhythm that and can lead blood clots in the heart) and chronic kidney disease (CKD-a longstanding disease of the kidneys leading to renal failure). A review of the Minimum Data Set (MDS -…

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

Based on observation, interview and record review, the facility failed to ensure adequate oversight of the Food and Nutrition Services by qualified personnel when the Registered Dietitian (RD) did not conduct a comprehensive (complete) care plan for one of two sampled residents (Resident 34) who had a significant weight loss. This failure had a potential to result in inaccurate nutrition assessment, ineffective nutrition intervention and goals for residents. Findings: A review of Resident 34's admission record indicated the facility originally admitted the resident on 1/4/2024 and readmitted the resident on 3/22/2024 with diagnoses including chronic kidney disease (CKD-a longstanding disease of the kidneys leading to renal failure), pressure ulcer of sacral region (the triangular bone at the base of the spine that connects the spine to the pelvis) and pressure ulcer of left hip (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence). A review of the Minimum Data Set (MDS - resident assessment tool) dated 9/28/2024, 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 observation, interview, and record review, the facility failed to provide comfortable and safe temperatures in the facility for one of four residents (Resident 44). These failures had the potential to cause harm. Findings: A review of Resident 44's admission Record indicated Resident 44 was re-admitted to the facility on [DATE], with diagnoses including renal dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) and essential hypertension (high blood pressure). A review of the Minimum Data Set (MDS, federally mandated assessment tool), dated 12/12/24, indicated Resident 44 had the capacity to understand and make decisions. Resident 44's cognition (thought process) was intact. During a concurrent observation and interview on 12/27/24 at 06:12 p.m., Resident 44 stated he layered his clothing because it was very cold in his room especially early in the morning. Resident 44 further stated it was so cold he doesn't want to get up…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 their Payroll Based Journal (PBJ - information of the provider's daily staffing hours for the appropriate care of the residents) data had been submitted to the Center for Medicare and Medicaid Services (CMS) for four of four required quarters (1st fiscal quarter due 02/14/2023, 2nd fiscal quarter due 05/15/2023, 3rd fiscal quarter due 8/14/2023, and 4th fiscal quarter due 11/04/2023) due in 2023. This deficient practice had the potential for low staffing in facility nursing care, leading to delay and/or lack of care, treatment, and services necessary to maintain physical and emotional well-being of residents. Findings: A review of the facility's Certification and Survey Provider Enhanced Reporting system (CASPER: Shows the facility percentage and how the facility compares with other facilities in their state and in the nation) indicated no PBJ data had been submitted from 7/1/2022 through 12/31/2023. A review of CMS' Staffing Data PBJ Submission website…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 a Registered Nurse (RN) was available to work for at least 8 consecutive hours a day. This deficient practice placed all 47 residents in the facility at risk for delayed care and services, missed treatments and/or medications, and a potential delay in emergency care. Findings. A review of Resident 27's admission Record indicated the facility admitted the resident on 9/29/2018 and readmitted the resident on 9/02/2020 with diagnoses including unspecified convulsions (seizures), traumatic brain injury, schizophrenia (mental disorder which leads to hallucinations, irrational thoughts, and behaviors), hypertension (high blood pressure), and major depressive disorder. A review of Resident 27's Minimum Data Set (MDS - a standardized assessment and care screening tool) dated 10/10/2023, indicated Resident 27's was cognitively (the mental ability to make decisions of daily living) intact. The MDS indicated Resident 27 required supervision with toilet transfers, dressing, and bathing. During an interview on…

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

Based on observation, interview, and record review the facility failed ensure medications were stored as per the facility's policy and procedures titled Storage of Medications dated 11/2020. By failing to: 1. Safely store medications for one of 12 sample residents (Resident 11). Antacid tablets (Calcium Carbonate-used to treat symptoms caused by too much stomach acid such as heartburn, upset stomach, or indigestion), Biotin, ( a B-Vitamin essential nutrient available as a dietary supplement), Vitamin D3 (A supplement that helps the body absorb calcium), Isopropyl alcohol 91% proof (A powerful agent used for disinfecting and sanitizing purposes) and Voltaren Gel (Medication used to relieve joint and muscle pain) were observed stored in Resident 11's bedside drawer. 2. Discard a bottle of Naproxen Sodium (nonsteroidal anti-inflammatory drug) 220 milligrams (mg) with 100 tablets with a labeled expiration date of 9/2023. 3. Discard two bottles of Magnesium Oxide (supplement to treat low magnesium levels in the body) 400mg with 120 tablets with a labeled expiration date of 10/2023. 4.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 and date when yellow jelly like substance in a container was prepared with a use by date (the last date recommended for the use of the food while at peak quality). 2. Failing to store meat product (tilapia fish fillet, pork chops, and sausage) below the vegetables. 3. Failing to discard jelly in the refrigerator that was past its use by date of 12/3/2023. Those deficient practices had the potential to result in foodborne illness (caused by consuming contaminated foods or beverages) among 48 residents who consumed food prepared by the facility kitchen. Findings: During an initial tour of the facility kitchen on 12/5/2022 at 7:24 a.m. with [NAME] 1(CK 1), there were a box of labeled pork, a box of labeled tilapia fish fillet and a plastic wrap with sausage links on the shelf above the vegetable shelf in the freezer. A container with jelly yellow like substance in the refrigerator did not have a label with the name of the substance or prepared on and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to meet the requirement of 80 square feet per resident in a double occupancy patient room and 100 square feet (Sq.Ft) per resident in a single occupancy room. There were twenty-two (23) resident rooms in the facility that did not meet the requirement of 80 square feet per resident. This deficient practice had the potential to result in inadequate space to provide safe nursing care and privacy for the residents. Findings: During the entrance conference with the facility Administrator (ADM) on 12/5/2023 at 11:00 a.m., the ADM presented a letter addressed to Department of Public Health, stating the facility had a request for the continuation of the waiver for twenty-three (23) rooms, which did not meet the room size requirement of 80 square feet per resident in a double occupancy room and one-hundred (100) square feet per resident in a single occupancy room. A review of the facility's room waiver letter and the client accommodations analysis…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to ensure that call button was placed within reach for two of 12 sampled residents (Residents 9 and 46). This deficient practice resulted in the residents not being able to access staff assistance as needed for Residents 9 and 46. Findings: A review of Resident 9's admission Record indicated Resident 9 was originally admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD - group of lung diseases that block airflow and make it difficult to breathe), epilepsy (a brain disorder that causes recurring, unprovoked seizures [a burst of uncontrolled electrical activity between brain cells]), and hyperlipidemia (HLD -an excess of lipids or fat in the body). A review of Resident 9's Minimum Data Set (MDS-a standardized assessment and care screening tool), dated 11/6/2023, indicated Resident 9 cognitive skills (thought processes) for daily decision making were not intact. Resident 9…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 communicate in a timely manner a residents change in condition to the physician for one of 12 sampled residents (Resident 4). This deficient practice has the potential to result in the delay in care for Resident 4. Findings: A review of Resident 4's admission Record indicated Resident 4 was originally admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses that included (COPD - group of lung diseases that block airflow and make it difficult to breathe), acute respiratory failure (when the lungs cannot release enough oxygen into the body which prevents the organs from properly functioning), and hypertension (hypertensive [high or raised] blood pressure). A review of Resident 4's Minimum Data Set (MDS-a standardized assessment and care screening tool), dated 9/22/2023, indicated Resident 4 was intact in cognitive skills (thought processes) for daily decision making and needed some help with self-care, required extensive assistance…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to notify the physical of resident refusal to be transferred to the general acute care hospital (GACH) for one of 12 sampled residents (Resident 47). This deficient practice had the potential to result in delay of care hospitalization for Resident 47. Findings: A review of Resident 47's admission Record indicated Resident 47 was originally admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses that included diabetes mellitus (DM -when the blood sugar is too high), and hypertensive heart disease, cerebral infarction (a result of disrupted blood floor to the brain), and personal history transient ischemic attack (TIA - a temporary blockage of blood flow to the brain). A review of Resident 47's Minimum Data Set (MDS-a standardized assessment and care screening tool), dated 9/23/2023, indicated Resident 47 had cognitive skills (thought processes) for daily decision making were intact. Resident 47 needed some help with self-care,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 staff properly assessed and document resident's medical diagnosis listed on admission Record, (a medical record that includes past and present medical history and findings), and on Preadmission Screening and Resident Review, (PASARR- a federally required screening to help identify individuals with possible serious mental illnesses requiring a specialized follow up evaluation). The deficient practice resulted in Resident 362 not receiving a PASARR II (assessment that determines if resident's mental condition could be met in the nursing facility or if the individual requires specialized services) and subsequent follow up. Findings: A review of Resident 362's admission Record indicated, Resident 362 was admitted to the facility on [DATE] with a diagnosis of unspecified schizophrenia (a mental illness that affects your thoughts, mood, and behavior). During a concurrent interview and record review on 12/6/23 at 4:01 p.m. the 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.

Based on observation, interview, and record review, the facility failed to: 1. Ensure transportation to dialysis was arranged for one out of four sampled residents (Resident 23). 2. Document and notify the physician that Resident 23 missed dialysis (a procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly) on 9/21/2023 and 12/2/2023. This deficient practice had the potential to cause a life-threatening build of toxins in the resident's body which could cause worsening in existing medical conditions, permanent damage to organs, and death. Findings, A review of Resident 23's admission Record indicated the facility admitted the resident on 8/14/2023 with diagnoses including type 2 diabetes (a group of diseases that result in too much sugar in the blood), end stage renal disease (the gradual loss of kidney function), left hand contracture (a condition of shortening and hardening of muscles), allergic urticaria (a skin condition that causes itchy welts), hypotension (low blood pressure), anemia (low red blood cells), hyperlipidemia…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 assistance for resident who required supervision while eating for one (1) of 12 sampled residents (Resident 39). This deficient practice had the potential not to meet the resident's nutritional needs, not to respect the resident's dignity, and also had the potential for weight loss and food aspiration (when something you swallow goes down the wrong way and enters your airway [windpipe] or lungs), which could lead to hospitalization and death. Findings: During an observation on 12/5/2023 at 7:39AM, Resident 39 was observed attempting to eat breakfast independently without supervision. Resident 39 looked up but not at her cereal bowl and attempted sometimes to scoop her breakfast cereal with a spoon to eat without success. A review of admission Record indicated Resident 39 was originally admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses that included atrial fibrillation (an type of abnormal heartbeat),…

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